Cs 205 B Form – Fill Out and Use This PDF

PLEASE PRINT:

1.EXACT TITLE OF EXAMINATION

_

_

LAST NAME	FIRST NAME	M.I.
MAILING ADDRESS
CITY	STATE	ZIP CODE

3.PLACE OF EXAMINATION

Please check the examination center where you wish to be tested.

SELDENRIVERHEAD

4.DAYTIME TELEPHONE NUMBER (include area code) You may be contacted by prospective employers.

( )

5. LEGAL RESIDENCE CODES Identify each of the districts of which you are a legal resident, NOT where you wish to be employed. If your legal residence changes, you must notify the Suffolk County Civil Service Department at once in writing. Complete the boxes with the correct codes for your legal residence. See last page of application for list of residence codes.

COUNTY	TOWN	SCHOOL	VILLAGE	LIBRARY
		DISTRICT		DISTRICT
C -	T -	S -	V -	L -

6.GEOGRAPHIC ZONES

Check one or more of the boxes below indicating the geographic zones in which you would be willing to accept an appointment. Your name will be certified only for job vacancies in the geographic zones you check.

Zone 1 Riverhead, Southold, Shelter Island, Southampton, and East Hampton Townships

Zone 2 Brookhaven Township

Zone 3 Smithtown and Islip Townships

Zone 4 Huntington and Babylon townships

7.Check appropriate box to the right of each question:

A. Have you ever been convicted of any crime (felony or misdemeanor)?

YES NO

B. Have you ever forfeited bail bond posted to guarantee your appearance

in court to answer to any criminal charge? YES NO

C. Were you ever dismissed or discharged from any employment for

reasons other than lack of work or funds?

YES

NO

D. Did you ever resign from any employment rather than face dismissal?

YES NO

E. 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?

YES

NO

SOCIAL SECURITY NUMBER

LEGAL ADDRESS (Not a Post Office Box)

CITY

STATE

ZIP CODE

Successful completion of an appropriate medical examination may be required.

If you answered YES to any part of question 7 you MUST give specifics in the COMMENTS section below.

None of the above circumstances represents an automatic bar to employment. Each case is considered and evaluated on individual merits in relation to the duties and responsibilities of the position for which you are applying. Background investigations may be conducted on all candidates considered for employment. A False statement may result in the disqualification of your application in accordance with the provisions of Section 50 of the Civil Service Law.

A candidate appointed to a vacancy in the service of Suffok County shall be required to disclose, and a candidate appointed to any other vacancy in the civil service may be required to disclose, whether he/she is currently receiving any form of disability payment from New York State.

THE FOLLOWING QUESTIONS ARE OPTIONAL.

8.Are you a Saturday sabbath observer who, for religious reasons only, requests permission to take this examination after sundown on Saturday?

Yes NO

If you checked YES, you will be asked to provide verification.

9.Do you need special accommodations to participate in this examination?

YES NO

If you checked YES, please describe the type assistance you request in the COMMENTS section below.

10.COMMENTS

(Attach additional sheets if necessary)

TEST SCORE

VETS CREDIT

TOTAL SCORE

NOTES

PENDING TRANSCRIPT

PENDING NECESSARY SPECIAL REQUIREMENT

ELIGIBLE	INELIGIBLE

DATE

11.EDUCATION

A.Have you graduated from senior high school? If yes, complete name and location.

YES

NO

VETERANS' CREDITS

Veterans' credits are granted on the following basis:

DISABLED VETERANS: 10 points for Open-Competitive Exams 5 points for Promotional Exams

NON-DISABLED VETERANS: 5 points for Open-Competitive Exams 2.5 points for Promotional Exams

These additional credits, which are combined with the final score obtained in the examination, may be granted only to PASSING CANDIDATES at the time of establishment of the eligible list.

NON-DISABLED VETERANS

In order to be eligible for additional credits as a non-disabled veterans, you must:

1.Have served on ACTIVE DUTY, other than active duty for training purposes, with the Armed Forces of the United States during any of the following periods:

WORLD WAR II - December 7, 1941 through and including December 31, 1946

KOREA	- June 27, 1950 through and including January 31, 1955
VIETNAM	- December 22, 1961 through and including May 7, 1975
LEBANON*	- June 1, 1983 through and including December 1, 1987
GRENADA*	- October 23, 1983 through and including November 21, 1983
PANAMA *	- December 20, 1989 through and including January 31, 1990
PERSIAN GULF	- August 2, 1990 - to the end of hostilities as yet undefined

*To receive veterans' credits for service in these campaigns, an applicant must also have been the recipient of one of the following:

Armed Forces Expeditionary Medal Navy Expeditionary Medal Marine Corps Expeditionary Medal

2.Have been honorable discharged or released under honorable conditions from such service.

3.Submit a photocopy of separation papers (i.e. FORM DD-214 or NAVPRS-553) from the Armed Forces of the United States before this eligible list is established.

DISABLED VETERANS

In order to be eligible for additional credit as a disabled veteran, in addition to meeting the requirements of items 1, 2 & 3 listed above, you must also complete ,FOR EACH TITLE,

Form VC-3,(Authorization for Disability Record), in duplicate and forward BOTH copies immediately to the Regional Office of the United States Veterans Administration where your application for disability pension is on file. The Veterans Administration will retain a copy for its files, and will return a copy to this Department for processing. Disabled veterans must have a war-incurred disability of at least ten percent (10%) certified by the Veterans Administration at the time of application for additional credits.

