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FORM NYS-APP (12/13 L)

www.cs.ny.gov

APPLICATION FOR NYS EXAMINATIONS

		Send		Application Processing
		Completed		New York State Department of Civil Service
ee		Application to:		Albany, NY 12239
ee		Read Instructions on Page 3 First - Please Print Clearly
		Read Instructions on Page 3 First - Please Print Clearly
	If applicable, please complete additional information on Page 4.
ur			Mo.	Day Yr.	You must ile a separate
	Announced				application for each
ce	Test Date:				different test date.
ce	Test Date:				different test date.

tion.		Exam No(s).		Titles(s)
tion.

Last Name	First Name			MI



Mailing Address: No., Street, Apt., or P.O. Box
Mailing Address: No., Street, Apt., or P.O. Box

City or Post Ofice		State	Zip Code
City or Post Ofice		State	Zip Code

Email Address

s obser-

Social Security Number

Home Phone

ck the( )

( ) epartment

ea) and

RELIGIOUS ACCOMMODATION

I cannot be tested on the scheduled test date due to a conlict with a religious observance or practice.

REASONABLE ACCOMMODATIONS IN TESTING

I require reasonable accommodations to take this test.

ELIGIBILITY FOR EMPLOYMENT

You must be legally eligible to work in the United States at time of appointment and throughout your employment with New York State. If appointed, you must produce documents that establish your identity and eligibility to work in the United States, as required by the Federal Immigration Reform and

Control Act of 1986, and the Immigration and Nationality Act. r terms and conditions of

er, sexual orientation, veteranFor Civil Service Use Only us, or arrest and/or criminal

nity to participate in and
odations and reasonable
er, it is the policy of the	G	U
W	G	U

NON-REFUNDABLE PROCESSING FEE

Refer to the front of the exam announcement for the required processing fee. Enclose a check or mon required, made payable to the New York State Department of Civil Service. DO NOT SEND CASH. If you disapproved, the fee will not be refunded. Check the box, “I have enclosed the fee.”

If you are a NYS employee in a position represented by CSEA and you are applying for an OPEN-COMPETITIVE examination, you are not required to submit a processing fee under current negotiated agreements. Check the box “I a

is paid by my union for an OPEN-COMPETITIVE examination (CSEA Negotiating Units 02, 03, 04 or 47).” Refunds will not be issued to employees covered by the agreements if they submit a fee.

No fee is due if you are unemployed and primarily responsible for the support of a household. Do no application. Check the box, “I am unemployed and primarily responsible for the support of a househo

No fee is due if you are determined eligible for Medicaid, or receiving Supplemental Social Security (Temporary Assistance for Needy Families/Family Assistance or Safety Net Assistance) or are certiied Workforce Investment Act eligible through a state or local social service agency. Do not enclose an Check the box, “I am receiving public assistance.”

All claims are subject to veriication. Those not supported by appropriate documentation are grounds appointment.

Check One	No Fee Is Due Because:
I have enclosed the fee.	I am a NY State employee and my fee is paid by my
(Enclose a check or money order payable to the	union for an OPEN-COMPETITIVE examination.
NYS Department of Civil Service).	(CSEA Negotiating Units 02, 03, 04 or 47)
DO NOT SEND CASH.	I am unemployed and primarily responsible for the
(The Fee will NOT BE REFUNDED	support of a household.
if your application is DISAPPROVED.)	I am receiving public assistance.
if your application is DISAPPROVED.)

RELIGIOUS ACCOMMODATIONS

Most written tests are held on Saturdays. If you cannot take the test on the announced test date due vance or practice, check the box under “Religious Accommodation.” We will make arrangements for you date (usually the following day).

