Application Xd10 Form PDF Details

In today's dynamic job market, the Application Xd10 form serves as a critical gateway for individuals seeking examination or employment opportunities within Westchester County's Department of Human Resources. This comprehensive document not only streamlines the application process but also underscores Westchester County's commitment to equal employment opportunities, irrespective of age, race, creed, color, national origin, sex, disability, marital status, sexual orientation, or any other protected status. Applicants are encouraged to provide detailed information related to their social security number, personal details, legal address, and relevant educational and professional background. Moreover, the form prompts candidates to indicate their residency, should they vie for open-competitive examinations, ensuring a meticulous assessment of eligibility based on the municipality or district of residence. It meticulously caters to individuals with disabilities or those needing alternative test arrangements, reinforcing inclusivity. Notably, the application process delves into the applicant's past employment history, military service, or any convictions, reflecting a thorough vetting process. This not only maintains the integrity of the hiring process but also aligns with Westchester County's drug-free workplace policy. Additionally, the form provides avenues for veterans and children of firefighters or police officers killed in the line of duty to claim supplementary credits, embodying the county's respect and recognition for service and sacrifice.

QuestionAnswer
Form NameApplication Xd10 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameshow to xd10, xd 10 application, xd 10 form, xd10 westchester gov

Form Preview Example

APPLICATIONFOREXAMINATION/EMPLOYMENT

UPON COMPLETIONMAILORDELIVERTO:

WESTCHESTERCOUNTYDEPARTMENT OF HUMANRESOURCES RECRUITMENT&SELECTIONUNIT

148MartineAvenue,Suite100

WhitePlains,NewYork 10601

READINSTRUCTIONSONPAGE4 BEFOREBEGINNING

Thisapplicationispartoftheexaminationandmustbefilledoutcomplete- ly and accurately. Answer all questions fully, printed in ink or typed. Attachadditionalsheetsanddocuments,ifneeded,togivecompleteinforma- tion. If you apply for more than one examination, a separate application or copymustbefiledforeach. (PLEASEPRINTORTYPE)

WESTCHESTER COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER. It is the policy of Westchester County to provide for and promote the equal opportunity of employment, compensationandothertermsandconditionsofemploymentwithoutdiscriminationbecauseofage,race,creed,color,nationalorigin,sex,disability,maritalstatus,sexualorientation, oranyotherprotectedstatus.

1. SocialSecurityNumber

2. LastName

FirstName

M.I.

 

 

 

 

MailingAddress

 

 

 

 

 

 

 

City

State

ZipCode

REQUIREDINFORMATION

LEGALADDRESS(NotaPostOfficeBox#)

NumberandStreet

City

State

 

ZipCode

 

 

3.HomePhone

BusinessPhone

(

)

(

)

 

 

 

 

Open Competitive Examinations Only-Legal Residence Codes: If you are apply-

ing for an open-competitive examination, please indicate, in the boxes below, each of the municipalities/districtsinwhichyouarealegalresidentandhavebeenforatleast30days priortotheexaminationdate.Fillintheboxeswiththeresidencycodesofyourlegalresi- dence,aslistedonpage2ofthisapplication.Ifyoudonotliveinoneofthelistedmunic- ipalities/districts,usethecodesprovidedfor“Other”.Basedonthelegaladdressyoupro- vide and the information you submit below, the Westchester County Department of Human Resources will determine, subject to verification, your legal residence for eligible list resident certifications. It is your responsibility to provide us sufficient information regarding legal residence for you to be included. If your residency changes, you must immediately notify the Westchester County Department of Human Resources, in writing.

County

City

Town

Village

School

Fire

 

 

 

 

District

District

4. ExamNumber

Title

 

 

 

 

 

 

DateofExamination

Mo

Day

Yr

5.Areyoufilingforexaminationswithothercivilservicecommissionsthatarebeing heldonthesamedate? YES NO

Ifyes,pleaseattachaseparatesheetlistingwhichcommissionsandthetitlesofthe examinations.

6.Areyourequestingtestingaccommodation(s)?

YES

NO

(suchasforadisabilityoranalternatetestdate)

Pleasesubmityourrequestsforaccommodationsinwritingonanattachedsheet.

Youwillhavetoprovidedocumentationtosupportyourrequest(s).Follow

instruction“G”onthelastpageofthisapplication.

