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HRM-300	New York State Department of Taxation and Finance	Please print
(6/10)	Applicant History	Use pen
(6/10)		Use pen

(to be prepared by candidate)

New York State Law prohibits discrimination because of age, race, creed, color, national origin, gender, sexual orientation, disability, marital status, genetic predisposition, carrier status, or arrest records unless based upon a bona fide occupational qualification or other exception. If you are a person with a disability and wish to request that a reasonable accommodation be provided for you to participate in a job interview, please call the department's Office of Diversity and Affirmative Action at (518) 457-1907.

Personal history (see Privacy notification below)

Last name			First name		Initial	Social security number

Street address						Telephone number(s)
Street address
						Work: (	)
City	State	ZIP Code		E-mail
						Home: (	)

Please answer the following questions by placing a checkmark ( ), in the appropriate box. If you answer Yes to question 3, 4, 5(a), or 5(b) you must give details in the space provided on the back page. You are cautioned that knowingly providing a false answer or omitting information may prevent your appointment or cause its cancellation.

Yes

6 (b) Are you certified by the Veterans' Administration

Yes

1 (a) Are you a citizen of the United States?

as a disabled veteran?

(b) If not, do you have the legal right to accept

Yes

employment in the United States?

7 Do you have a valid motor vehicle operator's license?

Yes

If Yes: enter issuing State:

and License #:

for an employment visa (e.g. H-1B visa status)?

Yes

2 If under age 18, do you have working papers?

Yes

8 Are you an exempt volunteer firefighter?

Yes

3 Were you ever dismissed, except for lack of work, or

Yes

9 (a) Have you ever worked for New York State?

have you ever resigned from any position in lieu of

dismissal?

If Yes, complete below and see InterviewerIcandidate, please

If Yes, give details in the space provided on the back page.

note below.

Yes

Dates;

Status*

4 Are there any criminal charges pending against you?

Department

(from - to)

Titles

If Yes, give details in the space provided on the back page.

5 (a) Except for adjudications as a youthful offender,

wayward minor, juvenile delinquent or sealed

convictions under Criminal Procedure Law

sections 160.55 and 160.58, have you ever been

found guilty of any misdemeanor, felony, offense,

or traffic infraction (except parking violations) or

Yes

* (P) Permanent (CP) Contingent permanent

(T) Temporary

(PR) Provislonal

forfeited bail in any court either in this state or

elsewhere?

(b) Is information about a name change, use of an

(b) For Peace Officer candidates only - Have you ever

Yes

assumed name or nickname necessary to

been found guilty of any misdemeanor, felony,

conduct a check on your work record?

offense, or traffic infraction (except parking

Yes

violations), or forfeited bail in any court whether in

If Yes, explain

this state or elsewhere?

If Yes to 5(a) or (b), give details in the space provided on

the back page. Include date, nature of misdemeanor, felony,

Yes

offense, or traffic infraction, and court location.

A conviction is not an automatic bar to employment.

If Yes, give Retirement System Number:

Each case is considered on individual merits.

6 (a) Did you serve in active duty with the armed forces of

Interviewer/candidate, please note: Candidates with prior permanent

the United States, other than active duty for training

Yes

or contingent permanent state service may be eligible for reinstatement

purposes, during one or more of the following

depending on title. This should be discussed at the time of interview

Time of War periods:

because a candidate who accepts a list appointment cannot be

In the armed forces:

reinstated to his or her previous title.

• Aug. 2, 1990, to the date when the Persian Gulf hostilities ends;

Privacy notification -The right of the Commissioner of Taxation and Finance and the Department of

• Dec. 22, 1961, to May 7, 1975;

Taxation and Finance to collect and maintain personal information, including mandatory disclosure of

• June 27, 1950, to Jan. 31, 1955;

social security numbers in the manner required by tax regulations, instructions, and forms, is found in

• Dec. 7, 1941, to Dec. 31, 1946; or

Article 3 of the New York State Retirement and Social Security Law; Articles 8 and 22 of the New York

State Tax Law; 26 USC 6109(d) and 26 CFR 301.6109-1(b); and 42 USC 405(c)(2)(C)(i).

earned the armed forces, navy, or marine corps expeditionary medal for service in:

The Tax Department uses this information to help determine eligibility for initial and continued

• Panama (Dec. 20, 1989, to Jan. 31, 1990);

employment, for administrative record keeping and identification, to administer employee benefit

programs, to properly account for applicable federal and state taxes, and for any other purpose

• Lebanon (June 1, 1983 to Dec. 1, 1987);

authorized by law.

• Grenada (Oct. 23, 1983, to Nov. 21, 1983); or

Failure to provide the required information may hinder or prevent your employment or retention as an

in the U.S. Public Health Service:

employee and may as far as withholding of federal and state taxes is concerned, subject you to civil or

criminal penalties or both.

• June 26, 1950, to July 3, 1952;

This information is maintained by the Director of the Office of Human Resource Management, NYS Tax

• July 29, 1945, to Sept. 2, 1945.

Department, W A Harriman Campus, Albany NY 12227; telephone (518) 457-2786.

HRM-300 (6/10) (back)

Education and training history

(Attach additional sheets if necessary to give your complete background.)

Yes No

Circle the highest grade completed: 1 2 3 4 5

6 7 8

9 10

11 12

Did you graduate?

If you have a New York State High School Equivalency Diploma (GED), please provide: Number

Additional

Name of school and location

Attended (month/year)

Number

Did you

Major

College

Degree

education

From

of years

graduate?

subject

credits

received

credited

College, university

or technical school

Other schools or

special courses

Employment history

Note: Begin with your most recent employment and be sure to include any employment with New York State. List all previous employment. To report additional employment records, complete and attach Form HRM-300-ATT. A resume is not a substitute for completing this section.

Dates (month/year)

Employer's name

Job title and duties

Last salary

					$
From:	Street address						Weekly
From:	Street address

							Every 2 weeks
							Every 2 weeks
To:	City	State	ZIP code				Twice a month
To:	City	State	ZIP code

							Monthly
							Monthly
Number of hours	Reason for leaving			Supervisor's name and telephone number			Annually
worked per week							Annually
worked per week							Hourly
							Hourly

Dates (month/year)	Employer's name			Job title and duties		Last salary
					$
From:	Street address						Weekly
From:	Street address

							Every 2 weeks
							Every 2 weeks
To:	City	State	ZIP code				Twice a month
To:	City	State	ZIP code

							Monthly
							Monthly
Number of hours	Reason for leaving			Supervisor's name and telephone number			Annually
worked per week							Annually
worked per week							Hourly
							Hourly

Dates (month/year)	Employer's name			Job title and duties		Last salary
					$
From:	Street address						Weekly
From:	Street address

							Every 2 weeks
							Every 2 weeks
To:	City	State	ZIP code				Twice a month
To:	City	State	ZIP code

							Monthly
							Monthly
Number of hours	Reason for leaving			Supervisor's name and telephone number			Annually
Number of hours	Reason for leaving			Supervisor's name and telephone number
worked per week
worked per week							Hourly
							Hourly

If you answered Yes to questions 3, 4, 5(a) or 5(b), provide additional information in this space. Attach additional sheets if necessary,

I understand that knowingly making a false written statement on this application or any attachment is punishable as a class A misdemeanor pursuant to section 210.45 of the New York State Penal Law. If appointed, the penalty may be dismissal from the New York State Department of Taxation and Finance.

I agree to and accept this condition of employment, and I hereby certify that all statements made by me on this application or any attachments are, to the best of my knowledge, true and complete. Appointment to many positions in State government require candidates to undergo an investigative screening. This may include a thorough character investigation, a Federal Bureau of Investigation Criminal Record History Check, or other similar procedures. Candidates entering state government may be fingerprinted and may be required to pay any necessary fees for that procedure. The investigative findings may bar appointment or result in removal after appointment depending on the criminal convictions discovered, the falsified or omitted information revealed and the nature of the job.

Date		Signature

Question	Answer
Form Name	Hrm 300 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	1983, 1990, false, New_York

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