Written Appeal To Disqualification Form - Erie County Department Of Personnel
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1ERIE COUNTY DEPARTMENT OF PERSONNEL - CIVIL SERVICE EXAM DIVISION
Written Appeal to Disqualification Form
IF YOU WOULD LIKE TO APPEAL A DECISION OF DISQUALIFICATION FOR ADMITANCE INTO AN ERIE
COUNTY CIVIL SERVICE EXAM PLEASE COMPLETE THE FOLLOWING REQUIRED INFORMATION AND
SUBMIT IN HARD COPY ONLY
*Appeals must be submitted by date and time indicated on
disqualification letter*
PRINT NAME_____________________________
Phone Number ___________________________
Email: _______________________________
SOCIAL SECURITY # _____-______-______
Exam No. & Title for which you are appealing disqualification:____________________________________
Written Appeal
Please list all qualifications you possess which you feel would qualify you to sit for the above
listed Exam. (You may want to review the Exam Announcement for the minimum qualifications required)
Please note: It is the responsibility of the candidate to prove that he/she meets the announced
qualifications to the satisfaction of this office. Applicants appealing a disqualification should be sure to
list all relevant experience, include: dates of employment, hours worked per/week and duties for each
experience listed.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
***CANDIDATES WILL BE NOTIFIED BY MAIL AND/OR BY PHONE AS TO
THE OUTCOME OF THEIR APPEAL***
THIS AFFIRMATION MUST BE COMPLETED. I affirm that the statements made on this form are true
under the penalties of perjury. I understand that all statements made by me in connection with this form are
subject to investigation and verification and that a material misstatement, omission, or fraud may disqualify
me from appointment or lead to revocation of my appointment.
SIGNATURE ____________________________________DATE ________/_____/__________
.
For your convenience, this Form may be filled out electronically but requires an original signature for submission
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