TOMPKINS COUNTY APPLICATION FOR EMPLOYMENT

4. VETERANS CREDIT (IF APPLICABLE, CHECK ONE):      VETERAN _______  DISABLED VETERAN______

5. INDICATE A YES OR NO RESPONSE TO EACH QUESTION LISTED BELOW:
A. Are you an American citizen or, if not, do you have the legal right to accept employment in the US?______
B. Do you require special arrangements for examination (Saturday Sabbath observer or disability)? *______
C. Do you now, or have you ever, worked for any agency under Tompkins County's jurisdiction?______
D. Have you filed for or taken an examination with Tompkins County within the last two years?______
E. Were you ever dismissed from any employment for reasons other than lack of work? *______
F. Have you ever forfeited a bail bond posted to guarantee your appearance in court? *______
G. Have you ever been convicted of any crime (felony or misdemeanor)? *______
H. Are you an exempt volunteer firefighter?______
I. Are you presently in default on any loan made or guaranteed by the New York State Higher * Education Services Corporation?______

*If yes, please use the space below to give a full explanation. A "yes" answer to E, F, G or I above, will not necessarily disqualify you. Each case is evaluated on an individual basis in relation to the duties and responsibilities of the position for which you have applied. You may omit parking violations.
 
 
 
 

6. Law enforcement positions and positions requiring a commercial driver's license have minimum age restrictions. If you are applying for one of these positions OR if you are under the age of 18, enter your date of birth here: ___/___/___.

7. TITLE, YOUR NAME, ADDRESS, ETC.: (Interviewers will receive copies of pages 2, 3, 4 only and any attachments.)
 

Title of Position:	__________________________________	Final Approval	_________________
Applicant's Name:	__________________________________	Conditional Approval	_________________
Address:	__________________________________	Home Number:	_________________
City/State/Zip Code:	__________________________________	Work Number:	_________________
Social Security Number:	__________________________________	Driver's License Number:	_________________

8. EDUCATION: (If more space is required, attach additional sheets in the same format.)
 

High School/  GED	Name and Address of School	GED #	Graduated?	Date?
Accredited College or University	Name and Address of School	Major	Total Credits	Degree?
Accredited College or University	Name and Address of School	Major	Total Credits	Degree?
Professional/ Technical School	Name and Address of School	Type of Course	Total Credits	Degree?
Other School or Special Coursework	Name and Address of School	Type of Course	Total Credits	Degree?

9. LICENSES: List below any licenses, certifications or other authorizations to practice a trade or profession.
 

Name of Trade or Profession:	License Number:	Granted by:
Specialty:	Date License First Issued:	Registered From: ___________ Registered To:_____________
Name of Trade or Profession:	License Number:	Granted by:
Specialty:	Date License First Issued:	Registered From:_____________ Registered To:_______________

 

Title of Position:	.
Applicant's Name:	.

10. EXPERIENCE:

On the following pages list a consecutive history of all employment or occupations that you ever had, including military experience. Start with your current or most recent employment first and work your way backward. Include any verifiable volunteer experience that you feel is relevant. Applicants may be required to furnish satisfactory proof of experience claimed. If unemployed at any time, write "unemployed" in the space for firm name and give the reason for unemployment. The "DUTIES" section should contain only the work personally performed by you with estimated percentages of time for each type of work. State the size and kind of work force, if any, supervised by you and the extent of such supervision. You are responsible for submitting an accurate, adequate and clear description of your experiences. Omissions, vagueness or fabrications will not be interpreted in your favor. Attach additional sheets as necessary in the same format as below.
 

Length of Employment	Firm Name	Address	City/State/Zip
FROM:  Mo.     Yr.	.	.	.
TO:        Mo.      Yr.	Type of Business	Your Title	Name of Your Supervisor
TOTAL: Yrs.    Mo.	.	.	.
HOURS WORKED PER WEEK:	Duties:

Length of Employment	Firm Name	Address	City/State/Zip
FROM: Mo. Yr.	.	.	.
TO: Mo. Yr.	Type of Business	Your Title	Name of Your Supervisor
TOTAL: Yrs. Mo.	.	.	.
HOURS WORKED PER WEEK:	Duties:

 
 
 

Title of Position:	.
Applicant's Name:	.