15.A. Do you claim additional credits as an honorably discharged war veteran for this examination?

1. YES, AS A NON-DISABLED VETERAN

2. YES, AS A DISABLED VETERAN

3. NO.

If you checked YES, complete 15B and C:

B.Have you previously used veterans' credits to receive a permanent competitive class appointment in the service of the State of New York or any civil division within the State?

YES NO If you check YES complete the information in 15D below.

CIVIL SERVICE LAW LIMITS THE USE OF VETERANS' CREDITS TO ONE PERMANENT COMPETITIVE CLASS APPOINTMENT WITHIN NEW YORK STATE.

C.With the exception of the federal service, have you ever been employed by a governmental agency outside the Suffolk County (e.g. New York City, New York State, Office of Court Administration, or another county within New York State?)

YES NO If you checked YES complete the information in 15D below:

D. Government Name

Length of Employment From

To

Department

Your Official Title(s)

(Attach additional sheets if necessary)

LEGAL RESIDENCE CODES -

COUNTY
NAME	CODE
Suffolk County	C-1
Other	C-0
TOWNS
Babylon	T-01
Brookhaven	T-02
East Hampton	T-03
Huntington	T-04
Islip	T-05
Riverhead	T-06
Shelter Island	T-07
Smithtown	T-08
Southampton	T-09
Southold	T-10

INCORPORATED VILLAGES

NAMECODE

Amityville	V-01
Asharoken	V-02
Babylon	V-03
Belle Terre	V-04
Bellport	V-05
Brightwaters	V-06
Dering Harbor	V-07
East Hampton	V-08
Greenport	V-09
Head-of-the-Harbor	V-10
Huntington Bay	V-11
Islandia	V-30
Lake Grove	V-12

Lindenhurst	V-13
Lloyd Harbor	V-14
Nissequogue	V-15
North Haven	V-16
Northport	V-17
Ocean Beach	V-18
Old Field	V-19
Patchogue	V-20
Poquott	V-21
Port Jefferson	V-22
Quogue	V-23
Sag Harbor	V-24
Saltaire	V-25
Shoreham	V-26
Southampton	V-27
Village of the Branch	V-28
Westhampton Beach	V-29
Other	V-00

SCHOOL DISTRICTS

Amagansett	S-101
Amityville	S-301
Babylon	S-302
Bay Shore	S-201
Bayport-Blue Point	S-202
Brentwood	S-203
Bridgehampton	S-102
Center Moriches	S-204
Central ISlip	S-205
Cold Spring Harbor	S-303
Commack	S-304
Comsewogue	S-206
Connetquot	S-207
Copiague	S-305

Deer Park	S-306
East Hampton	S-103
East Islip	S-208
East Moriches	S-209
Eastport	S-104
East Quogue	S-105
Elwood	S-307
FIre Island School	S-210
Fishers Island	S-106
Greenport	S-107
Half Hollow Hills	S-308
Hampton Bays	S-108
Harborfields	S-309
Hauppauge	S-211
Huntington	S-310
Islip	S-212
Kings Park	S-311
Laurel	S-109
Lindenhurst	S-312
Little Flower	S-110
Longwood	S-214
Mattituck - Cutchogue	S-111
Middle Country	S-213
Miller Place	S-215
Montauk	S-112
Mt. Sinai	S-216
New Suffolk	S-113
North Babylon	S-313
Northport - E. Northport	S-314
Oysterponds	S-114
Patchogue-Medford	S-217
Port Jefferson	S-218
Quogue	S-115
Remsenberg - Speonk	S-116
Riverhead	S-117
Rocky Point	S-219

Sachem	S-220
Sag Harbor	S-118
Sagaponack	S-119
Sayville	S-221
Shelter Island	S-120
Shoreham-Wading River	S-121
Smithtown	S-315
Southampton	S-122
South Country	S-222
South Haven	S-223
South Huntington	S-316
South Manor	S-224
Southold	S-123
Springs	S-124
Three Village	S-225
Tuckahoe	S-125
Wainscott	S-126
West Babylon	S-317
West Islip	S-226
Westhampton Beach	S-127
West Manor	S-228
William Floyd	S-227
Wyandanch	S-318

LIBRARIES
NAME	CODE
Amityville	L-01
Babylon Public	L-02
Bay Shore - Brightwaters	L-03
Bayport - Blue Point	L-04
Brentwood	L-05
Center Moriches	L-06
Central Islip	L-07
Commack	L-08
Comsewogue	L-09

Connetquot

Copiague

Deer Park

East Islip

Half Hollow Hills

Harborfields

Hauppauge

Huntington

Islip

Lindenhurst

Longwood

Mastic-Moriches-Shirley

Middle Country

Montauk

North Babylon

Northport

Patchogue-Medford

Sachem

Sayville

Shoreham-Wading River

Smithtown

South Huntington

West Babylon

West Islip

Wyandanch

Other

L-10 L-11 L-12 L-13 L-14 L-15 L-34 L-16 L-17 L-18 L-21 L-19 L-20 L-33 L-22 L-23 L-24 L-25 L-26 L-27 L-28 L-29 L-32 L-30 L-31 L-00