Application for Examination or Employment for County, Towns, Villages, and School Districts (Essex County is an Equal Opportunity Employer) Title of position applying for: Exam no. (if applicable): If you previously saved your latest application with a PIN/password, you can retrieve it by entering your SSN and PIN/password here, then click the button. Otherwise, please fill-in all applicable fields starting with the title of the position applying for (all fields with red borders are required). You can work on your application in more than one session by saving it with a PIN/password at the bottom of the form. SSN (xxx-xx-xxxx): PIN/password (case sensitive): This application is part of your examination. ANSWER ALL QUESTIONS FULLY AND CAREFULLY. ALL STATEMENTS ARE SUBJECT TO VERIFICATION. Last name: First name: Middle name: Home phone: Cell: Your IP address is 54.156.76.187. If you encounter any problems using this web page, please contact us at webmaster@co.essex.ny.us and provide this IP address and the browser you are using. Printable application (Adobe Reader required; you can return to this screen after printing, with your browser's back button) PO Box and/or street address: City / Town: State: Zip Code: Social Security Number (xxx-xx-xxxx): Date of Birth: Email address: State your actual legal residence and indicate for how long you have resided there continuously, up to and including the date of this application: School district: Years: Months:
Village or city: Years: Months: Town: Years: Months: County: Years: Months: State: Years: Months: Check the appropriate box to the right of each question: Were you ever dismissed or discharged from any employment for reasons other than lack of work or funds? Have you ever been convicted of any crime, felony or disdemeanor? Are you now under any charges for any crime? If "Yes", give particulars and disposition of each charge on a separate sheet and attach same to the printed application. NONE OF THE ABOVE CIRCUMSTANCES REPRESENT AN AUTOMATIC BAR TO EMPLOYMENT. EACH CASE IS CONSIDERED AND EVALUATED ON INDIVIDUAL MERITS IN RELATION TO THE DUTIES AND RESPONSIBILITIES OF THE POSITION(S) FOR WHICH YOU ARE APPLYING. Check the appropriate box to the right of each question: Are you currently a U.S. citizen? (Citizenship is not a requirement for employment except for public officer positions) If not a U.S. citizen, do you have a legal right to accept employment in the United States? Please give your alien registration number: Are you a retiree from New York State or any civil division thereof? Are you an exempt volunteer fireman? Do you have a valid license to operate a motor vehicle in New York State? If "Yes", please provide the following: Class: Number: Date of expiration: Veterans credits: are you a veteran? If "No", skip to EDUCATION. Do you claim additional credits on this examination as an honorably discharged veteran? Disabled war veteran credit? Non-disabled war veteran credit? If "Yes" you must complete an application for veteran's credits and provide a copy of your DD-214 form to claim credit. Since January 1, 1951 , have you ever used additional credits as a disabled or non-disabled veteran for appointment to any position in the public employment of New York State or any of its civil divisions? EDUCATION: if credit is claimed for partially completed college curriculum or correspondence course, attach a list of courses and credits or semester hours completed. Indicate how many credit hours or courses are required for graduation. DO NOT send transcripts unless required by announcement or to be used to meet minimum qualifications. Have you graduated from high school? If "Yes", give year graduated: If "Yes", give name and location of high school: If "No", give highest grade completed: Have you successfully completed a typing course? If you have a high school equivalency diploma - number and/or date of issue: COLLEGE, UNIVERSITY, PROFESSIONAL OR TECHNICAL SCHOOLS (enter up to four here): Name and address of school #1: Name and address of school #3: Dates of attendance (month and year) from - to: Type of course or major: Number of college credits earned: Degree received: Degree received: Date of degree:

 

 

 


Name and address of school #2: Dates of attendance (month and year) from - to: Type of course or major: Number of college credits earned: Date of degree:
Dates of attendance (month and year) from - to: Type of course or major: Number of college credits earned: Degree received: Date of degree:
Name and address of school #4: Trade or profession: Dates of attendance (month and year) from - to: Type of course or major: Number of college credits earned: Degree received: Date of degree: Registration period from (mm/yy) and to (mm/yy):
If a license, certificate, or other authorization to practice a trade or profession is listed as a requirement on the announcement or the examination(s) for which you are applying, complete the following: License number: Date license first issued: Specialty: Licensing agency name and address: Check box below if you desire special accommodations because you are a: Sabbath observer - for religious reasons cannot be tested on Saturdays: Handicapped person: Please indicate type of assistance required: Have you any objections to this department making inquiry regarding your character and qualifications or contacting your former or present employers? If "Yes", please give particulars: EXPERIENCE: beginning with the most recent, list all employment, military service, or volunteer experience that proves you meet the minimum qualifications for the position you are applying for. We cannot interpret omissions or vagueness in your favor. You are responsible for an accurate and clear description of your experience. For DUTIES describe the nature of the work which you personally performed including the estimated percentage of time spent on each type of activity. If you supervised, state how many people and the nature of such supervision. EXPERIENCE MUST BE COMPLETED ON THE APPLICATION FORM. CREDIT WILL NOT BE GIVEN FOR WORK EXPERIENCE SUBMITTED ON A RESUME. APPLICANTS MAY BE REQUIRED TO FURNISH SATISFACTORY PROOF OF EXPERIENCE CLAIMED. Employer name: Address: City, state, zip: Phone: Supervisor's name: Supv. title: Your title: Type of business: Employed from month: year: to month: year: Check one: Hours per week (no overtime): Reason for leaving: % of time on each duty Duties: describe below the nature of the work performed by you, with an estimated percentage of time on each type of work. State the size and kind of working force supervised by you (if any) and the extent of such supervision. Employer name: Address: City, state, zip: Phone: Supervisor's name: Supv. title: Your title: Type of business: Employed from month: year: to month: year: Check one: Hours per week (no overtime): Reason for leaving: % of time on each duty Duties: describe below the nature of the work performed by you, with an estimated percentage of time on each type of work. State the size and kind of working force supervised by you (if any) and the extent of such supervision. % of time on each duty Duties: describe below the nature of the work performed by you, with an estimated percentage of time on each type of work. State the size and kind of working force supervised by you (if any) and the extent of such supervision. Employer name: Address: City, state, zip: Phone: Supervisor's name: Supv. title: Your title: Type of business: Employed from month: year: to month: year: Check one: Hours per week (no overtime): Reason for leaving: Employed from month: year: to month: year: Check one: Hours per week (no overtime): Reason for leaving: Employer name: Address: City, state, zip: Phone: Supervisor's name: Supv. title: Your title: Type of business: % of time on each duty Duties: describe below the nature of the work performed by you, with an estimated percentage of time on each type of work. State the size and kind of working force supervised by you (if any) and the extent of such supervision.


Note: when filling out this online application form, check to make sure that all questions have been answered. An incomplete application may result in its disapproval. A resume may not be substituted. By entering the affirmation date here and submitting this online form, I affirm that the statements made on this online application are true under the PENALTIES OF PERJURY: Affirmation date: Provide any other name you have used in education or employment: The entering of a PIN or password here will allow you to retrieve your application from the County jobs page using the combination of your SSN and PIN/password. You would then be able to submit it again for future vacancies or exams, or to finish the application at another time before submitting it to the County. If you already have a PIN you may continue to use it, but an 8 - 10 character password is preferred, with at least one each of the following: a lower case letter, an upper case letter, and a digit (special characters allowed) PIN/password: Click the submit button if you are ready to submit it to the County Personnel Department: Click the Save ONLY button if you want to continue to work on your application at another time: