Dmna Form 1041 PDF Details

The DMNA 1041 form serves as a vital document for individuals seeking employment with the New York State Division of Military and Naval Affairs (DMNA), outlining a comprehensive procedure for applicants to submit their personal information, employment history, and qualifications. This form is specifically designed to ensure all applicants are evaluated fairly, emphasizing the Division's commitment to equal employment opportunities without discrimination based on race, color, creed, religion, national origin, sex, marital status, sexual orientation, or disability. Key sections within the form include detailed queries about the applicant's military status, participation in emergency volunteer organizations, legal eligibility for employment in the United States, ability to perform job duties safely, and various other personal and professional details that might influence their employment eligibility. Moreover, the form requires applicants to disclose any possible conflicts of interest and criminal history, which the DMNA will consider in its hiring process. Completeness, honesty, and accuracy in providing the requested information are crucial, as failure to disclose relevant details may lead to negative implications for the applicant's chances of employment or future dismissal if inaccuracies are discovered post-hire. Furthermore, the DMNA 1041 form includes a section for educational background, necessary for positions requiring specific qualifications, and stipulates that all information provided by applicants will be verified to maintain integrity and transparency throughout the hiring process.

QuestionAnswer
Form NameDmna Form 1041
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdmna1041 dmna form 1041

Form Preview Example

State of New York

Division of Military and Naval Affairs

Employment Application

POSITION APPLIED FOR

Title

Date Available

APPLICANT INFORMATION (please complete all questions. Type or print in ink.)

Last Name

 

First Name

 

Initial

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

Home Phone

List any other names used if different from above

Business Phone

Cell Phone

The New York State Division of Military and Naval Affairs (DMNA) provides equal opportunities in employment and prohibits discrimination on the basis of race, color, creed, religion, national origin, sex marital status, sexual orientation, or disability.

1. United States Military Status:

 

 

 

 

 

A. Veteran Status:

Veteran

Non-Veteran

Disabled Veteran

Dates of Service:

From

 

 

To

 

 

 

 

 

 

 

 

B. Reserve/Guard Status:

Active

Inactive

 

None

 

Branch

 

 

 

Type of Discharge

 

2.Do you participate in any Emergency Volunteer Organizations?

3.Do you have legal right to accept employment in the United States?

(Employment is contingent upon your providing proof of the right to accept employment in the United States.)

4.Are you able to perform duties of the position for which you have applied without danger to yourself or others?

5.Are you presently a member of the NYS Retirement System?

6.Do you have a valid driver’s license which allows you to drive in New York State?

7.Have you ever had your driver’s license revoked or suspended?

8.Are you presently receiving a retirement allowance?

9.Have you ever been dismissed from a job for any reason except lack of work funds?

10.Have you ever been convicted of a crime?

11.Are you aware of any current criminal investigation into your conduct or criminal charges pending against you?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

Explain any “Yes” answers to questions 7-11 in the REMARKS SECTION on the back page. Failure to disclose such information may reflect negatively on your selection for employment, and may be considered justification for dismissal if discovered at a later date. Give complete details including date, location and disposition of any criminal offenses. None of these circumstances represent an automatic bar to selection.

DMNA Form 1041, May 12. All previous editions are obsolete and may not be used.

12.Please indentify any individual you know that is currently employed by the DMNA or any of its force providers (New York Army or Air National Guard, New York Guard or New York Naval Militia.) Please use additional sheets if necessary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

Location

 

 

 

 

 

 

Acquaintance

 

Relative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

Location

 

 

 

 

 

 

Acquaintance

 

Relative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

Location

 

 

 

 

 

 

Acquaintance

 

Relative

 

13. If offered a position with the DMNA , will you also intern, volunteer or maintain employment elsewhere?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No If “Yes,” please indentify other concurrent position, including self-employment)

 

 

 

 

 

 

 

 

 

 

Name of Organization

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

City

State

 

 

 

Zip Code

Dates: From

 

 

 

To

Title or Position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYMENT INFORMATION

(List all periods of employment, beginning with the most recent. Resumes will not be accepted in lieu of application.)

A. Name of present or last Employer

Address

Supervisor’s Name and Title

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates: From

 

 

To

Annual Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

May we contact?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Title and Duties

 

 

 

 

 

 

 

 

 

Reason for leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Name of present or last Employer

Address

Supervisor’s Name and Title

 

 

 

 

Telephone Number

 

Dates: From

 

 

To

Annual Salary

 

 

 

 

 

 

 

 

 

 

May we contact?

