Westchester County Application Form – Fill Out and Use This PDF

APPLICATIONFOREXAMINATION/EMPLOYMENT

WESTCHESTER COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER. It is the policy of Westchester County to provide for and promote the equal opportunity of employment, compensationandothertermsandconditionsofemploymentwithoutdiscriminationbecauseofage,race,creed,color,nationalorigin,sex,disability,maritalstatus,sexualorientation, oranyotherprotectedstatus.

ALLSTATEMENTSARESUBJECTTOVERIFICATION. MISREPRESENTATIONSMAYCONSTITUTECAUSEFORDISQUALIFICATIONORDISCHARGE. IT IS A CRIME PURSUANT TO SECTION 210.45 OF THE NEW YORK STATE PENAL LAW, PUNISHABLE AS A CLASS “A” MISDEMEANOR, TO KNOW- INGLYMAKE AFALSESTATEMENTHEREIN.

FOR COUNTY EMPLOYMENT: IN ACCORDANCE WITH WESTCHESTER COUNTY’S COMPREHENSIVE DRUG-FREE WORKPLACE POLICY AND PROCEDURES, AND COMMITMENTTOMAINTAINASAFE,ALCOHOLANDDRUG-FREEWORKENVIRONMENT,YOUMAYBEREQUIREDTOSUBMITTOURINANALYSIS,BREATH,AND/OR BLOODTEST. INADDITION,IFOFFEREDEMPLOYMENT,YOUWILLBESUBJECTTOTHEWESTCHESTERCOUNTYFINGERPRINTINGPOLICYUNDERWHICHYOUR APPOINTMENTMAYBECONDITIONEDONTHERESULTSOFAFINGERPRINTINGINVESTIGATION.

THISAFFIRMATIONANDAUTHORIZATIONFORRELEASEOFPERSONALINFORMATIONMUSTBECOMPLETED: Bymysignaturebelow,I herebyauthor- ize the Westchester County Department of Human Resources, the County of Westchester, and/or its respective Departments, Offices or Agencies to request verbal records or writ- tenverificationofanyorallinformationcontainedherein. Ifurtherauthorizeareviewandfulldisclosureofallrecordsconcerningmewhethersaidrecordsareofapublic,private or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of records. I further release the Westchester County Department of HumanResources, theCountyofWestchester,and/oritsrespectiveDepartments,OfficesorAgencies,andtheirrespectiveofficersand/oremployeesfromanyandallliabilitywhich maybeincurredasaresultofcollectingsuchinformation. Further,mysignaturebelowcertifiesIhavereadandfullyunderstandthe“AffirmationandAuthorizationforReleaseof PersonalInformation”andhaveacknowledgedthataphotocopyofthefrontpageoftheApplicationforExamination/Employmentcontainingthisreleasewillbevalidasanorigi- nalthereof,eventhoughsaidphotocopydoesnotcontainanoriginalwritingofmysignature. Iaffirmthatallstatementsmadeonthisapplication(includinganyattachedpaper) are true under the penalties of perjury. (Applicants are advised that all statements made by them in connection with their application(s) for examination/employ- mentaresubjecttoinvestigationandverification,includingabackgroundinvestigationbytheprospectiveappointingauthority.)

SignatureofApplicant

Date

Isadditionalinformationrelativetochangeofname,useofanassumednameornicknamenecessarytoenableacheckonyourschooland/orworkrecord?

NO YES

Ifyes,pleaseindicatehere:

DONOTWRITEBELOW-FORHUMANRESOURCESUSE

EnteredBy:

JCC:

Dispo:

Fee:

Vet:

Disapproved: Section7:

Page1

BACKGROUND,EDUCATIONANDTRAINING

VETERANS:IfyouservedorifyouareanactivememberoftheArmedForcesoftheUnitedStates,readandfilloutSectionHonpage4

(FORMDD214orproofofcurrentserviceMUSTBEATTACHED)

