Form P 200 – Fill Out and Use This PDF

ONONDAGA COUNTY APPLICATION FOR OPEN COMPETITIVE EXAMINATION FORM P-200 REV 03/2015
*New York State prohibits discrimination because of race, creed, color, national origin, sex, age, disability, marital status or arrest record. ONONDAGA
MAIL OR DELIVER TO: Onondaga County Department of Personnel, 421 Montgomery Street, 13th Floor, Syracuse NY 13202-2959 Phone (315) 435-3537
	www.ongov.net
		______________________________
Job / Exam Title	TYPE OR PRINT CLEARLY IN INK	Exam #

NAME AND ADDRESS: IMMEDIATE notice should be given to this office if any changes in name or address occur.

Last Name

First Name

Middle

Social Security #

Legal Address:

Mailing Address (If different from legal):

Street

Street or PO Box

Apt/Rd#

City/Village

City/Village

State

ZIP

Town

E-Mail Address

School District

Home Phone (

)

County

Work Phone

(

)

State

ZIP

Cell Phone

(

)

ADDITIONAL INFORMATION

1. If you were ever dismissed or resigned in lieu of dismissal from any public (government) employment due to disciplinary reasons, explain below.

2. If you need special exam arrangements (religious accommodation or disabled), indicate accommodations needed below.

Use This Space For Explanations

VETERAN'S CREDIT: Veteran	Disabled Veteran	Currently On Active Duty

Documentation of your veteran status (i.e.discharge papers) should be attached to your application or mailed to this department prior to the eligible list establishment date. Current active duty military personnel must provide proof of active military status at time of application to receive conditional credit.

Since January 1, 1951, have you used additional credits as a disabled/non-disabled veteran for appointment to any position in the public

	employment of New York State or any of its civil divisions? YES				NO
	COMPLETE FOR LAW ENFORCEMENT, CORRECTION, CUSTODY, FIREFIGHTER
1.		Are you a citizen of the United States?	YES	NO	2. Date of Birth		/ /_____
3.		Law enforcement, Correction and Custody positions: You must complete form P-202 and attach it to your application.
	Payment Enclosed: Check # __________ Cash			Money Order	Visa MC Discover		Waived (proof must be attached)

DECLARATION (this affirmation must be signed and dated) I understand that false statements made herein are punishable as a Class A Misdemeanor, pursuant to section 210.45 of the Penal Law of the State of New York. I declare that, subject to the penalties of perjury, any statements made on this application and any attachments are the truth and to the best of my knowledge correct.

APPLICANT’S SIGNATURE

DATE

PERSONNEL DEPARTMENT USE ONLY: Reviewer

Date

Approved 

Disapproved 

Comments:

Recv’d By

VER2.02.2

ONONDAGA COUNTY DEPARTMENT OF PERSONNEL

EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE

The following information is voluntary and will be maintained confidentially.

SOCIAL SECURITY #: ____________________________________
EXAM TITLE: ___________________________________________					EXAM DATE: ________________________
MALE 	FEMALE 
 White/Non-Hispanic		 Black	 Hispanic	 Asian/Pacific Islander		 American Indian/Alaskan Native

Onondaga County does not discriminate because of race, creed, color, citizenship, national origin, age, sex, religion, marital status, conviction record, disability, genetic predisposition or carrier status, pregnancy, or sexual orientation. Onondaga County's programs are accessible to all as required by 45FR84.22B. If you have a disability for which you wish accommodation in visiting a county office or in receiving county services, please contact the head of the respective department or his/her representative to make arrangements. Onondaga County's Equal Employment Program and compliance with the Vocational Rehabilitation Act (Section 504) is coordinated by the County Personnel Department. NOTE: Federal law requires employers to hire only U.S. citizens or aliens with the authorization to work in the U.S. Federal Law also requires that at the time of appointment, you provide to the employer certain information, including date of birth, country of origin, right to work in the U.S., and to provide for review certain documents establishing your identity and work authorization, such as birth certificate, etc.

VER2.02.2