Form Dpf-178 - Application For Reemployment - New Jersey Civil Service Commission
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1READ CAREFULLY
DO NOT WRITE IN THIS BLOCK
NEW JERSEY CIVIL SERVICE COMMISSION
The falsification of an application for
(For Civil Service Commission Use Only)
reemployment constitutes a crime of
APPLICATION FOR REEMPLOYMENT
the fourth degree and is punishable
as such (N.J.S.A. 2C:21-4, N.J.A.C.
4A:10-2.4). Such conduct also shall
INSTRUCTIONS: Type or write clearly. Applicant MUST complete Sections A
be cause for rejection of the
and B. Questions # 2 & 4 are voluntary and are asked for recordkeeping purposes
application, removal of the applicant
only. Appointing Authority will complete Section C and mail completed
from employment secured thereby
application to New Jersey Civil Service Commission, PO Box 314, Trenton, N.J.
and possible disqualification from
08625-0314. Do not write in Section D.
future merit system employment.
1. NAME (last, first, middle initial)
2. Check the ethnic group you are a member of:
1
Black (Non-Hispanic)
2
White (Non-Hispanic) 3
Hispanic 5
American Indian or Alaskan Native
4
Asian or Pacific Islander (Including Indian Sub-Continent)
4. SEX
5. LAST PERMANENT TITLE
6. TITLE CODE
3. SOCIAL SECURITY NUMBER
7. ADDRESS
8. TELEPHONE (Area Code / Number)
9. DATE OF REGULAR APPOINTMENT
(Number & Street, City, State, and Zip Code)
10. SALARY (Last Permanent Title)
11. DATE OF RESIGNATION
SECTION A
$ Per
TO BE
12. VETERAN STATUS
13. IN WHICH SERVICE WERE YOU EMPLOYED? (Check One)
COMPLETED
STATE SERVICE
LOCAL GOVERNMENT SERVICE
1
Veteran 2
Disabled Veteran 3
Non Veteran
BY
(Complete Item 14)
(Complete Item 15)
APPLICANT
14. IF YOU WERE EMPLOYED IN STATE SERVICE, CHECK COUNTY OF PREFERENCE FOR REEMPLOYMENT.
(There can be no assurance that you will be reemployed in that area)
Passaic (R)
Atlantic (A)
Camden (D)
Essex (G)
Hunterdon (K)
Monmouth (N)
Sussex (U)
Gloucester (H)
Salem (S)
Bergen (B)
Cape May (E)
Mercer (L)
Morris (P)
Union (V)
Hudson (J)
Somerset (T)
Burlington(C)
Cumberland (F)
Middlesex (M)
Ocean (Q)
Warren (W)
15. If you were employed in Local Government Service, give name of jurisdiction:
16. Since your resignation have you been convicted of a crime that has not been expunged by the court?
Yes
No
(If Yes, give complete details and date of each offense and disposition on back)
17. Have you been dismissed from a government or other position since your resignation date?
(If Yes, give date and reason for each dismissal on back)
Yes
No
NOTE TO APPLICANT: You must be available for reinstatement at said position upon date of certification. If you
SECTION B
are not available at the time of certification, your name will be removed from the reemployment list permanently.
FOR
APPLICANT’S
18. As of this date I am available for reemployment at my former regular title or any comparable title.
SIGNATURE
Applicant’s Signature:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
19. Name and Address of Appointing Authority
SECTION C
TO BE
COMPLETED
AND SIGNED
In view of the applicant’s record of past performance, I certify that reemployment of the applicant at his former regular title, or any
20.
BY
comparable title, would be in the best interests of Government Service. I further certify that the applicant resigned in good standing and held
APPOINTING
permanent status as indicated in number 5 above.
AUTHORITY
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Appointing Authority Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
21. CIVIL SERVICE COMMISSION ACTION:
SECTION D
Name Placed on Regular
Previous Title
New Title
(Indicate): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
FOR
Reemployment List
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _
CIVIL
SERVICE
COMMISSION
Date:
Action Completed By:
USE ONLY
DPF-178 REVISED 04-03-09
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