REASONABLE ACCOMMODATIONS IN TESTING

We provide reasonable accommodations for persons with disabilities to take a test. If you need a rea box, “I require reasonable accommodations to take this test.” On or before the last date for iling of Civil Service or call (518) 457-2487 (press 2, then press 2) (in the Albany area) or 1-877-697-56 describe the accommodation you need. For TDD services, call NY Relay at 711 (requires a fee) or 1-8

I afirm under penalties of perjury that all statements made on this application (including any attac understand that all statements made by me in connection with this application are subject to investi that a material misstatement or fraud may disqualify me from appointment and/or lead to revocation o

Signature of Applicant	Date	Please print any other last name by which
		you are or have been known.

It is the policy of the State of New York to provide for and promote equal opportunity employment, c employment without unlawful discrimination on the basis of age, race, color, religion, disability, n or military service member status, marital status, domestic violence victim status, genetic predispo conviction record unless based upon a bona ide occupational qualiication or other exception.

It is the policy of New York State Department of Civil Service to provide qualiied persons with disa receive the beneits, services, programs and activities of the Department, and to provide such person modiications as are necessary to provide such equal opportunity, including accommodations in the exa Department to provide reasonable accommodations for religious observance.

FORM NYS-APP (12/13 L)

www.cs.ny.gov

Application for NYS Examinations

Page 2

YOUR EDUCATION:

Read the exam announcement for educational requirements, if any. If specialized coursework is required, attach a copy of the transcript or a list of the required courses and the number of credit hours you completed.

Do you have a High School or		Yes	If yes, Name and location of High School
Equivalency Diploma?		No	or Issuing Governmental Authority:
	College, University, Professional or			Semester	Quarter	Type of	Major Subject	Did You	Degree
	College, University, Professional or			Credits	Hours	Degree	or Type of	Did You	Degree
	Technical Schools			Credits	Hours	Degree	or Type of	Graduate	Expected
	Technical Schools			Received	Received	Received	Course	Graduate	Expected
				Received	Received	Received	Course
Name								Yes	MO.	YR.
								No		/
										/
Address (City, State)

Name								Yes	MO.	YR.
								No		/
										/
Address (City, State)

LICENSE OR CERTIFICATION:

Complete the following if a license, certificate or other authorization to practice a trade or profession is required on the announcement(s).

Trade or Profession	License Number	Date License	Registration				If you are not
		First Issued	MO.	YR.	MO.	YR.	currently licensed,
			FROM	/	TO	/	check this box:
Specialty	Granted by (licensing agency)

DESCRIBE YOUR EXPERIENCE:

Beginning with your most recent, list all employment, military service, or volunteer experience that shows you meet the minimum qualifications for the examination(s). We cannot interpret omissions or vagueness in your favor. You are responsible for an accurate and clear description of your experience. Do not send your resume. Under DUTIES describe the nature of the work which you personally performed including the estimated percentage of time spent on each type of activity. If you supervised, state how many people and the nature of such supervision.

LENGTH OF EMPLOYMENT				FIRM NAME	ADDRESS	CITY AND STATE
MO.	YR.	MO.	YR.
FROM	/	TO	/
EARNINGS		(CIRCLE ONE)		DUTIES:
$		/WK./MO./YR.
TYPE OF BUSINESS


YOUR EXACT TITLE


NAME OF YOUR SUPERVISOR


SUPERVISOR’S TITLE


No. of hours worked per week
(exclusive of overtime):

LENGTH OF EMPLOYMENT				FIRM NAME	ADDRESS	CITY AND STATE
MO.	YR.	MO.	YR.
FROM	/	TO	/
EARNINGS		(CIRCLE ONE)		DUTIES:
$		/WK./MO./YR.
TYPE OF BUSINESS


YOUR EXACT TITLE


NAME OF YOUR SUPERVISOR


SUPERVISOR’S TITLE


No. of hours worked per week
(exclusive of overtime):

BE SURE TO READ THE REQUIRED QUALIFICATIONS ON THE EXAMINATION ANNOUNCEMENT(S)

ALL STATEMENTS ARE SUBJECT TO VERIFICATION

FORM NYS-APP (12/13 L)
www.cs.ny.gov
					Application for NYS Examinations	Page 3

LENGTH OF EMPLOYMENT				FIRM NAME	ADDRESS	CITY AND STATE
MO.	YR.	MO.	YR.
FROM	/	TO	/
EARNINGS		(CIRCLE ONE)		DUTIES:
$		/WK./MO./YR.
TYPE OF BUSINESS


YOUR EXACT TITLE


NAME OF YOUR SUPERVISOR


SUPERVISOR’S TITLE


No. of hours worked per week
(exclusive of overtime):

(Attach additional 8 ½” x 11” sheets if necessary.)