Yes

No

 

 

 

Your Title and Duties

Reason for leaving

2

DMNA Form 1041, May 12. All previous editions are obsolete and may not be used.

C. Name of present or last Employer

Address

 

Supervisor’s Name and Title

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

Dates: From

 

 

 

 

To

 

 

 

 

 

 

 

 

Annual Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Title and Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please attach additional sheets if necessary.)

 

 

 

 

 

 

 

 

 

 

 

 

 

14. If not stated above, have you previously been employed by New York State, Municipal, County or Local Government?

Yes

 

 

No

 

 

 

If “Yes,” please complete the following information.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates employed:

From

 

 

To

 

 

 

 

 

 

 

Annual Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency/Department

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bureau

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EDUCATION (Note: Applicants may be required to provide proof of diploma, degree, transcript, licenses, certifications, and registrations.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of School

 

Name and Location of School(s) Attended

 

Graduated

Type of Diploma or Degree

Certification Type

Certification

 

 

 

 

 

(if applicable)

 

 

Current

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High School

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Undergraduate

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colleges or University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Law School

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Technical, Vocational

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Professional

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

DMNA Form 1041, May 12. All previous editions are obsolete and may not be used.

REFERENCE RELEASE STATEMENT

I hereby give my consent to references (employment and personal) to release pertinent information about my qualifications and fitness for the position for which I have applied with the DMNA.

Signature of Applicant

Date

AFFIRMATION

I affirm that the answers given to the above questions and all statements made by me on this application (including any attachments) are true and correct to the best of my knowledge under penalty of making a false official statement. I understand that false statements may prevent my employment or, if hired, may cause dismissal. I understand the information provided is for consideration of employment at the DMNA and the record will be maintained on file in accordance with any applicable statutes by the State Human Resources Office. I am aware that all information contained herein is subject to verification by the DMNA and that upon my separation from the DMNA , all properties issued to me (i.e., photo ID, keys, credit cards, etc.) must be returned.

Signature of Applicant

Date

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION

The information you are providing on this application is being requested pursuant to Section 19 of the New York State Military Law for the principal purpose of determining eligibility of applicants to participate in an interview for a position in which they have applied. This information will be used in accordance with Section 96(1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide this information may result in disapproval of the application. This information will be maintained by the State Human Resources Management Office, Latham, New York 12110. For further information relating only to the Personal Privacy Protection Law, call (518)457-9375.

REMARKS SECTION

4

DMNA Form 1041, May 12. All previous editions are obsolete and may not be used.

How to Edit Dmna Form 1041 Online for Free

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This document requires specific information; in order to ensure accuracy and reliability, take the time to consider the next suggestions:

1. The Dmna Form 1041 involves specific details to be entered. Make certain the following blanks are filled out:

Filling in segment 1 of Dmna Form 1041

2. Once your current task is complete, take the next step – fill out all of these fields - B ReserveGuard Status, Active, Inactive, None, Branch, Type of Discharge, Do you participate in any, Do you have legal right to accept, Are you able to perform duties of, Are you presently a member of the, Do you have a valid drivers, Have you ever had your drivers, Are you presently receiving a, Have you ever been dismissed from, and Have you ever been convicted of a with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Do you have legal right to accept, Branch, and Are you able to perform duties of inside Dmna Form 1041

3. This next step is focused on Please indentify any individual, Name Location, Acquaintance, Relative, Name Location, Acquaintance, Relative, Name Location, Acquaintance, Relative, If offered a position with the, Yes, If Yes please indentify other, Name of Organization, and Address Street City State Zip Code - fill in each one of these blanks.

Address Street City State Zip Code, Yes, and Name of Organization of Dmna Form 1041

4. To go forward, your next section will require completing a few blank fields. Examples include Address, Supervisors Name and Title, Dates, From, May we contact, Yes, Your Title and Duties, Reason for leaving, B Name of present or last Employer, Address, Supervisors Name and Title, Dates, From, May we contact, and Yes, which you'll find key to carrying on with this particular process.

Dmna Form 1041 writing process described (step 4)

Always be extremely mindful when filling out Supervisors Name and Title and May we contact, as this is where a lot of people make errors.

5. This last stage to conclude this document is crucial. Make sure to fill out the displayed fields, including Your Title and Duties, Reason for leaving, and DMNA Form May All previous, before submitting. If not, it could produce an incomplete and potentially unacceptable form!

Reason for leaving, Your Title and Duties, and DMNA Form May All previous in Dmna Form 1041

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