Employment/civil Service Exam Application - Niagara County Human Resources Department

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Niagara County Human Resources Department

Employment/Civil Service Exam Application

You must complete a separate application for each examination. You must pay online or attach a

check or money order (payable to Niagara County Civil Service.) All fees are non-refundable.

Attach your check or copy of your online payment for each examination.

NCCS Revised 12/1/2015

Position applying for: ______________________________________________________

Examination #: __________________

Name: _________________________________________________________________

Examination date: ________________

Last

First

Middle

Is additional information relative to a change of name, use of an assumed name, or nickname necessary to enable a c heck on

your work or school record? If yes, please provide any such additional names. ________________________________________

Mailing Address: _____________________________________________________________________________________________

Street (or PO Box)

City

State

Zip Code

Residence Address: ___________________________________________________________________________________________

Street (P.O. Box will not be accepted, must use current home address)

City

State

Zip Code

County

Have you been a resident of Niagara County for the past one (1) month?

Yes

Home Telephone Number: ______________________________ Other Telephone Number: _______________________________

Email address: ________________________________________ Social Security Number (complete): ______--_____--__________

Have you served in the U.S. Armed Forces?

Yes

No Dates of active service: From___________ To____________

Do you wish to claim veterans credits for this exam?

Yes

Wartime v eterans o f t he A rmed F orces a nd A ctive Duty members soon t o b e d ischarged w ishing t o c laim ad ditional

examination credits a s v eterans o r disabled v eterans must co mplete t he Application f or Veteran Credits form and submit a

copy of the discharge papers (form DD-214 Member copy 4) to our office for each examination.

Have you ever, since January 1, 1951, been permanently appointed or promoted in the service of NY State or any of its civil

divisions from an eligible list as a result of additional veteran credits granted you on such list?

Yes

If yes, name the agency that established the eligible list: _____________________________________________________________

Are you a citizen of the United States?

Yes

If no, do you have a legal right to work in the U.S.?

Yes

Do you have a valid NY State Driver’s License?

Yes

If yes, what class? ______________________________

I declare that the statements made in this application (including statements made in my accompanying papers) have been examined

by m e a nd t o t he be st o f m y k nowledge a nd be lief a re t rue a nd c orrect. A ny f alse s tatements m ade a re pu nishable a s a C lass A

Misdemeanor under Section 210.45 of the Penal Law and may result in termination of employment. I further understand, and will

otherwise s ubmit thereto, that i n a ccordance with e xisting pre-employment physical a nd dr ug testing po licy, I may be r equired to

submit to a physical examination and urinalysis test as a condition for employment. Applicants may also be required to undergo a

State a nd na tional c riminal history ba ckground i nvestigation, w hich will i nclude a f ingerprint c heck, t o de termine s uitability f or

appointment. Failure to meet the standards for the background investigation may result in disqualification.

_____________________________________________________

_________________________________________

Signature

Date

For Office Use Only

Payment#: _________ Amount of payment: _________

Qualified:

Yes

No Conditional: ______________

Fee: _______________ Received by: _______________

Reviewed by:________________ Date: ___________________

Online Payment: _____

UE Waiver: _____

PA Waiver: _____

Comments: ___________________________________________

Niagara County Human Resources Department * 111 Main Street – Suite G2 * Lockport, NY 14094

Phone: (716) 438-4071 * Exam Information: (716) 439-7281 * Web-site:

Niagara County policy prohibits discrimination in employment, program activities, contracting, and procurement against any person due to such person’s age, marital status,

disability, genetic predisposition or carrier status, race, color, creed, sexual orientation or national origin.

An Equal Opportunity Employer

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