INSTRUCTIONS

EXAMINATION APPLICATION

Use this form to apply for all New York State Civil Service examinations (the five-digit examination number). Read each exam announcement carefully to be sure that you meet the Minimum Qualifications.

You must file a separate application for each different test date. You may list up to four exam numbers on one application, as long as they are all being held on the same date.

Unless the exam announcement has different instructions, mail your application (and the required processing fee, if any) to Application Processing, NYS Department of Civil Service, Albany, NY 12239.

ADMISSION TO EXAMINATION

We usually review your application before the test to be sure that you qualify. Generally we will advise you if we need more information. You may be admitted to the test pending a full review of your application. If you take the test but your application is disapproved later, you will not receive a test score. If your application is disapproved, we will notify you of the reason.

If you are applying for a written test and you do not receive an admission notice from us at least three days prior to the test date, immediately call (518) 474-6470 in the Albany area, or toll free at 1-877-697-5627 (press 2, then press 1).

PLACE OF EXAMINATION

Unless the exam announcement states otherwise, written tests are	Albany	Kingston	Rochester
held in the following locations, although some may not be open for	Amsterdam	Middletown	Saranac Lake
every examination. You will be assigned to the nearest OPEN	Binghamton	New York City (Manhattan) Syracuse
location based on the postal ZIP code for your mailing address.	Buffalo	Nyack	Utica
	Fredonia	Port Jefferson	Watertown
Oral tests are usually held in Albany only.	Hicksville	Poughkeepsie

EXTRA CREDITS FOR WAR TIME VETERANS

Answering these questions means that you are requesting the extra credits. Do not answer the questions if you are not a war time active duty member of the Armed Forces or a War Time Veteran or if you do not want to request the extra credits. If you are currently in the Armed Forces on full-time active duty (other than for training) or if you are a War Time Veteran or Disabled Veteran, you are eligible for extra credits added to your exam score if you pass. These extra credits can be used only once for any permanent government employment in New York State. If you want to have these extra credits added to your exam score, you must answer the questions on Page 4 now. You can waive the extra credits later if you wish. At the time of interview and appointment you will be required to produce the documentation, such as discharge papers, to prove that you are eligible for the extra credits.

ADDITIONAL EXAMINATION CREDITS PURSUANT TO CIVIL SERVICE LAW SECTION 85-a

If you are a child or sibling of a firefighter, police officer, emergency medical technician, or paramedic who was killed in the line of duty in the service of New York State, you may be entitled for additional examination credits pursuant to Civil Service Law Section 85-a. For further information, please contact the Department of Civil Service at (518) 473-8102.

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION

The information which you are providing on this application is being requested pursuant to Section 50.3 of the New York State Civil Service Law for the principal purpose of determining the eligibility of applicants to participate in the examination(s) for 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 Director, Division of Staffing Services, Department of Civil Service, Albany, New York 12239. For further information, relating only to the Personal Privacy Protection Law, call (518) 457-9375. (For examination information, call (518) 457-2487 (press 2, then press 3); or toll free at 1-877-697-5627 (press 2, then press 3).

4. Yes

5. Yes

1. Yes

2. Yes

3. Yes

FORM NYS-APP (12/13 L)

www.cs.ny.gov

Application for NYS Examinations

Page 4

DO NOT COMPLETE THIS SECTION UNLESS YOU:			Wish to claim War Time Veterans Credits, AND
			Have NOT used veterans credits for appointment to a position in NY State or Local Government.