 
 

Length of Employment	Firm Name	Address	City/State/Zip
FROM: Mo. Yr.	.	.	.
TO: Mo. Yr.	Type of Business	Your Title	Name of Your Supervisor
TOTAL: Yrs. Mo.	.	.	.
HOURS WORKED PER WEEK:	Duties:

 
 

Length of Employment	Firm Name	Address	City/State/Zip
FROM: Mo. Yr.	.	.	.
TO: Mo. Yr.	Type of Business	Your Title	Name of Your Supervisor
TOTAL: Yrs. Mo.	.	.	.
HOURS WORKED PER WEEK:	Duties:

 
 
 
 

Title of Position:	.
Applicant's Name:	.

Length of Employment	Firm Name	Address	City/State/Zip
FROM: Mo. Yr.	.	.	.
TO: Mo. Yr.	Type of Business	Your Title	Name of Your Supervisor
TOTAL: Yrs. Mo.	.	.	.
HOURS WORKED PER WEEK:	Duties:

Length of Employment	Firm Name	Address	City/State/Zip
FROM: Mo. Yr.	.	.	.
TO: Mo. Yr.	Type of Business	Your Title	Name of Your Supervisor
TOTAL: Yrs. Mo.	.	.	.
HOURS WORKED PER WEEK:	Duties:

CONSTITUTIONAL OATH  (Signing the constitutional oath is required for appointment) I do hereby pledge and declare that I will support the Constitution of the United States and the Constitution of the State of New York, and that I will faithfully discharge the duties of the position specified on this application according to the best of my ability.

AFFIRMATION AND RELEASE  I affirm under the penalty of perjury that the statements made on this application (including any attachments) are true. I authorize the Commissioner of Personnel of Tompkins County, or his/her representatives, to obtain from all persons, schools, companies, corporations, credit bureaus and law enforcement agencies any records, documents and other information relative to my suitability to perform the duties of the position and I further release all parties supplying said information from all liability and responsibility arising from their supplying said information.

SIGNATURE:__________________________

DATE:_______

SIGNATURE__________________________

DATE:_______

 

Qualified applicants are considered for employment, and employees are treated during employment, without regard to race, color, religion, sex, national origin, age, marital status, medical condition or handicap.  To help us comply with Federal/State equal employment opportunity record-keeping, reporting and other legal requirements, please answer the questions below and submit this for with your application.  This Pre-Employment Information Form will be kept in a Confidential File, separate from the attached Application for Employment. Completion of this form is voluntary.

1. Exam No.:___________ 2. Job Title:__________________________________________________

3. Social Security Number:________________________________

4. Last Name:________________________ 5. First Name:______________________ 6. MI:_____

7. Address:______________________________ 8. City:_____________________________

9. State:__________ 10. Zip Code:____________

11. Sex (Check)  Male___ Female___

12. Race/Ethnic Group: (Check)
White___ Black___ Hispanic___Am. Ind/Alaskan Native___Asian/Pacific Isl.___

13a) Do you have a Disability or Handicap? Yes___ No___

b) If yes, what is Nature of Impairment?
Hearing___ Visual___ Mental___ Multiple___ Orthopedic___ Speech___ Other___

c) Do you need Special Assistance on the Job? Yes___ No___

Describe in detail on the reverse side the impairment and any special assistance needed.

15. Military Status? Vietnam Era Veteran Yes___ No___
Disabled Veteran Yes___ No___

16. How did you hear of this Position?
College Placement Service_____ NAACP_____   Radio_____ TV_____ Newspaper_____
Examination Notice_____ VESID_____ Veterans Office_____ Community Center_____
Job Service_____ Offender Aid and Restoration_____ Econ. Opportunity Corp._____
Youth Employment Service_____ O.P.E.N._____ BOCES Adult Education_____
Minority Applicant Pool_____  Fed. Employment Guide_____
Internet/Web Posting_____ Other (Please Specify)_____

AGREEMENT: The answers given on this form are true and complete to the best of my knowledge.

APPLICANT’S SIGNATURE:_________________________________ DATE:_____________________