7.Checkappropriatebox:

 

 

A.Wereyoueverdismissedordischargedfromany

YES

NO

employmentforreasonsotherthanlackofworkor

funds?

 

 

B.Didyoueverresignfromanyemploymentratherthan

YES

NO

facedismissal?

C.DidyoueverreceiveadischargefromtheArmed

YES

NO

ForcesoftheUnitedStateswhichwasotherthan

Honorable”,orwhichwasissuedunderotherthan

 

 

honorablecircumstances?

 

 

D.Haveyoueverbeenconvictedofacriminaloffense

YES

NO

(felonyormisdemeanor)?

E.Haveyoueverforfeitedabailbondpostedtoanswer

YES

NO

anycriminalcharge?(givedetails)

F. Areyounowunderchargesforanycriminal offense?

YES

NO

(givedetails)

If you answered “YES” to any of the questions 7 A-F above, you must give specifics. (Attachadditional8½”by11”sheets.) Ifsuchexplanationisinsufficient,aconfiden- tialinvestigationsupplementwillbesenttoyou.

Noneoftheabovecircumstancesrepresentsanautomaticbartoemployment. Eachcase is considered and evaluated on individual merits in relation to the duties and responsi- bilitiesoftheposition(s)forwhichyouareapplying.

ALLSTATEMENTSARESUBJECTTOVERIFICATION. MISREPRESENTATIONSMAYCONSTITUTECAUSEFORDISQUALIFICATIONORDISCHARGE. IT IS A CRIME PURSUANT TO SECTION 210.45 OF THE NEW YORK STATE PENAL LAW, PUNISHABLE AS A CLASS “A” MISDEMEANOR, TO KNOW- INGLYMAKE AFALSESTATEMENTHEREIN.

FOR COUNTY EMPLOYMENT: IN ACCORDANCE WITH WESTCHESTER COUNTY’S COMPREHENSIVE DRUG-FREE WORKPLACE POLICY AND PROCEDURES, AND COMMITMENTTOMAINTAINASAFE,ALCOHOLANDDRUG-FREEWORKENVIRONMENT,YOUMAYBEREQUIREDTOSUBMITTOURINANALYSIS,BREATH,AND/OR BLOODTEST. INADDITION,IFOFFEREDEMPLOYMENT,YOUWILLBESUBJECTTOTHEWESTCHESTERCOUNTYFINGERPRINTINGPOLICYUNDERWHICHYOUR APPOINTMENTMAYBECONDITIONEDONTHERESULTSOFAFINGERPRINTINGINVESTIGATION.

THISAFFIRMATIONANDAUTHORIZATIONFORRELEASEOFPERSONALINFORMATIONMUSTBECOMPLETED: Bymysignaturebelow,I herebyauthor- ize the Westchester County Department of Human Resources, the County of Westchester, and/or its respective Departments, Offices or Agencies to request verbal records or writ- tenverificationofanyorallinformationcontainedherein. Ifurtherauthorizeareviewandfulldisclosureofallrecordsconcerningmewhethersaidrecordsareofapublic,private or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of records. I further release the Westchester County Department of HumanResources, theCountyofWestchester,and/oritsrespectiveDepartments,OfficesorAgencies,andtheirrespectiveofficersand/oremployeesfromanyandallliabilitywhich maybeincurredasaresultofcollectingsuchinformation. Further,mysignaturebelowcertifiesIhavereadandfullyunderstandthe“AffirmationandAuthorizationforReleaseof PersonalInformation”andhaveacknowledgedthataphotocopyofthefrontpageoftheApplicationforExamination/Employmentcontainingthisreleasewillbevalidasanorigi- nalthereof,eventhoughsaidphotocopydoesnotcontainanoriginalwritingofmysignature. Iaffirmthatallstatementsmadeonthisapplication(includinganyattachedpaper) are true under the penalties of perjury. (Applicants are advised that all statements made by them in connection with their application(s) for examination/employ- mentaresubjecttoinvestigationandverification,includingabackgroundinvestigationbytheprospectiveappointingauthority.)

 

SignatureofApplicant

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

Isadditionalinformationrelativetochangeofname,useofanassumednameornicknamenecessarytoenableacheckonyourschooland/orworkrecord?

NO YES

 

Ifyes,pleaseindicatehere:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DONOTWRITEBELOW-FORHUMANRESOURCESUSE

EnteredBy:

 

JCC:

 

 

Dispo:

 

 

Fee:

 

 

Vet:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPT/D:/

ApprovedBy:

 

Date:

Conditional:

Paid

DateReceived

Disapproved: Section7:

Page1

BACKGROUND,EDUCATIONANDTRAINING

VETERANS:IfyouservedorifyouareanactivememberoftheArmedForcesoftheUnitedStates,readandfilloutSectionHonpage4

(FORMDD214orproofofcurrentserviceMUSTBEATTACHED)

CHILDREN OF FIREFIGHTERS AND POLICE OFFICERS KILLED IN THE LINE OF DUTY: In conformance withsection 85a of the New York State Civil Service Law, children of firefighters and police officers killed in the line of duty shall be entitled to receive an additional ten points in a competitive examination for original appointment in the same muni- cipalityinwhichhisorherparenthasserved.Ifyouarequalifiedtoparticipateinthisexaminationandareachildofafirefighterorpoliceofficerkilledinthelineofdutyinthismuni- cipality,pleaseinformthisdepartmentofthismatterwhenyousubmityourapplicationforexamination.Acandidateclaimingsuchcredithasaminimumoftwomonthsfromtheappli- cationdeadlinetoprovidethenecessarydocumentationtoverifyadditionalcrediteligibility.However,nocreditmaybeadded aftertheeligiblelisthasbeenestablished.

 

Iclaimadditionalcreditasachildofafirefighterorpoliceofficerkilledinthelineofduty.

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Areyou18yearsofageorolder?

 

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AreyouacitizenoftheUnitedStates?

Yes

No

 

Ifselectedforemployment,youwillberequiredtosubmitdocumentaryproofof

 

 

 

citizenshiporstatusasaforeigncitizenauthorizedtoworkintheUnitedStates.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DoyouhaveaHighSchoolDiploma?

Yes

No

NameandlocationofHighSchool

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OraHighSchoolEquivalency(GED)Diploma?

Yes No

IssuingGovernmentalAuthority

DocumentNumber

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSCRIPTS:

previouslyfiled

 

onrequestfromschool

 

 

 

Anofficialtranscriptisrequiredasverificationwithin60daysafterthedateoftheexaminationforperiodicexaminations;andpriortoparticipationincontinuousrecruitment examinations.If theexaminationannouncementasksforspecificcoursework,listthecourseswhichyouhavepassedonanattachedsheet.If youclaimcreditforapartiallycom- pletedcollegecurriculum,attachalistofcoursesandcreditsorsemesterhourscompleted.Indicatehowmanycredithoursor coursesarerequiredforgraduation.

COLLEGE/UNIVERSITY

 

NameofSchooland

DatesofAttendance

 

TypeofCourse

Numberof

Were

Typeof

DateDegree

 

 

Cityinwhichlocated

(Month/Year)

 

orMajor

CollegeCredits

You

Degree

Receivedor

 

 

 

From To

 

 

Received

Graduated?

Received

Expected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROFESSIONALSCHOOLS,RESIDENCIES,MILITARYSERVICESCHOOLS,OTHERSCHOOLS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE:Ifalicense,certificateorotherauthorizationtopracticeatradeorprofessionislistedasarequirementontheannouncementoftheexamination,

orposting,forwhichyouareapplying,completethefollowingandattachacopy:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofTradeorProfession

 

 

Specialty

 

 

 

LicenseNumber

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Grantedby(LicensingAgency) CityorState

 

 

DateLicenseFirstIssued

 

 

 

Registered From (Mo/Yr) To (Mo/Yr)

 

 

 

 

 

 

Note: Ifapositionrequiresaspecifiedlicensetooperateamotorvehicle,theapplicantmustprovidetheappointingauthoritywith proofofacurrent,validlicense(subjecttoverifi-

cation)priortoappointment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEGALRESIDENCECODES

 

 

 

 

 

 

COUNTIES

TLB

TownofLewisboro

VPL

VillageofPelham

SKL

Katonah-LewisboroSchoolDistrict

CODE

MUNICIPALITY

TMM

TownofMamaroneck

VPM

VillageofPelhamManor

SLL

LakelandSchoolDistrict

BRNX

BronxCounty

TMP

TownofMountPleasant

VPV

VillageofPleasantville

SMM MamaroneckSchoolDistrict

COLB

ColumbiaCounty

TNW

TownofNewCastle

VPC

VillageofPortChester

SMP

Mt.PleasantSchoolDistrict

DUTH

DutchessCounty

TNC

TownofNorthCastle

VRB

VillageofRyeBrook

SNS

NorthSalemSchoolDistrict

KING

KingsCounty(Brooklyn)

TNS

TownofNorthSalem

VSD

VillageofScarsdale

SNT

PocanticoHillsSchoolDistrict

NASS

NassauCounty

TOS

TownofOssining

VNT

VillageofSleepyHollow

SOS

OssiningSchoolDistrict

NYNY

NewYorkCounty(Manhattan)

TPL

TownofPelham

VTK

VillageofTuckahoe

SPC

PortChesterSchoolDistrict

ORAN

OrangeCounty

TPR

TownofPoundRidge

VTT

VillageofTarrytown

SPK

PeekskillCitySchoolDistrict

PUTN

PutnamCounty

TRY

TownofRye

VTH

Other

SPL

PelhamSchoolDistrict

QUEN

QueensCounty

TSM

TownofSomers

 

 

 

 

 

SPV

PleasantvilleSchoolDistrict

RICH

RichmondCounty(StatenIsland)

TYT

TownofYorktown

SCHOOLDISTRICTS

SRN

RyeNeckSchoolDistrict

ROCK

RocklandCounty

TTH

Other

SRY

RyeCitySchoolDistrict

CODE

DISTRICT

SUFF

SuffolkCounty

 

 

 

 

SSD

ScarsdaleSchoolDistrict

 

 

 

 

SAR

ArdsleySchoolDistrict

SULL

SullivanCounty

 

 

 

 

SSM

 

SomersSchoolDistrict

VILLAGES

SMK

BedfordCentralSchoolDistrict

 

ULST

UlsterCounty

STK

 

TuckahoeSchoolDistrict

CODE

MUNICIPALITY

SBB

BlindBrookSchoolDistrict

 

WEST

WestchesterCounty

STT

TarrytownSchoolDistrict

VAR

Village of Ardsley

SBH

ByramHillsSchoolDistrict

WTH

Other

SVL

 

ValhallaSchoolDistrict

VBC

Village of Buchanan

SBM

BriarcliffManorSchoolDistrict

 

 

 

 

SYH

YorktownHeightsSchoolDistrict

CITIES

 

VBM

Village of Briarcliff Manor

SBV

BronxvilleSchoolDistrict

 

STH

 

Other

 

VBV

Village of Bronxville

 

CODE

MUNICIPALITY

SCH

ChappaquaSchoolDistrict

 

 

 

 

 

 

 

VCR

Village of Croton-on-Hudson

SCR

CrotonSchoolDistrict

 

 

 

 

 

 

CPK

Peekskill

FIREDISTRICTS

VDF

Village of Dobbs Ferry

SCT

HendrickHudsonSchoolDistrict

CRY

RyeCity

VEF

Village of Elmsford

SDF

DobbsFerrySchoolDistrict

CODEDISTRICT

CTH

Other

FEC

EastchesterFireDistrict

VHH

Village of Hastings-on-Hudson

SEC

EastchesterSchoolDistrict

 

 

 

 

 

 

FFV

FairviewFireDistrict

TOWNS

VHR

Village of Harrison

SEF

ElmsfordSchoolDistrict

FGV

GreenvilleFireDistrict

CODE

MUNICIPALITY

VIR

VillageofIrvington

SEM

EdgemontSchoolDistrict

FHD

HartsdaleFireDistrict

TBF

TownofBedford

VLM

VillageofLarchmont

SHD

GreenburghCentral#7 SchoolDistrict

FLM

LakeMoheganFireDistrict

VMK

VillageofMountKisco

TCT

TownofCortlandt

SHH

HastingsSchoolDistrict

FTH

Other

TEC

TownofEastchester

VMM

Villageof Mamaroneck

SHR

HarrisonCentralSchoolDistrict

TGB

TownofGreenburgh

VOS

VillageofOssining

SIR

IrvingtonSchoolDistrict

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page2

DESCRIPTIONOFEXPERIENCE

ALLSECTIONSMUSTBEFILLEDOUTCOMPLETELY. DONOTLEAVEBLANK. ARESUMEISNOTASUBSTITUTE.

Carefullyread the minimum qualificationsfor the position/examinationfor whichyou are applying. Fee(s) will not be refunded if you do not meet the established qualifications.

Listbelowallrelevantworkexperience.Aresumeisnotasubstitute. Bemorespecificindescribingyourexperiencesrelatingtotheminimumqualificationsofthepositionorexam- ination for which you are applying. Begin with your most recent employment. You are responsible for submitting an accurate, adequate and clear description of your experience. Omissions orvaguenesswillnotbeinterpretedinyourfavor. Includemilitaryserviceexperiencewhenappropriate.Verifiedanddocumentedvolunteer(unpaid)experiencewillonly becreditedwhenspecificallyallowedbythejobdescriptionorexaminationannouncement. Ifyourtitleordutieschangedmateriallyinthecourseofyourserviceinanyoneorgani- zation,indicatesuchchangeclearlyandasaseparateemployment. (Ifmorespaceisneeded,attach8½”X11”sheetsofpaper usingthesameformat.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LengthofEmployment

 

 

 

 

NameofEmployer

 

 

Address

 

CityandState

 

 

Mo.

Yr.

 

Mo.

Yr.

 

 

 

 

 

 

 

 

 

 

 

From

/

To

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earnings

 

 

#of hours/week

 

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TypeofBusiness

 

 

 

 

Describedutiesbelow:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YourExactTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofyourSupervisor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’sTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ReasonforLeaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LengthofEmployment

 

 

 

 

NameofEmployer

 

 

Address

 

CityandState

 

Mo.

Yr.

 

Mo.

Yr.

 

 

 

 

 

 

 

 

 

 

 

From

/

To

/

 

 

 

 

 

 

 

 

 

 

 

Earnings

 

#of hours/week

 

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TypeofBusiness

 

 

 

 

Describedutiesbelow:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YourExactTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofyourSupervisor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’sTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ReasonforLeaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LengthofEmployment

 

 

 

 

NameofEmployer

 

 

Address

 

CityandState

 

Mo.

Yr.

 

Mo.

Yr.

 

 

 

 

 

 

 

 

 

 

 

From

/

To

/

 

 

 

 

 

 

 

 

 

 

 

Earnings

 

#of hours/week

 

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TypeofBusiness

 

 

 

 

Describedutiesbelow:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YourExactTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofyourSupervisor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’sTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ReasonforLeaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LengthofEmployment

 

 

 

 

NameofEmployer

 

 

Address

 

CityandState

 

FromMo.

/ Yr.

ToMo.

/ Yr.

 

 

 

 

 

 

 

 

 

 

 

Earnings

 

#of hours/week

 

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TypeofBusiness

 

 

 

 

Describedutiesbelow:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YourExactTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofyourSupervisor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’sTitle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ReasonforLeaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haveyouansweredallappropriatequestions? Anincompleteapplicationmaybedisapproved.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

StudentLoanSupplement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DoyouhaveanyloansmadeorguaranteedbytheNewYorkStateHigherEducationServicesCorporationwhicharecurrentlyoutstanding?

Yes No

 

Ifso,areyoupresentlyindefaultonanysuchloan?

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page3

INSTRUCTIONSANDINFORMATION

Thereisanon-refundableapplicationfilingfeeperexaminationnumber. Nocashaccepted. Acheckormoneyorderonly(payabletoWestchesterCountyDepartmentofHuman Re- sources) must accompany this application. One check may be used. Record all exam numbers on the check. Applications received without the filing fee will be returned. Waivers: See section“C,”below.

A.EXAMINATIONANNOUNCEMENT

Before filling out your application, carefully read the examination announcement. Announcements may be viewed at the Westchester County Department of Human Resources or theDepartment’swebsite,www.westchestergov.com/hrandatmunicipalbuildingsandpubliclibrariesthroughoutWestchesterCounty.

B.QUALIFICATIONS

The burden of establishing required qualifications is the responsibility of the applicant. Fees are not refunded for disqualification. Out-of-title experience cannot be credited towards meeting the minimum qualifications. Applications will be rejected for lateness, if postmarked or received after the last filing date. Part-time experience will be pro-rated basedona35-hourworkweek.

C.APPLICATIONFEEWAIVER

The application fee maybe waived with proof of supplemental Social Security payments, public assistance, receiving foster care,or unemployed and primarily responsible for the supportofahousehold.

D.ADMISSIONTOEXAMINATION

Admission notices are mailed the week prior to the examination date. If you do not receive a notice three days prior to the exam date, call (914) 995-2117. Candidates will be required to bring proof of identification to the examination such as a passport, photo driver license, or a photo non-driver I.D. Participation in the examination does not mean you have been found to meet the announced requirements. Applicants may be admitted on the basis of statements made on the application which are subject to reviewandverification. Scoreswillnotbeavailableifadisqualificationdeterminationismadesubsequenttotheexamination.

E.DISQUALIFICATIONAPPEAL

AnyappealofadisqualificationnoticemustbemadeinwritingandreceivedintheDepartmentofHumanResourcesbythedateandtimeindicatedonthenotice.

F.LEGALADDRESSCHANGES

Youmustreportachangeinaddresstoinsurepropernotificationoftestresultsandcertificationofcivilservicelists.Residencymustbeestablished30dayspriortotheexamination dateinordertomeetresidencepreferencerequirements.

G.TESTING ACCOMMODATION(ATTACHREQUEST)

If you require special arrangements, a written request should be attached to this application describing the type of special arrangements required. Most written tests are held on Saturdays. If you cannot take the test on the announced test date due to a conflict with a documented religious observance or practice we will make arrangements for you to takethetestonadifferentdate. Pleasechecktheappropriateboxbelow.

ANALTERNATETESTDATEMAYBEREQUESTEDONLYFORONEOFTHEFOLLOWINGREASONS: (CHECKAPPROPRIATEBOX)

1. Adeathintheimmediatefamilyorhouseholdwithintheweekprecedingtheexamination.

2. Medicalemergenciesinvolvingthecandidateormember(s)oftheimmediatefamily.

3. MilitaryOrders(Acopyofordersisrequired).

4. ReligiousObservance-Candidatemustsubmitrequiredform.

5. Wedding-mustbeamemberoftheweddingpartyormemberoftheimmediatefamilyofthebrideorgroom.

6. Vacationforwhichanon-refundabledownpaymentwasmadebeforetheexamannouncementwasissued.

7. Requiredcourtappearances.

WITHTHEEXCEPTIONOFREASONS1AND2,REQUESTSMUSTBEMADEINWRITINGWITHDOCUMENTATIONATTACHEDTOTHE APPLICATION.

H.VETERANSCREDITS

Ifyou received or expect to receive an honorable discharge from the Armed Forces of the United States, as a war-time veteran or disabled veteran as defined below, you may claim extracreditstobeaddedtoyourexamscore,ifyoupass. TheArmedForcesoftheUnitedStatesmeanstheArmy,Navy,MarineCorps,AirForceandCoastGuard,andallcomponents thereof, and the National Guard when in the service of the United States pursuant to call as provided by law on a full-time, active duty basis other than active duty for training pur- poses.

Discharged Veterans are required to submit a copy of their DD214 discharge papers. Active duty members of the Armed Forces must submit proof of active duty status, such as current Military I.D., Military Orders or other official Military document that substantiates active duty status. To claim credits as a Disabled Veteran, you must be entitled to receive paymentsforaservice-connecteddisability(ratedat10%ormore)incurredduringtimeofhostileactionorwar.

AreyouclaimingcreditasaVeteran?

AsaDisabledVeteran?

Activeservicemember?

 

 

 

HaveyouusedyourVeteranscreditsforpermanentappointmentorpromotioninNewYorkStateoranyofitscivildivisionssinceJanuary1,1951?

Yes No

CHECK ANDINDICATEBELOWTHETIMEPERIODSYOUSERVEDORARESERVINGINTHEARMEDFORCESOFTHEUNITEDSTATES

 

 

 

 

FROMMO/YR

 

TOMO/YR

WorldWarII:

December7,1941-December31,1946

(

)

(

)

USPublicHealthService:

July29,1945-September2,1945

(

)

(

)

KoreanConflict:

June27,1950-January31,1955

(

)

(

)

USPublicHealthService:

June26,1950-July3,1952

(

)

(

)

VietnamConflict:

February28,1961-May7,1975

(

)

(

)

* HostilitiesinLebanon:

June1,1983-December1,1987

(

)

(

)

* HostilitiesinGrenada:

October23,1983-November21,1983

(

)

(

)

* HostilitiesinPanama:

December20,1989-January31,1990

(

)

(

)

PersianGulfConflict:

August2,1990-(

)

(

)

(

)

ActiveDuty:

 

 

(

)

(

)

*FortheseservicedatesVeteransmusthavereceivedtheArmedForcesExpeditionaryMedalforServiceinZoneofConflict.

LEAVETHISSPACE BLANK

FormXD10

Page4

Revised8/2011

 

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