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CY094 (11/12) White – Civil Service Copy Canary – Treasurer’s Copy Pink – Department Copy MSD-426 Phone: (315) 253-1284 Email: [EMAIL REDACTED] Website: www.cayugacounty.us/civilservice Fax: (315) 253-1084 From: County School Town Village Special District Department / Division: Name of Employee: Employee Title of Position (as classified by Civil Service Commission): Position Home Address: Salary (as it will appear on payroll report): Hours to work per week: Name and Title of Last Employee in Position: Social Security Birth Date: Non-Vet ☐ Veteran ☐ Disabled Vet ☐ Exempt Vol. Firefighter ☐ Disabled Vet Spouse ☐ CHECK NATURE OF PERSONNEL CHANGE DATE EFFECTIVE: ACTION NECESSARY BY APPOINTING OFFICER APPOINTMENTS Permanent (Competitive Class) Return “Certificate of Eligibles” Provisional (Competitive Class) Attach Application Permanent Promotion (Competitive) Return “Certificate of Eligibles” Provisional Promotion (Competitive) Attach Application Contingent Permanent (Competitive) Return “Certificate of Eligibles” Contingent Permanent Promotion (Competitive) Return “Certificate of Eligibles” Exempt Class Attach Application Non-Competitive Class Attach Application Labor Class Attach Application Unclassified Service Submit This Form Only For Term of Office From: To: Give Facts Under Remarks Select Type: Temporary ☐ / Substitute ☐ / Seasonal ☐ From: To: Attach Application, Give Facts Under “Remarks” TERMINATIONS Resignation Attach Signed Resignation Retirement Give Effective Date Deceased Indicate Date Removal Give Facts Under “Remarks” Lay-off (lack of Work or Funds) Give Facts Under “Remarks” OTHER CHANGES Leave of Absence: Paid ☐ / Unpaid ☐ / FMLA ☐ / Military ☐ From: To: Circle Type of LOA, Give Facts Under “Remarks” Transfer Give Facts Under “Remarks” Demotion Give Facts Under “Remarks” Suspension Give Facts Under “Remarks” Reinstatement Give Facts Under “Remarks” Reclassification Change Give Facts Under “Remarks” Change in: Salary ☐ / Name ☐ / Address ☐ Circle Type of Change, Give Facts Under “Remarks” Position Abolished Give Facts Under “Remarks” End of Probation Period: 8 / 12 / 26 / 52 / 78 week Circle End of Week, Give Facts Under “Remarks” On Worker’s Compensation Give Facts Under “Remarks” Other Give Facts Under “Remarks” REMARKS: (Attach additional information if needed) FOR CIVIL SERVICE ONLY CERTIFICATION OF CAYUGA COUNTY CIVIL SERVICE COMMISSION: I HERBY CERTIFY that, with the exceptions, as shown, the employees named in this estimate, payroll, or account, containing names, have been appointed to or promoted to or employed in the positions, and at the rates of compensation shown in accordance with the Civil Service Law and the rules made pursuant thereof and are certified through unless otherwise noted. But when any person whose name appears on the estimate, payroll or account shall have been separated from the service or if status shall change in any way, this certificate shall apply to that person only up to the time such separation or change shall have taken place. Name: Title: Date: Exception(s): CAYUGA COUNTY CIVIL SERVICE COMMISSIONS: ☐ APPROVED ☐ DISAPPROVED Name: Date: Title: ☐ CERTIFIED TO RULE 1(6) PART-TIME EMPLOYMENT: “Part-time Employment” means any employment or combination of one or more employments in a civil division in which an individual works less than 50% of the time prescribed as the standard work week by the governing body or other appropriate authority of the civil division OR wherein the employee earns not more than one-half (1/2) of the rate assigned to the position if the position has been allocated to graded salary schedule. FOR CIVIL SERVICE USE ONLY Date Received in Civil Service Office: Appointing Officer (Signature): Title: Address: REPORT OF PERSONNEL CHANGE Report ALL personnel changes as changes occur – Submit all three copies of this form “Department Copy” (Pink) will be returned to you stamped APPROVED or DISAPPROVED Date: Cayuga County Department of Human Resource & Civil Service 160 Genesee Street, 2nd Floor Auburn, NY 13021 SEND COMPLETED FORMS TO: