Non Attorney Employment Application Form - State Of New York, Office Of The Attorney General Page 4

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REFERENCE RELEASE STATEMENT
I hereby give my consent to references (employment and personal), to release pertinent information about my qualifications and
fitness for the position for which I have applied with the Office of the Attorney General.
Signature of applicant
Date
AFFIRMATION
I affirm that the answers given to the above questions and all statements made by me on this application (including any
attachments) are true and correct to the best of my knowledge under the penalties of perjury. I understand that false statements
may prevent my employment or, if hired, may be cause for dismissal. I am aware that all information contained herein is subject to
verification by the Office of the Attorney General and that upon my separation from the Office of the Attorney General, all properties
issued to me (i.e., photo ID, keys, credit cards, etc.) must be returned.
Signature of applicant
Date
REMARKS SECTION
EXPLAIN any "YES" answers to Questions 6-9 in the space below. Failure to disclose such information may reflect negatively on your selection for
employment, and may be considered justification for dismissal if discovered at a later date. Give complete details including date, location and
disposition of any criminal offenses. None of these circumstances represent an automatic bar to selection.
- 4 -
HRM001 - (rev. 9/12)

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