CHILDREN OF FIREFIGHTERS AND POLICE OFFICERS KILLED IN THE LINE OF DUTY: In conformance withsection 85a of the New York State Civil Service Law, children of firefighters and police officers killed in the line of duty shall be entitled to receive an additional ten points in a competitive examination for original appointment in the same muni- cipalityinwhichhisorherparenthasserved.Ifyouarequalifiedtoparticipateinthisexaminationandareachildofafirefighterorpoliceofficerkilledinthelineofdutyinthismuni- cipality,pleaseinformthisdepartmentofthismatterwhenyousubmityourapplicationforexamination.Acandidateclaimingsuchcredithasaminimumoftwomonthsfromtheappli- cationdeadlinetoprovidethenecessarydocumentationtoverifyadditionalcrediteligibility.However,nocreditmaybeadded aftertheeligiblelisthasbeenestablished.

	Iclaimadditionalcreditasachildofafirefighterorpoliceofficerkilledinthelineofduty.						Yes No
	Areyou18yearsofageorolder?		Yes No
	AreyouacitizenoftheUnitedStates?		Yes	No		Ifselectedforemployment,youwillberequiredtosubmitdocumentaryproofof
						citizenshiporstatusasaforeigncitizenauthorizedtoworkintheUnitedStates.
	DoyouhaveaHighSchoolDiploma?		Yes	No	NameandlocationofHighSchool
	OraHighSchoolEquivalency(GED)Diploma?		Yes No		IssuingGovernmentalAuthority			DocumentNumber
	TRANSCRIPTS:	previouslyfiled			onrequestfromschool

Anofficialtranscriptisrequiredasverificationwithin60daysafterthedateoftheexaminationforperiodicexaminations;andpriortoparticipationincontinuousrecruitment examinations.If theexaminationannouncementasksforspecificcoursework,listthecourseswhichyouhavepassedonanattachedsheet.If youclaimcreditforapartiallycom- pletedcollegecurriculum,attachalistofcoursesandcreditsorsemesterhourscompleted.Indicatehowmanycredithoursor coursesarerequiredforgraduation.

COLLEGE/UNIVERSITY

	NameofSchooland	DatesofAttendance		TypeofCourse	Numberof	Were	Typeof	DateDegree
	Cityinwhichlocated	(Month/Year)		orMajor	CollegeCredits	You	Degree	Receivedor
		From To			Received	Graduated?	Received	Expected

PROFESSIONALSCHOOLS,RESIDENCIES,MILITARYSERVICESCHOOLS,OTHERSCHOOLS

LICENSE:Ifalicense,certificateorotherauthorizationtopracticeatradeorprofessionislistedasarequirementontheannouncementoftheexamination,

orposting,forwhichyouareapplying,completethefollowingandattachacopy:

NameofTradeorProfession

Specialty

LicenseNumber

Grantedby(LicensingAgency) CityorState

DateLicenseFirstIssued

Registered From (Mo/Yr) To (Mo/Yr)

Note: Ifapositionrequiresaspecifiedlicensetooperateamotorvehicle,theapplicantmustprovidetheappointingauthoritywith proofofacurrent,validlicense(subjecttoverifi-

cation)priortoappointment.

LEGALRESIDENCECODES

COUNTIES

TLB

TownofLewisboro

VPL

VillageofPelham

SKL

Katonah-LewisboroSchoolDistrict

CODE

MUNICIPALITY

TMM

TownofMamaroneck

VPM

VillageofPelhamManor

SLL

LakelandSchoolDistrict

BRNX

BronxCounty

TMP

TownofMountPleasant

VPV

VillageofPleasantville

SMM MamaroneckSchoolDistrict

COLB

ColumbiaCounty

TNW

TownofNewCastle

VPC

VillageofPortChester

SMP

Mt.PleasantSchoolDistrict

DUTH

DutchessCounty

TNC

TownofNorthCastle

VRB

VillageofRyeBrook

SNS

NorthSalemSchoolDistrict

KING

KingsCounty(Brooklyn)

TNS

TownofNorthSalem

VSD

VillageofScarsdale

SNT

PocanticoHillsSchoolDistrict

NASS

NassauCounty

TOS

TownofOssining

VNT

VillageofSleepyHollow

SOS

OssiningSchoolDistrict

NYNY

NewYorkCounty(Manhattan)

