Orange County Application For Examination/Employment: Mail or Hand Deliver To

ORANGE COUNTY APPLICATION FOR EXAMINATION/EMPLOYMENT
MAIL OR HAND DELIVER TO:
DEPARTMENT OF HUMAN RESOURCES

30 MATTHEWS STREET, SUITE 303A
GOSHEN, NY 10924
TELEPHONE: (845) 291-2707
Carefully read the appropriate examination announcement before completing this application. This application is part
of your examination and must be filled out completely and accurately. Answer all questions fully and carefully. Print
legibly in ink or typewrite. Attach additional sheets if necessary in order to give complete and detailed information.
1. If you are filing for more than one examination on this application be sure that they are all SCHEDULED TO BE HELD ON
THE SAME DATE (check the announcement for each examination). If you wish to file for examinations being held on
different dates, submit a separate application for each date.
Exam #s
Exam Date
(if applicable)
(if applicable)
Exam Name OR Title of Position
Human Resources
Use Only
#1
#2
#3
#4
#5
2. SOCIAL SECURITY NUMBER

3. FULL NAME/LEGAL RESIDENCE*
Last name
4. RESIDENCY: State your permanent legal residence and

indicate how long you have resided there continuously, up
to and including the date of this application. THIS
First Name
Initial
SECTION WILL DETERMINE YOUR ELIGIBILITY (IF ANY)

FOR CERTIFICATION ON A RESIDENT LIST.
YRS
YRS
VILLAGE OF
Street Address
City
MOS
MOS
State
Zip Code
TOWN OF
COUNTY OF
Mailing Address (if different from legal residence)

STATE OF
Phone #
*NOTIFY THIS DEPARTMENT IMMEDIATELY OF ADDRESS CHANGES*
5. SPECIAL ARRANGEMENTS: Check box below if you

need special accommodations to participate in the exam:
Religious Observer for religious reasons cannot
be tested on date of examination.
Other __________________________________
(requires supporting documentation)
Disabled Persons under remarks indicate type
of assistance required
SCHOOL
DISTRICT
6. VETERANS CREDITS: If you are serving, or have

served, in the armed forces of the United States on a fulltime active duty basis during wartime, you may be eligible
to receive credits as a Disabled or Non-Disabled Veteran.
YES*, I WISH TO CLAIM CREDITS AS A NON-DISABLED
VETERAN, PLEASE SEND APPLICATION
YES*, I WISH TO CLAIM CREDITS AS A DISABLED
VETERAN, PLEASE SEND APPLICATION
NO, I DO NOT WISH TO CLAIM VETERANS CREDITS
*Please complete and attach Application for Veterans Credits.
7. E-MAIL ADDRESS:
8. CHECK APPROPRIATE BOX TO RIGHT OF EACH QUESTION
YES NO
A. Were you ever dismissed or discharged from any employment for reasons other than lack of work or funds?
B. Did you ever resign from any employment rather than face dismissal?
C. Did you receive a dishonorable discharge from the armed forces of the United States?
D. Have you ever been convicted of any crime (felony or misdemeanor)? If so, please submit a
Certificate of Conviction with your application.
E. Are you now under charges for any crime (felony or misdemeanor)?
F. Have you ever forfeited bail bond posted to guarantee your appearance in court to answer to any
criminal charge?
Convictions will not necessarily disqualify you from taking an exam but may bar you from appointment.
If you answered "YES" to any of the questions above, please provide specifics under "REMARKS". If you elect not to
provide specifics or if such explanation is insufficient, a confidential inquiry will be sent to you.
9. A. If minimum and/or maximum age limits are established for the position please
enter your date of birth:
Month
Day
Year
B. If citizenship is a requirement for the position for which you are applying, please answer the following:
Are you a citizen of the United States?
YES
NO
YES
NO
D. Are you a retiree from New York State or any civil division thereof?
YES
NO
E. Are you an Exempt Firefighter?
YES
NO
C. If not a citizen, do you have the legal right to accept employment in the United States?
Please provide Alien Registration Number:
10. Do you possess a license to operate a motor vehicle in New York State? YES
Class:
NO
11. LICENSES: If a license, certificate or other authorization to practice a trade or profession is a requirement of the position
for which you are applying, complete the following question: (attach copy)
Trade/Profession
City/State
_________________________________
License/Certificate # _______________________________
Expiration Date
_________________________________
Licensing Agency
IF NOT currently licensed check this box
_______________________________
_______________________________
12. EDUCATION: Do you have a high school or equivalency diploma?
YES
NO
COLLEGE, UNIVERSITY, PROFESSIONAL OR TECHNICAL SCHOOL INFORMATION
Name & Location of School
Attendance Dates (Mo/Yr)

From
To
Course or Major Subject
#Credits
Recd
Other Schools or Special Courses
HAVE YOU PREVIOUSLY SUBMITTED PROOF OF EDUCATIONAL ACHIEVEMENTS?
YES
NO
Degree
Recd
Date of
Degree
13. Do you object to this department making inquiry regarding your character and qualifications from your present employer?
YES
NO
If answer is YES please explain under REMARKS.
14. DESCRIPTION OF EXPERIENCE: Beginning with your most recent experience, describe in detail all employment that is
pertinent to the required minimum qualifications indicated on the exam announcement for the title for which you are
applying. Omissions or vagueness will NOT be interpreted in your favor. If relevant volunteer experience is acceptable as
qualifying, describe it in the same way as paid work. If you have had military service which included experience pertinent
to the position, describe such experience as a separate employment. Under "Duties" for each employment describe the
nature of the work which you personally perform and the percentage of time spent in each function. If you supervised a
work group, state its size and nature and the extent of such supervision. If your title or duties changed materially in the
course of your service in any one organization, indicate such change clearly and as a separate employment.
Length of Employment
MO/YR
MO/YR
From
/
to
/
Firm Name
# of hours worked per week

(exclude overtime)
Duties (include % of time in each function)
Address
Type of Business
Your Title
Supervisors Name & Title
Reason for Leaving
Earnings
(Circle One)
WK MO YR
MO/YR
MO/YR
From
/
to
/
Firm Name

(exclude overtime)
Address
Type of Business
Your Title
Reason for Leaving
Earnings
(Circle One)
WK MO YR
MO/YR
MO/YR
From
/
to
/
Firm Name

(exclude overtime)
Type of Business
Your Title
Reason for Leaving
Earnings
(Circle One)
WK MO YR
Address
REMARKS:
ALL STATEMENTS ARE SUBJECT TO VERIFICATION. MISREPRESENTATIONS MAY CONSTITUTE CAUSE FOR
DISQUALIFICATION OR DISCHARGE. IT IS A CRIME PURSUANT TO SECTION 210.45 OF THE NEW YORK STATE
PENAL LAW, PUNISHABLE AS A CLASS A MISDEMEANOR, TO KNOWINGLY MAKE A FALSE STATEMENT
HEREIN.
Background Investigation: Applicants may be required to undergo extensive investigation of criminal history and
background, which will include a fingerprint check, to determine suitability for appointment. Costs related to such investigation
may be borne by the applicant. Failure to meet the standards of investigation may result in disqualification.
For County employment: You may be required to submit to a pre-employment drug test. Your appointment may be
conditioned on such test result.
THIS AFFIRMATION AND AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION MUST BE COMPLETED:
By my signature below, I hereby authorize the Orange County Department of Human Resources, the County of Orange, and/or
its respective Departments, Offices or Agencies to request verbal records or written verification of any or all information
contained herein. I further authorize a review and full disclosure of all records concerning me whether said records are of a
public, 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 Orange County Department of Human Resources, the County of Orange, and/or its respective
Departments, Offices or Agencies, and their respective officers and/or employees from any and all liability which may be
incurred as a result of collecting such information. Further, my signature below certifies I have read and fully understand the
Affirmation and Authorization for Release of Personal Information and have acknowledged that a photocopy of this
Application for Examination/Employment containing this release will be valid as an original thereof, even though said
photocopy does not contain an original writing of my signature. I affirm that all statements made on this application (including
any attached paper) are true under the penalties of perjury.
_____________________________________
SIGNATURE OF APPLICANT
_________________
___________________________________________
DATE
PLEASE PRINT ANY OTHER NAME BY WHICH

YOU ARE OR HAVE BEEN KNOWN
CHECK TO MAKE SURE THAT ALL APPLICABLE QUESTIONS HAVE BEEN ANSWERED. AN INCOMPLETE
APPLICATION MAY RESULT IN DISAPPROVAL. A RESUME MAY NOT BE SUBMITTED IN LIEU OF COMPLETING THE
APPLICATION.
The New York State Human Rights Law prohibits discrimination in employment because of age, race, creed, color, national
origin, sexual orientation, military status, sex, disability, genetic predisposition or carrier status, or marital status. Accordingly,
nothing in this application form should be viewed as expressing, directly or indirectly, any limitation, specification, or
discrimination as to age, race, creed, color, national origin, sexual orientation, military status, sex, disability, genetic
predisposition or carrier status, or marital status in connection with employment in the municipal service of the County of
Orange.
ORANGE COUNTY GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
9/28/2015

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ORANGE COUNTY APPLICATION FOR EXAMINATION/EMPLOYMENT

MAIL OR HAND DELIVER TO:

DEPARTMENT OF HUMAN RESOURCES

Exam Name OR Title of Position

2. SOCIAL SECURITY NUMBER

4. RESIDENCY: State your permanent legal residence and

SECTION WILL DETERMINE YOUR ELIGIBILITY (IF ANY)

Mailing Address (if different from legal residence)

5. SPECIAL ARRANGEMENTS: Check box below if you

6. VETERANS CREDITS: If you are serving, or have

8. CHECK APPROPRIATE BOX TO RIGHT OF EACH QUESTION

E. Are you an Exempt Firefighter?

IF NOT currently licensed check this box

12. EDUCATION: Do you have a high school or equivalency diploma?

COLLEGE, UNIVERSITY, PROFESSIONAL OR TECHNICAL SCHOOL INFORMATION

Name & Location of School

Attendance Dates (Mo/Yr)

Course or Major Subject

Other Schools or Special Courses

HAVE YOU PREVIOUSLY SUBMITTED PROOF OF EDUCATIONAL ACHIEVEMENTS?

If answer is YES please explain under REMARKS.

# of hours worked per week

Duties (include % of time in each function)

# of hours worked per week

Duties (include % of time in each function)

# of hours worked per week

Duties (include % of time in each function)

PLEASE PRINT ANY OTHER NAME BY WHICH

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