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2. 

3. WYOMING COUNTY CIVIL SERVICE
   143 North Main Street, Warsaw NY 14569
   Phone: (585) 786-8830

5. APPLICATION FOR: EMPLOYMENT
6. OR EXAMINATION #:
8. Position Title:
9. Exam Number:
13. First Name:
14. Last Name:
16. Preferred Phone #:
17. Email Address:
19. HOME ADDRESS
21. Address
23. City
24. State
25. Zip Code
27. MAILING ADDRESS
29. Address
31. City
32. State
33. Zip Code

35. 
    CHANGE OF ADDRESS: You must notify this agency immediately of any change of address. The number and title of the examination or eligible
    list must also be included in this notification. FAILURE TO COMPLY MAY RESULT IN YOUR NAME BEING REMOVED FROM AN
    ELIGIBLE LIST.
    Call this agency immediately if you do not receive a notice within seven days of the date of the examination informing you whether or not you are
    to be admitted.

39. LEGAL RESIDENCE
41. County of:
42. How many years?:
43. How many months?:
45. City, Town, or Village of:
46. How many years?:
47. How many months?:
49. State of:
50. How many years?:
51. How many months?:
53. Please select school district in which you reside:
    -- Select One --AtticaLetchworthPerryPioneerWarsawWyomingOther
57. Are you a Citizen of the United States?:
    -- Select One --YESNO
58. IF NOT, DO YOU HAVE THE LEGAL RIGHT TO ACCEPT EMPLOYEMENT IN THE UNITED STATES?:
    -- Select One --YESNO

    (Non-citizens may be required to produce 1-151 or 1-1551 Alien Registration Card at time of appointment)

62. EMPLOYMENT PREFERENCES:

    Please check the type of work you would be willing to accept.

    1. Full-Time
    2. Part-Time
    3. Temporary
63. AGENCIES:

    Please check those agencies in which you would be willing to accept work.

    1. County
    2. Towns
    3. Villages
    4. School Districts
67. EDUCATION
69. Name of School/Program:
70. H/S or GED?:
    -- Select One --High SchoolGED
72. Date degree/diploma or GED received or expected:
73. If GED, what is the number?:
75. Name of College:
76. Major and/or Minor:
78. Type of Degree:
79. Credits Earned:
80. Date Degree Received/Expected:
82. Graduate School or Other Education:
83. Major and/or Minor:
85. Type of Degree:
86. Credits Earned:
87. Date Degree Received/Expected:
91. LICENSES/CERTIFICATES OR AUTHORIZATIONS TO PRACTICE A SKILL, TRADE, OR PROFESSION
93. Skill, Trade, or Profession:
94. License/Certificate Number:
96. Issued By: (Name or City, State, or Agency)
97. License Dates: (From-To)
98. Permanent:
    -- Select One --YESNO
100. Skill, Trade, or Profession:
101. License/Certificate Number:
103. Issued By: (Name or City, State, or Agency)
104. License Dates: (From-To)
105. Permanent:
     -- Select One --YESNO
109. DRIVER'S LICENSE INFORMATION
111. Choose one:
     -- Select One --NONENEW YORK STATEOUT OF STATE
112. Indicate State, if not New York:
114. Motorist ID #:
115. Class:
117. Restrictions:
118. Endorsements:
119. Expiration Date:
123. Have you been convicted of a violation of law (Felony/Misdemeanor)?
     -- Select One --*YESNO

     (Omit any offense adjudicated in Juvenile Court or under a youthful offender law.)  Convictions will not necessarily disqualify you from employement.

124. *If yes, you must list violations with dates of conviction and resultant penalties:
126. Have you ever been discharged or resigned from employment for reasons other than lack of work or funds?
     -- Select One --*YESNO
127. *If, yes, you must give an explanation for each discharge or resignation:
129. Are you under the age of 18?
     -- Select One --*YESNO

     *If yes, you will be required to supply a work permit.

131. Have you ever worked for Wyoming County before?:
     -- Select One --*YESNO
132. *If yes, when and under what name?:
136. WORK EXPERIENCE

138. DO NOT SUSTITUTE A RESUME FOR THIS SECTION.  Complete all information requested. Describe in detail all the duties performed which are relevant to the position for which you have applied. List most current employment first.  

     Full-time is 30+ hours/week

     Part-time is rated as follows:

             0-09 hours/week = 0

             10-19 hours/week = 1/4 

             20-29 hours/week = 1/2

     
     

140. Length of Employment:

     Month/Year to Month/Year

141. Employer:
142. Employer Phone #:
144. Hours Worked per/week:
145. Employer Address:
147. Paid/Unpaid:
     -- Select One --PAIDUNPAID
148. Your Title:
149. Type of Business:
151. Name of Supervisor:
152. Title of Supervisor:
154. May We Contact?:
     -- Select One --YESNO
155. Reason for Leaving:
157. Job Duties:
161. Length of Employment:

     Month/Year to Month/Year

162. Employer:
163. Employer Phone #:
165. Hours Worked per/week:
166. Employer Address:
168. Paid/Unpaid:
     -- Select One --PAIDUNPAID
169. Your Title:
170. Type of Business:
172. Name of Supervisor:
173. Title of Supervisor:
175. May We Contact?:
     -- Select One --YESNO
176. Reason for Leaving:
178. Job Duties:
182. Length of Employment:

     Month/Year to Month/Year

183. Employer:
184. Employer Phone #:
186. Hours Worked per/week:
187. Employer Address:
189. Paid/Unpaid:
     -- Select One --PAIDUNPAID
190. Your Title:
191. Type of Business:
193. Name of Supervisor:
194. Title of Supervisor:
196. May We Contact?:
     -- Select One --YESNO
197. Reason for Leaving:
199. Job Duties:
203. How did you learn about this job opportunity (website, Pennysaver, etc.)?:
207. VETERANS AND DISABLED VETERANS

209. If you have served or are currently serving in the Armed Forces of the United States of America in a designated time of war, and wish to claim additional examination credits, you must file a separate "Application for Veteran's Credit" VC-1 form.

210. Do you want the VC-1 form to be mailed to you?:
     -- Select One --YESNO
212. If you wish to claim credits, please check the appropriate choice:
     -- Select One --DISABLED VETERANNON-DISABLED VETERANCURRENTLY IN THE ARMED FORCES
216. SPECIAL TESTING ACCOMMODATIONS
218. Check below if you require special testing accommodations due to:
     -- Select One --RELIGIOUS OBSERVANCEDISABILITYALTERNATE DATE NEEDED
219. Please provide an explanation of your need for special testing accommodations:
221. Are you cross-filing?:
     -- Select One --*YESNO
223. *If yes, provide the Exam Number, Title, and Location of the other Exams:
225. Please indicate the exam site at which you wish to be tested:
227. WYOMING COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER

     It is the policy of the Wyoming County Civil Service Office to provide accommodations in testing to individuals with disabilities and religious observers and to provide for and promote equal opportunity employment, compensation, and other terms and conditions of employment to all employees and applicants without regard to race, color, religion, creed, sex/gender, sexual orientation, predisposing genetic characteristics, national origin, age, physical and/or mental disability, marital status, and/or military status, arrest history or criminal conviction status, status as a domestic violence victim or covered veteran's status or status as a member of any other protected group in accordance with applicable federal, state and local laws.

229. VETERANS CREDITS

     All claims and grants of veterans' credits are tentative and must be verified through inspection of discharge papers and other related documents, prior to the establishment of the eligible list.  You will be advised as to which documents must be produced for this verification.  All statements you make in support of your claim for additional credits are subject to investigation by this agency.  In the event of subsequent disclosure of any material misstatement or fraud in this claim, your appointment may be rescinded.  You may also be disqualified from further appointment on which you have been granted additional credits as a result of material misstatement or fraud.  Persons claiming credits as disabled war veterans may be contacted by this agency for additional information.

231. IMPORTANT

     This section MUST BE completed.  Failure to sign this section will result in disapproval of your application for employment or examinations.  

     Affidavit: I certify that the answers provided by me in this application are true and complete to the best of my knowledge, and I understand that any omission, falsification, or misrepresentation of information by me in this application is grounds for refusal to hire or, if I have been hired, for termination and I release Wyoming County from any liability if I am terminated because of any material misstatements, omissions, or false information provided on this application/  I hereby confirm that I have never had my professional license, registration or certifications revoked, suspended, denied, restricted, limited or placed in a probationary status, nor do I have any knowledge that my professional license, registration or certification is currently under investigation except as disclosed in this application.

     I authorize the County to investigate my background, references, employment record, criminal conviction record, and other matters related to my suitability for employment.  This specifically includes, without limitations, a criminal background check.  I also authorize my former employers or any third part to disclose to the county all reports without giving me prior notice of such disclosure.  I hereby release the County, former employers, and all references listed above from any and all claims, demands, or liabilities arising out of, or related to such investigation or disclosure.  A copy of this Authorization shall have the same force and effect as the original. 

     I also understand that a conditional offer of employment may be based on the results of a later medical examination and drug screening to determine whether I meet the physical requirements of the job for which I am hired.  In addition, if accepted for employment, I hereby agree to abide by the rules and policies of Wyoming County.

235. Electronic Signature:
236. Today's Date:
238. PLEASE NOTE:

     As we move through the process of applying for employment or applying for an exam, there will be other information that we ask you to provide.

     
     

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240. 1. Receive an email copy of this form.
241. Email address

     This field is not part of the form submission.

242. Submit

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