			EXTRA CREDITS FOR WAR TIME VETERANS
Your answers MUST be ‘YES’ to be eligible for additional credits.
Yes	No	I expect to receive or have already received, a discharge which was honorable or release under honorable circumstances from the Armed Forces of the United States. The “Armed
		Forces of the United States” means the Army, Navy, Marine Corps, Air Force and Coast Guard, including all components 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 purposes.
Yes	No	I am now serving, or have served, on an active duty basis other than active duty for training purposes during one or more of the following Time of War periods.
		In the Armed Forces:	or earned the Armed Forces, Navy, or Marine Corps	or in the U.S. Public Health Service:
		• Aug. 2, 1990 to the date when the	expeditionary medal for service in:	• June 26, 1950 to July 3, 1952;
		Persian Gulf hostilities ends:	• (Panama) Dec. 20, 1989 to Jan. 31, 1990;	• July 29, 1945 to Sept. 2, 1945.
		• Feb. 28, 1961 to May 7, 1975;	• (Lebanon) June 1, 1983 to Dec. 1, 1987;
		• June 27, 1950 to Jan. 31, 1955;	• (Grenada) Oct. 23, 1983 to Nov. 21, 1983;
		• Dec. 7, 1941 to Dec. 31, 1946;
Yes	No	I am a United States citizen or an alien lawfully admitted for permanent residence.
To claim additional credits as a Disabled Veteran, you must also answer YES to this question:
Yes	No	I have a service connected disability rated at 10% or more by the US Department of Veterans Affairs. This disability was incurred during a “Time of War” period listed above.

New York State Residency Requirement for Extra Credits as a War Time Veteran or Disabled Veteran: You will be required to provide proof of current New York residency at time of appointment.

ADDITIONAL QUESTIONS FOR OPEN-COMPETITIVE APPLICANTS ONLY

Certain job titles, including many law enforcement positions (such as Correction Officer, Parole Officer and Park Patrol Officer) and direct patient care positions (such as Mental Health Therapy Aide and Secure Care Treatment Aide), are subject to additional agency criminal history background investigations, as required by law. Applicants should read the official examination announcement for more specific information.

For other titles, please be advised that, while you are required to provide the requested information at this time and the Department of Civil Service may begin the review process, the specific information supplied in this section will not be shared with the interviewing agency(ies) until at least after the first interview. Answering YES to Question 5 may or may not preclude employment, depending on the nature of the criminal offense, its relationship to the position sought, and other factors that must be considered before employment may be lawfully denied based on prior convictions.

If you answer YES to any of these questions, please provide an explanation in the REMARKS section provided below:

Were you ever discharged from any employment except for lack of work, funds, disability or medical condition? Did you ever resign from any employment rather than face a dismissal?

Did you ever receive a discharge from the Armed Forces of the United States which was not an “Honorable Discharge” or a “General Discharge under Honorable Conditions?”

Do you have an arrest or criminal accusation currently pending against you? Have you ever been convicted of a criminal offense (felony or misdemeanor)?

You should answer NO to Question 5 if:

a.Your conviction (felony or misdemeanor) was sealed by a court, or

b.The criminal action or proceeding was terminated in your favor, e.g. was dismissed, you received an Adjournment in Contemplation of Dismissal and the adjournment period has elapsed, you were acquitted, or

c.The proceeding on the criminal offense resulted in a juvenile delinquency adjudication or youthful offender adjudication, or

d.After completing a treatment program, your plea to a felony or a misdemeanor was withdrawn and you were resentenced to a violation which was sealed by the court or the completion of the program resulted in a dismissal of all charges by the court, or

e.The criminal action or proceeding terminated in a conviction for a non-criminal offense (e.g., a violation such as disorderly conduct).

Failure to disclose a prior conviction that does not meet the criteria above, or to truthfully answer these questions, may result in denial of employment based on falsification of the employment application.

REMARKS:

(Attach additional 8 ½” x 11” sheets if necessary.)

Question	Answer
Form Name	Form Nys App
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	nys app forms, nys exam application, heap application new york pdf, nys app

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