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CORTLAND COUNTY PERSONNEL/CIVIL SERVICE COUNTY OFFICE BUILDING 60 Central Avenue * Cortland, NY 13045-2746 Telephone [PHONE REDACTED] FAX [PHONE REDACTED] TTY Users: 1-[PHONE REDACTED] Website: APPLICATION FOR EXAMINATION OR EMPLOYMENT Cortland County City of Cortland School Districts Towns Villages Cortland Housing Authority Soil & Water Conservation District FOR INTERNAL USE ONLY Approved Disapproved Conditional Vet AP Sent AP Recd Approved V DV Disapproved ANSWER ALL QUESTIONS FULLY AND CAREFULLY. Submit additional information to [EMAIL REDACTED] A separate application is required for each position/exam you are applying for. All forms are available online. 1. Last Name: First: MI Social Security Number: 2. Position/Examination Title Applying for: Exam Number: 3. Veteran’s Credit (select one): YES NO A. If you are a Veteran, submit forms DD214 and the Veteran Application additionally. B. If you are currently in the armed forces, acceptable proof may include a Military I.D. card, military orders or official military documents that substantiate active military service at the time of the examination. 4. Are you applying for one of the following Departments or Positions: Law Enforcement, Firefighters, Highway, DPW, Youth Bureau: AND/OR are you under the age of 18? YES____NO____Date of Birth: 5. Questionnaire: Answer the following questions A. Are you an American citizen or, if not, do you have the legal right to accept employment in the U.S. B. Do you now, or have you ever worked for an agency under Cortland County’s jurisdiction? C. Are you registered with the County Clerk as an exempt volunteer fire fighter? D. Do you require special arrangements for examination (Religious or disability)? E. Were you ever dismissed from any employment for reasons other than lack of work, disability, or medical condition? F. Have you ever been convicted of a felony or misdemeanor? Include sealed records (except as allowed under law), convictions even if over 10 years ago, and youthful offender records when applying for law enforcement and/or mental health positions. You may omit traffic violations. YES / NO *If you answered “yes” to E or F above, complete the Disclosure and Consent Form for Background Investigation. A “yes” answer to E or F 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. ---PAGE BREAK--- ALL APPLICANTS WILL BE CONSIDERED FOR EMPLOYMENT WITHOUT ATTENTION TO AGE, RACE, COLOR, RELIGION, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, NATIONAL ORIGIN, POLITICAL AFFILIATION, VETERAN, OR DISABILITY STATUS. 6. DEMOGRAPHIC INFORMATION: FOR INTERNAL USE ONLY: Title of Position Applying for: Final Approval: Applicant's Full Name: Conditional: Street City State Zip Code MAILING ADDRESS IF DIFFERENT FROM ABOVE Village: Town: County: School District: Home Telephone: Cell Phone: Do you have a valid NYS Drivers License? Years and/or Months There Years and/or Months There Years and/or Months There Years and/or Months There Business Telephone: Email: SUBSCRIBE TO VACANCIES/EXAMS? Driver’s License Number: State: Class: Endorsements: 7. EDUCATION: Submit a transcript if applying for a position/exam that requires a degree/credit hours. Type of School Name of School Degree Major/Subject Total Credits Received Degree Type Degree received? High School N/A Graduated? Yes / No N/A N/A GED/ TASC GED#/TASC: State: N/A N/A College/ University Yes / No College/ University Yes / No Professional Technical School Yes / No Other School or Special Coursework Yes / No 8. LICENSES: List below any licenses, certifications or authorizations to practice a trade or profession Name of Trade or Profession: License Number: Granted by: Specialty: Date License First Issued: Current registration date: Expiration date: Name of Trade or Profession: License Number: Granted by: Specialty: Date License First Issued: Current registration date: Expiration date: YES N O YES N ---PAGE BREAK--- COMPLETION OF THIS SECTION IS REQUIRED 9. EXPERIENCE: List a consecutive history of all employment or occupations that you have ever had, including military experience. Start with your current or most recent employment first and work your way backward. You are responsible for submitting an accurate, adequate and clear description of your experience. Omission, vagueness or fabrications will not be interpreted in your favor. Employment Dates Employer: Address: / To / Type of Business: Job Title: Supervisor: Hours per week: Type of Work: (Circle One) Paid Explain: Volunteer Internship Other(Explain) Why did you leave? Current Promoted Explain: Duties: Resigned Terminated Retired Other(Explain) Employment Dates Employer: Address: / To / Type of Business: Job Title: Supervisor: Hours per week: Type of Work: (Circle One) Paid Explain: Volunteer Internship Other(Explain) Why did you leave? Current Promoted Explain: Duties: Resigned Terminated Retired Other(Explain) Employment Dates Employer: Address: / To / Type of Business: Job Title: Supervisor: Hours per week: Type of Work: (Circle One) Paid Explain: Volunteer Internship Other(Explain) Why did you leave? Current Promoted Explain: Duties: Resigned Terminated Retired Other(Explain) ---PAGE BREAK--- EXPERIENCE CONTINUED: Employment Dates Employer: Address: / To / Type of Business: Job Title: Supervisor: Hours per week: Type of Work: (Circle One) Paid Explain: Volunteer Internship Other(Explain) Why did you leave? Current Promoted Explain: Duties: Resigned Terminated Retired Other(Explain) Employment Dates Employer: Address: / To / Type of Business: Job Title: Supervisor: Hours per week: Type of Work: (Circle One) Paid Explain: Volunteer Internship Other(Explain) Why did you leave? Current Promoted Explain: Duties: Resigned Terminated Retired Other(Explain) 10. Do you have a relative who works for the agency that you are applying for? List Name, Relationship, Agency/ Department (if known). Agencies/department may have nepotism policies that prohibit the employment of relatives under certain conditions. Names Relationship Department(s)[if known] I affirm that the statements made on this application (including any attachments) are true under the penalties of perjury. I authorize the Personnel Officer of Cortland 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 further release all parties supplying said information from all liability and responsibility arising from their supplying said information. I acknowledge and consent to a State and National criminal background investigation which will include a fingerprint check to determine suitability for employment. Failure to meet the standards of the background investigation may result in disqualification. Signature Date FAILURE TO SIGN APPLICATION WILL RESULT IN DISAPPROVAL