Application For Examination Or Employment Form
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4NASSAU COUNTY CIVIL SERVICE COMMISSION
APPLICATION FOR EXAMINATION OR EMPLOYMENT
40 MAIN STREET, HEMPSTEAD, N.Y. 11550
( FOR EXAMINATION - USE FOR ONLY ONE DATE -MAXIMUM OF 3 EXAMS)
EQUAL OPPORTUNITY EMPLOYER
ALL QUESTIONS MUST BE ANSWERED OR APPLICATION WILL NOT BE PROCESSED
PRINT IN INK OR TYPE
PHOTOCOPY/FAX NOT ACCEPTABLE
(A)Exam No. _____________, Title ____________________________________________
1.
(You must notify this Commission immediately – in writing – of any change of name or address.)
LAST NAME
FIRST NAME
M.I.
(B)Exam No. _____________, Title ____________________________________________
STREET ADDRESS
(C)Exam No. _____________, Title ____________________________________________
APPLICANTS - DO NOT WRITE IN THIS BOX
POST OFFICE
STATE
ZIP
(A)
Approved
Rejected
Cond.
by: ________/________________
(
/
)
MAILING ADDRESS (
IF DIFFERENT FROM ABOVE) - EXPLAIN UNDER #20
2. TELEPHONE NO. HOME (______)__________-________________
BUSINESS (______)__________-____________
(B)
Approved
Rejected
Cond.
by: ________/________________
(
/
)
3. SOCIAL SECURITY NO. ________/________/____________
.
4
DO YOU POSSESS A VALID N.Y. STATE MOTOR VEHICLE LICENSE?
YES
NO
If “YES” indicate class: __________________
(C)
Approved
Rejected
Cond.
by: ________/________________
IF REQUIRED FOR POSITION SOUGHT, ATTACH A COPY OF YOUR LICENSE.
(
/
)
5. HAVE YOU EVER APPLIED FOR ANY EXAMINATIONS ADMINISTERED
BY THE NASSAU COUNTY CIVIL SERVICE COMMISSION?
YES
NO
(If “YES” give details under No. 20)
6. RESIDENCE (PROOF MAY BE REQUIRED)
FROM
TO
CITY OR VILLAGE
TOWN
COUNTY
STATE
Mo./Yr.
Mo./Yr.
List here your actual, permanent, legal address, for the last five
Present
/
years, including the dates (month and year) that you lived there
.
Consult official announcement to ensure that you meet any
residency requirements before filing.
Fee Paid
VETERANS
SPECIAL
CK/MO #_________________ AM’T ________ P.A. # _________________ REC’D. BY __________
CREDITS
ARRANGEMENTS
CSX-1
REV. 4/98
CS-5087.REV. 4/98
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