TPL

TownofPelham

VTK

VillageofTuckahoe

SPC

PortChesterSchoolDistrict

ORAN

OrangeCounty

TPR

TownofPoundRidge

VTT

VillageofTarrytown

SPK

PeekskillCitySchoolDistrict

PUTN

PutnamCounty

TRY

TownofRye

VTH

Other

SPL

PelhamSchoolDistrict

QUEN

QueensCounty

TSM

TownofSomers

SPV

PleasantvilleSchoolDistrict

RICH

RichmondCounty(StatenIsland)

TYT

TownofYorktown

SCHOOLDISTRICTS

SRN

RyeNeckSchoolDistrict

ROCK

RocklandCounty

TTH

Other

SRY

RyeCitySchoolDistrict

CODE

DISTRICT

SUFF

SuffolkCounty

SSD

ScarsdaleSchoolDistrict

SAR

ArdsleySchoolDistrict

SULL

SullivanCounty

SSM

SomersSchoolDistrict

VILLAGES

SMK

BedfordCentralSchoolDistrict

ULST

UlsterCounty

STK

TuckahoeSchoolDistrict

CODE

MUNICIPALITY

SBB

BlindBrookSchoolDistrict

WEST

WestchesterCounty

STT

TarrytownSchoolDistrict

VAR

Village of Ardsley

SBH

ByramHillsSchoolDistrict

WTH

Other

SVL

ValhallaSchoolDistrict

VBC

Village of Buchanan

SBM

BriarcliffManorSchoolDistrict

SYH

YorktownHeightsSchoolDistrict

CITIES

VBM

Village of Briarcliff Manor

SBV

BronxvilleSchoolDistrict

STH

Other

VBV

Village of Bronxville

CODE

MUNICIPALITY

SCH

ChappaquaSchoolDistrict

VCR

Village of Croton-on-Hudson

SCR

CrotonSchoolDistrict

CPK

Peekskill

FIREDISTRICTS

VDF

Village of Dobbs Ferry

SCT

HendrickHudsonSchoolDistrict

CRY

RyeCity

VEF

Village of Elmsford

SDF

DobbsFerrySchoolDistrict

CODEDISTRICT

CTH

Other

FEC

EastchesterFireDistrict

VHH

Village of Hastings-on-Hudson

SEC

EastchesterSchoolDistrict

FFV

FairviewFireDistrict

TOWNS

VHR

Village of Harrison

SEF

ElmsfordSchoolDistrict

FGV

GreenvilleFireDistrict

CODE

MUNICIPALITY

VIR

VillageofIrvington

SEM

EdgemontSchoolDistrict

FHD

HartsdaleFireDistrict

TBF

TownofBedford

VLM

VillageofLarchmont

SHD

GreenburghCentral#7 SchoolDistrict

FLM

LakeMoheganFireDistrict

VMK

VillageofMountKisco

TCT

TownofCortlandt

SHH

HastingsSchoolDistrict

FTH

Other

TEC

TownofEastchester

VMM

Villageof Mamaroneck

SHR

HarrisonCentralSchoolDistrict

TGB

TownofGreenburgh

VOS

VillageofOssining

SIR

IrvingtonSchoolDistrict

Page2

DESCRIPTIONOFEXPERIENCE

ALLSECTIONSMUSTBEFILLEDOUTCOMPLETELY. DONOTLEAVEBLANK. ARESUMEISNOTASUBSTITUTE.

Carefullyread the minimum qualificationsfor the position/examinationfor whichyou are applying. Fee(s) will not be refunded if you do not meet the established qualifications.

