Form Msd 330 - Civil Service Application Form
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1
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3Form MSD 330
Leave this space blank
Allegany County is an Affirmative Action / Equal Opportunity Employer
Leave this space blank
Date Received
Checked by
CIVIL SERVICE APPLICATION
ALLEGANY COUNTY DEPARTMENT OF CIVIL SERVICE
7 COURT STREET
COUNTY OFFICE BUILDING
ed
Approv
BELMONT, NEW YORK 14813-1081
Conditional
Disapproved
NUMBER AND EXACT TITLE OF EXAM AS STATED ON THE ANNOUNCEMENT
This application is part of your examination. Answer all questions fully. Some questions can be answered with an “X” in the box which applies to you. Attach additional sheets if
necessary in order to give complete and detailed information.
1. FULL NAME
Sex
M
F
10
. Check appropriate box to the right of each question:
A. Were you ever dismissed or discharged form any
YES NO
employment for reasons other than lack of work or funds?
Last Name
First Name
Initial
B. Did you ever resign from any employment
YES NO
rather than face dismissal?
Street Address or RD or PO Box
C. Did you ever receive a discharge from the
YES NO
Armed Forces of the United States which was
City/Town
State
Zip Code
other than “Honorable” or which was issued
under other than honorable circumstances?
IMMEDIATE NOTICE SHOULD BE GIVEN OF ANY CHANGE IN POST OFFICE ADDRESS
BEFORE OR AFTER EXAMINATION
D. Have you ever been convicted of any crime
YES NO
2. PHONE: Home
Cell
(felony or misdemeanor)?
EMAIL:
E. Are you under charges for any crime?
YES NO
3. SOCIAL SECURITY NUMBER
F. Have you ever forfeited bail bond posted
YES NO
4. Do you have the legal right to reside and accept employment
YES NO
to guarantee your appearance in court to
in the United States?
answer to any criminal charge?
5. RESIDENCE
Jurisdiction of legal residence for previous month:
State
County
If you answered “YES” to any of the questions 10A-F above, you may give
specifics on a separate sheet. If you elect not to provide specifics, however,
City or Village
School District
or if such explanation is insufficient, a confidential investigation supplement
may be sent to you.
None of the above circumstances represents an automatic bar to employment.
6. Check below if you desire special arrangements because you are a:
Each case is considered and evaluated on individual merits in relation to the
Sabbath Observer
(For religious reasons cannot be tested on Saturdays)
duties and responsibilities of the position(s) for which you are applying.
Handicapped Person (Describe disability on a separate sheet and
indicate type of assistance required)
THE NEW YOUR STATE HUMAN RIGHTS LAW PROHIBITS DISCRIMINATION IN
EMPLOYMENT BECAUSE OF AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, SEX,
DISABILITY, MARTIAL STATUS, OR CIMINAL RECORD. ACCORDINGLY, NOTHING IN
7. Have you any objections to this department making inquiry regarding your
THIS APPLICATION FORM SHOULD BE VIEWED AS EXPRESSING, DIRECTLY OR
character and qualification from
YES NO
INDIRECTLY, ANY LIMITATION, SPECIFICATION, OR DISCRIMINATION AS TO AGE, RACE,
A. Your former employers?
CREED, COLOR, NATIONAL ORIGIN, SEX, DISABILITY, MARTIAL STATUS, OR CIMINAL
B. Your present employer?
RECORD IN CONNECTION WITH EMPLOYMENT BY ALLEGANY COUNTY
MUNICIPALITIES.
If answer is “YES” to either (A) or (B) explain.
NOTE: When filling out your application form, check to make sure that all
8. Were you ever dismissed from any public employment for disciplinary
questions have been answered. An incomplete application may result in its
reasons?
YES NO
disapproval.
If answerer is “YES” give full particulars.
THIS AFFIRMATION MUST BE COMPLETED
I affirm that the statements made on this application (including any attached
papers) are true under the penalties of perjury.
9. If a motor vehicle license is required for the position for which you are
applying, give the following:
Signature of Applicant
Date
(MUST BE ORIGINIAL SIGNATURE)
Class
Indicate any other surname (last name) by which you are or have been
known. (Please print)
Number
Police Officer Applicants Only
Expiration Date
Date of Birth
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
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