APPLICATION FOR NEW YORK STATE EXAMINATIONS OPEN TO THE PUBLIC
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OC-APP #4 20-484 (1/12L) |
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20-484 Food Service Worker 1 |
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SIDE/PAGE 1 |
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OPWDD, DOH, agencies |
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XD-72 |
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Send your completed and signed application to |
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other than OMH |
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the facility Personnel Office where you would like to take the Food |
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Service Worker 1 examination. |
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Please read the announcement carefully |
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See list of locations available on the examination announcement at: |
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before completing this application. |
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http://www.cs.ny.gov/examannouncements/announcements/oc- |
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cr/decentralized/20-484.cfm |
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PRINT |
Your Last Name |
First Name |
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Social Security Number |
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Street Number, Apt. or P.O. Box |
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Home Phone |
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PLEASE |
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Area Code |
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City or Post Office |
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Zip Code |
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Business Phone |
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Area Code |
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Please note: |
1 - An examination for Food Service Worker 1 is also offered for the Office of Mental Health. |
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For information on the locations of these positions, refer to the announcement for |
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Exam No. 20-483 Food Service Worker 1 – Office of Mental Health. |
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2 - The same Food Service Worker 1 written test is used for both exam numbers 20-483 and |
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20-484. You may take the FOOD SERVICE WORKER 1 written test only ONCE every testform period. |
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(See details on the announcement.) |
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REASONABLE ACCOMMODATIONS IN TESTING
I require reasonable accommodations to take this test. (See the announcement for details.)
STUDENT LOANS
Have you any student loans made or guaranteed by the NYS Higher Education Services Corporation which are currently outstanding?
If so, are you currently in default of any such loan?
YES NO
YES NO
YES NO
YES NO
YES NO
Were you ever discharged from any employment except for lack of work or funds, disability or medical condition?
Did you ever resign from any employment rather than face discharge?
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 conditions?
Have you ever been convicted of any crime (felony or misdemeanor)?
Are you now under charges for any crime?
If you answered YES to any of these questions, provide details under REMARKS on Page 2. Your failure to answer any of these questions or to provide details will significantly delay any determination concerning your qualifications and may deprive you of potential employment opportunities.
ELIGIBILITY FOR EMPLOYMENT
You must be eligible to work in the United States at the 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.
MEDICAL EXAMINATION, FINGER PRINTING AND BACKGROUND INVESTIGATION
A medical examination will be required for appointment.
Fingerprinting and criminal background check will be conducted if you are selected for appointment.
NOTE: Have you provided all requested information? An incomplete application may be disapproved.
I affirm under penalties of perjury that all statements made on this application (including any attached papers) are true. I understand that all statements made by me in connection with this application are subject to investigation and verification and that a material misstatement or fraud may disqualify me from appointment and/or lead to revocation of my appointment.
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Signature of Applicant |
Date |
Please print any other last name by which you are or have been known. |
Please continue application on Side/Page 2
YES NO
YES NO
YES NO
DO NOT COMPLETE THIS SECTION UNLESS YOU:
APPLICATION FOR NEW YORK STATE EXAMINATIONS OPEN TO THE PUBLIC
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20-484 Food Service Worker 1 |
OC-APP #4 20-484 (1/12L) |
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OPWDD, DOH, agencies other than OMH |
SIDE/PAGE 2 |
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XD-72 |
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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 wartime 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 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.
1. Wish to claim War Time Veterans Credits, AND
2. Have NOT used veterans credits for appointment to a position in New York State or Local Government employment
YOUR ANSWERS MUST BE “YES’ TO BE ELIGIBLE FOR ADDITIONAL CREDITS.
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.
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:
Aug. 2, 1990 to date when the Persian Gulf hostilities ends;
Feb. 28, 1961 to May 7, 1975;
June 27, 1950 to Jan 31, 1955;
Dec. 7, 1941 to Dec. 31, 1946;
Or earned the armed forces, navy, or marine corps expeditionary medal for service in:
(Panama) Dec. 20, 1989 to Jan. 31, 1990;
(Lebanon) June 1, 1983 to Dec. 1, 1987;
(Grenada) Oct. 23, 1983 to Nov. 21, 1983;
Or in the U.S. Public Health Service:
June 26, 1950 to July 3, 1952; July 29, 1945 to Sept. 2, 1945.
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:
I am receiving payments from the U.S. Dept. of Veterans Affairs for a service connected disability rated at 10% or more 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 State residency at time of appointment.
REMARKS:
ADDITIONAL EXAMINATION CREDITS PURSUANT TO CIVIL SERVICE LAW SECTION 85-a
If you are a child of a police officer or firefighter 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) 473-9726.
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 Office of the Mental Health. For further information, relating only to the Personal Privacy Protection Law, call (518) 457-9375. For exam information, call (518)457-2487 (press 2, then press 3); or toll free at 1-877-697-5627 (press 2, then press 3).
It is the policy of the State of New York to provide for and promote equal opportunity employment, compensation, and other terms and conditions of employment without discrimination on the basis of age, race, color, religion, disability, national origin, gender, sexual orientation, veteran or military service member status, marital status, domestic violence victim status, genetic predisposition or carrier status, or arrest and/or criminal conviction record unless based upon a bona fide occupational qualification or other exception.
It is the policy of the New York State Department of Civil Service to provide qualified persons with disabilities equal opportunity to participate in and receive the benefits, services, programs and activities of the Department, and to provide such persons reasonable accommodations and reasonable modifications as are necessary to provide such equal opportunity, including accommodations in the examination process. Further, it is the policy of the Department to provide reasonable accommodations for religious observers.
