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Name & Contact Information

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Examination #:
Position Applying For:*
Examination Date
Examination Date
First Name:*
Last Name:*
Middle Initial:
State any other name, assumed name or nickname, by which you are/have been known:
Mailing Address:*
City:*
State:*
Zip:*
Residence Address if Different:
P.O. Box will not be accepted, must use current home address
City:
State:
Zip:
Have you been a resident of Monroe County for the past four months? *
1. Yes
1. No
Main Telephone Number:
Social Security Number: __________
do NOT submit online
Alternative Telephone Number:
Email Address:*
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If applying for Police Officer, Deputy Sheriff or Firefighter position, please indicate date of birth:
Have you served in the Armed Forces of the U.S.A.?:
1. Yes
1. No
Dates of active service: From & To
Dates of active service: From & To Start Date
—
Dates of active service: From & To End Date
Veterans of the Armed Forces and Active Duty members soon to be discharged wishing to claim additional examination credits as veterans or disabled veterans must submit a form VC-1 and/or form VC-4 and a copy of their discharge papers (form DD-214) with our office. Have you ever 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 veterans credits granted you on such list?
1. Yes
1. No
If yes, name agency that established the eligible list:
Are you a citizen of the United States?
1. Yes
1. No
If no, do you have a legal right to work in the U.S.?
1. Yes
1. No
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License/Certifications
Do you have a license, certification, or other authorization to practice a trade or profession?
1. Yes
1. No
Is this certification permanent?
1. Yes
1. No
Name of trade or profession:
License/Certificate Number:
Licensing Agency:
Licensed from and to:
Licensed from and to: Start Date
—
Licensed from and to: End Date
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Training
Other training you received (i.e., work training programs, Armed Forces training). Please estimate training hours received:
Course/Program:
Hours:
Course/Program:
Hours:
Course/Program:
Hours:
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Work Experience
Describe your employment, including military experience, beginning with your current or most recent employment. Submission of a resume does not relieve you of the responsibility for completing all sections of this application. The resume is a supplement to the application, and not a substitute for it. To receive credit for a job, basic employment information such as address, name and title of supervisor, average number of hours in the workweek, reason for leaving, specific job duties, your job title, etc. must be shown.
Job Title:
Start and End Dates:
Start and End Dates: Start Date
—
Start and End Dates: End Date
Employer Name:
Employer Address:
Hours worked per week:
Was the Position Paid or Volunteer?
1. Paid
1. Volunteer
Reason(s) For Leaving:
Immediate Supervisor's name:
Title:
Phone:
Description of Duties:
Job Title:
Start and End Dates:
Start and End Dates: Start Date
—
Start and End Dates: End Date
Employer Name:
Employer Address:
Hours worked per week:
Was the position Paid or Volunteer?
1. Paid
1. Volunteer
Reason(s) for Leaving:
Immediate Supervisor's name:
Title:
Phone:
Description of Duties:
Job Title:
Start and End Dates:
Start and End Dates: Start Date
—
Start and End Dates: End Date
Employer Name
Employer Address
Hours worked per week:
Was the position Paid or Volunteer?
1. Paid
1. Volunteer
Reason(s) for Leaving:
Immediate Supervisor's name
Title:
Phone:
Description of Duties:
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Resume Upload (optional)
Cover Letter Upload (optional)
Other Documents (optional)
Upload any supporting documentation you would like to have considered, such as transcripts or writing samples, etc.
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I declare that the statements made in this application (including statements made in my accompanying papers) have been examined by me and to the best of my knowledge and belief are true and correct. Any false statements made may result in termination of employment or removal from Civil Service eligibility. I further understand, and will otherwise submit thereto, that in accordance with the County’s pre-employment drug testing policy, I may be required to submit to a urinalysis test as a condition for employment. Applicants may also be required to undergo a State and national criminal history background investigation, which will include a fingerprint check, to determine suitability for appointment. Failure to meet the standards for the background investigation may result in disqualification.
Electronic Signature: by typing my name in the box above I certify the above statement to be true and accurate.

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