Listbelowallrelevantworkexperience.Aresumeisnotasubstitute. Bemorespecificindescribingyourexperiencesrelatingtotheminimumqualificationsofthepositionorexam- ination for which you are applying. Begin with your most recent employment. You are responsible for submitting an accurate, adequate and clear description of your experience. Omissions orvaguenesswillnotbeinterpretedinyourfavor. Includemilitaryserviceexperiencewhenappropriate.Verifiedanddocumentedvolunteer(unpaid)experiencewillonly becreditedwhenspecificallyallowedbythejobdescriptionorexaminationannouncement. Ifyourtitleordutieschangedmateriallyinthecourseofyourserviceinanyoneorgani- zation,indicatesuchchangeclearlyandasaseparateemployment. (Ifmorespaceisneeded,attach8½”X11”sheetsofpaper usingthesameformat.)

LengthofEmployment

NameofEmployer

Address

CityandState

Mo.

Yr.

Mo.

Yr.

From

/

To

/

Earnings

#of hours/week

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

TypeofBusiness

Describedutiesbelow:

YourExactTitle

NameofyourSupervisor

Supervisor’sTitle

ReasonforLeaving

LengthofEmployment

NameofEmployer

Address

CityandState

Mo.

Yr.

Mo.

Yr.

From

/

To

/

Earnings

#of hours/week

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

TypeofBusiness

Describedutiesbelow:

YourExactTitle

NameofyourSupervisor

Supervisor’sTitle

ReasonforLeaving

LengthofEmployment

NameofEmployer

Address

CityandState

Mo.

Yr.

Mo.

Yr.

From

/

To

/

Earnings

#of hours/week

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

TypeofBusiness

Describedutiesbelow:

YourExactTitle

NameofyourSupervisor

Supervisor’sTitle

ReasonforLeaving

LengthofEmployment

NameofEmployer

Address

CityandState

FromMo.

/ Yr.

ToMo.

/ Yr.

Earnings

#of hours/week

WasthisexperiencegainedafterreceivingaHighSchoolorEquivalencyDiploma?

Yes No

$

TypeofBusiness

Describedutiesbelow:

YourExactTitle

NameofyourSupervisor

Supervisor’sTitle

ReasonforLeaving

Haveyouansweredallappropriatequestions? Anincompleteapplicationmaybedisapproved.

StudentLoanSupplement

DoyouhaveanyloansmadeorguaranteedbytheNewYorkStateHigherEducationServicesCorporationwhicharecurrentlyoutstanding?

Yes No

Ifso,areyoupresentlyindefaultonanysuchloan?

Yes No

Name

Address

Signature

Date

Page3

INSTRUCTIONSANDINFORMATION

Thereisanon-refundableapplicationfilingfeeperexaminationnumber. Nocashaccepted. Acheckormoneyorderonly(payabletoWestchesterCountyDepartmentofHuman Re- sources) must accompany this application. One check may be used. Record all exam numbers on the check. Applications received without the filing fee will be returned. Waivers: See section“C,”below.

A.EXAMINATIONANNOUNCEMENT

Before filling out your application, carefully read the examination announcement. Announcements may be viewed at the Westchester County Department of Human Resources or theDepartment’swebsite,www.westchestergov.com/hrandatmunicipalbuildingsandpubliclibrariesthroughoutWestchesterCounty.

B.QUALIFICATIONS

The burden of establishing required qualifications is the responsibility of the applicant. Fees are not refunded for disqualification. Out-of-title experience cannot be credited towards meeting the minimum qualifications. Applications will be rejected for lateness, if postmarked or received after the last filing date. Part-time experience will be pro-rated basedona35-hourworkweek.

C.APPLICATIONFEEWAIVER

The application fee maybe waived with proof of supplemental Social Security payments, public assistance, receiving foster care,or unemployed and primarily responsible for the supportofahousehold.

D.ADMISSIONTOEXAMINATION

Admission notices are mailed the week prior to the examination date. If you do not receive a notice three days prior to the exam date, call (914) 995-2117. Candidates will be required to bring proof of identification to the examination such as a passport, photo driver license, or a photo non-driver I.D. Participation in the examination does not mean you have been found to meet the announced requirements. Applicants may be admitted on the basis of statements made on the application which are subject to reviewandverification. Scoreswillnotbeavailableifadisqualificationdeterminationismadesubsequenttotheexamination.

E.DISQUALIFICATIONAPPEAL

AnyappealofadisqualificationnoticemustbemadeinwritingandreceivedintheDepartmentofHumanResourcesbythedateandtimeindicatedonthenotice.

F.LEGALADDRESSCHANGES

Youmustreportachangeinaddresstoinsurepropernotificationoftestresultsandcertificationofcivilservicelists.Residencymustbeestablished30dayspriortotheexamination dateinordertomeetresidencepreferencerequirements.

G.TESTING ACCOMMODATION(ATTACHREQUEST)

If you require special arrangements, a written request should be attached to this application describing the type of special arrangements required. Most written tests are held on Saturdays. If you cannot take the test on the announced test date due to a conflict with a documented religious observance or practice we will make arrangements for you to takethetestonadifferentdate. Pleasechecktheappropriateboxbelow.

ANALTERNATETESTDATEMAYBEREQUESTEDONLYFORONEOFTHEFOLLOWINGREASONS: (CHECKAPPROPRIATEBOX)

1. Adeathintheimmediatefamilyorhouseholdwithintheweekprecedingtheexamination.

2. Medicalemergenciesinvolvingthecandidateormember(s)oftheimmediatefamily.

3. MilitaryOrders(Acopyofordersisrequired).

4. ReligiousObservance-Candidatemustsubmitrequiredform.

5. Wedding-mustbeamemberoftheweddingpartyormemberoftheimmediatefamilyofthebrideorgroom.

6. Vacationforwhichanon-refundabledownpaymentwasmadebeforetheexamannouncementwasissued.

7. Requiredcourtappearances.

WITHTHEEXCEPTIONOFREASONS1AND2,REQUESTSMUSTBEMADEINWRITINGWITHDOCUMENTATIONATTACHEDTOTHE APPLICATION.

H.VETERANSCREDITS

Ifyou received or expect to receive an honorable discharge from the Armed Forces of the United States, as a war-time veteran or disabled veteran as defined below, you may claim extracreditstobeaddedtoyourexamscore,ifyoupass. TheArmedForcesoftheUnitedStatesmeanstheArmy,Navy,MarineCorps,AirForceandCoastGuard,andallcomponents 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 pur- poses.

Discharged Veterans are required to submit a copy of their DD214 discharge papers. Active duty members of the Armed Forces must submit proof of active duty status, such as current Military I.D., Military Orders or other official Military document that substantiates active duty status. To claim credits as a Disabled Veteran, you must be entitled to receive paymentsforaservice-connecteddisability(ratedat10%ormore)incurredduringtimeofhostileactionorwar.

AreyouclaimingcreditasaVeteran?	AsaDisabledVeteran?	Activeservicemember?
HaveyouusedyourVeteranscreditsforpermanentappointmentorpromotioninNewYorkStateoranyofitscivildivisionssinceJanuary1,1951?						Yes No
CHECK ANDINDICATEBELOWTHETIMEPERIODSYOUSERVEDORARESERVINGINTHEARMEDFORCESOFTHEUNITEDSTATES
				FROMMO/YR		TOMO/YR
WorldWarII:	December7,1941-December31,1946		(	)	(	)
USPublicHealthService:	July29,1945-September2,1945		(	)	(	)
KoreanConflict:	June27,1950-January31,1955		(	)	(	)
USPublicHealthService:	June26,1950-July3,1952		(	)	(	)
VietnamConflict:	February28,1961-May7,1975		(	)	(	)
* HostilitiesinLebanon:	June1,1983-December1,1987		(	)	(	)
* HostilitiesinGrenada:	October23,1983-November21,1983		(	)	(	)
* HostilitiesinPanama:	December20,1989-January31,1990		(	)	(	)
PersianGulfConflict:	August2,1990-(	)	(	)	(	)
ActiveDuty:			(	)	(	)

*FortheseservicedatesVeteransmusthavereceivedtheArmedForcesExpeditionaryMedalforServiceinZoneofConflict.

LEAVETHISSPACE BLANK

FormXD10

Page4	Revised4/2010