Application XD10 Form – Fill Out and Download This PDF

In Box 1 enter the Social Security Number, and in Box 2 enter the Last Name, First Name and M.I.

Enter the Mailing Address, City, State and Zip Code.

Under LEGAL ADDRESS (Not a Post Office Box #), enter the Number and Street, City, State and Zip Code.

In Box 3 enter the Home Phone and the Business/Cell Phone, and enter the E-Mail Address.

In Box 4 enter the Exam Number and the Title; enter the Date of Examination (if applicable) as Mo Day Yr.

In Box 5, mark YES or NO: Are you filing for examinations with other civil service commissions that are being held on the same date? If yes, attach a completed cross-filer form.

In Box 6, mark YES or NO: Are you requesting testing accommodation(s) (such as for a disability or an alternate test date)? Please submit your requests for accommodations in writing on an attached sheet. You will have to provide documentation to support your request(s). Follow instruction G on the last page of this application.

In Box 7 A, mark YES or NO: Were you ever dismissed or discharged from any employment for reasons other than lack of work or funds?

Under B, mark YES or NO: Did you ever resign from any employment rather than face dismissal?

Under C, mark YES or NO: Did you ever receive a discharge from the Armed Forces of the United States which was other than “Honorable”, or which was issued under other than honorable circumstances?

If you answered “YES” to any of the questions 7 A-C, you must give specifics, including date, nature, and current disposition (Attach additional 8½” by 11” sheets.) If such explanation is insufficient, a confidential investigation supplement will be sent to you. None of the circumstances in 7 A-C represents an automatic bar to employment.

Open Competitive Examinations Only: if you are applying for an open-competitive examination, fill in the boxes with the residency codes of your legal residence, as listed on page 2 of this application, for each of the municipalities/districts in which you are a legal resident and have been for at least 30 days prior to the examination date. If you do not live in one of the listed municipalities/districts, use the codes provided for “Other”. If your residency changes, you must immediately notify the Westchester County Department of Human Resources, in writing.

Sign on the Signature of Applicant line and enter the Date. Mark NO or YES: Is additional information relative to change of name, use of an assumed name or nickname necessary to enable a check on your school and/or work record? If yes, please indicate here.

All statements are subject to verification. Misrepresentations may constitute cause for disqualification or discharge. It is a crime pursuant to Section 210.45 of the New York State Penal Law, punishable as a Class “A” misdemeanor, to knowingly make a false statement herein.

VETERANS: If you served or if you are an active member of the Armed Forces of the United States, read and fill out Section H on page 4. (FORM DD214 or proof of current service MUST BE ATTACHED)

If you received or expect to receive an honorable discharge from the Armed Forces of the United States, as a veteran or disabled veteran, you may claim extra credits to be added to your exam score, if you pass. Discharged Veterans are required to submit a copy of their DD214 discharge papers.

To claim credits as a Disabled Veteran, you must be entitled to receive payments for a service-connected disability (rated at 10% or more) incurred while serving in the United States armed forces.

In conformance with section 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 municipality in which his or her parent has served.

The application fee may be waived with proof of supplemental Social Security payments, public assistance, receiving foster care, or unemployed and primarily responsible for the support of a household.

If you require special arrangements, a written request should be attached to this application describing the type of special arrangements required. Alternate test dates are granted at the discretion of the Department of Human Resources.

Under COLLEGE/UNIVERSITY enter the Name of School and City in which located, the Dates of Attendance (Month/Year) From To, the Type of Course or Major, the Number of College Credits Received, Were You Graduated?, the Type of Degree Received and the Date Degree Received or Expected.

ALL SECTIONS MUST BE FILLED OUT COMPLETELY. DO NOT LEAVE BLANK. A RESUME IS NOT A SUBSTITUTE. List all relevant work experience. Begin with your most recent employment.

Applications will be rejected for lateness, if postmarked or received after the last filing date.

Westchester County Department of Human Resources, 148 Martine Avenue, Suite 100, White Plains, New York 10601.

There is a non-refundable application filing fee per examination number. No cash accepted. A check or money order only (payable to Westchester County Department of Human Resources) must accompany this application.