NASSAU COUNTY CIVIL SERVICE COMMISSION 40 Maiil Street, Hempstead. NY 11550

EQUAL OPPOR11JNITY EMPLOYER

PRINT IN INK OR TYPE PHOJ'OCOPYfFAX NOT ACCEPTABLE 1. (You lftlt llGCilY thd C 11 man -la

--�·- -- - ----

STATE STATE

IMAILINC ADDRF.SS (IF DIFFERENT FROMABOVE}-EXPLAIN UNDER t20 C ADDRF.SS (IF DIFFERENT FROM ABOVE}-EXPLAIN UNDER t20

2.. TXLEPBONE NO.HOME(__J, ________ _

BUSINESS (__J, _______ _

3. SOCIAL SECURITY NO. I I

-4. DO YOU POSSESS AV ALID N.Y STATE MOTOR VEHICLE UCENSE?

D YF.S D NO If"YES" indicate class: _____ _

IF REQUIRED FOR POSl110N SOUGHT, AlTACH A COPY OF YOUR LICENSE. I I IF REQUIRED FOR POSl110N SOUGHT, AlTACH A COPY OF YOUR LICENSE.

5. HA VE YOU EVER APPLIED FOR ANY EXAMINATIONS ADMINISTEREDBY TIIENASSAU COUNTY CIVIL SER.VICE a:>MMISSION"D YES □ NO (If'"Y'ES"' give details under No. 20)

APPUCATION FOR.EXAMINATION OR EMPLOYMENT ( FOR EXAMINATION - USE FOflONLY ONE DATE-MAXIMUM OF l EXAMS}

ALL QUES110NS.Mi§I BE Al'tSWEllED OR APPLICATION WD.L NOT BE PR0CESSm

(A) &amNo. ____ _,Tltle _______________ _

(B)&amNo. ____ _,Title _______________ _

(q F.xamNo. ____ _,Tille _______________ _

APPLICANTS - DO NOT WRITE IN THIS BOX

(A) Approved□ Rqected□ Omd□ by: I

( I )

(B) Approved□ Rejected□ Coad.O by: I

( I l

cq Approved□ Rejected□ cond.D by- I

( I l

FROM 6. RESIDENCE {fBQ.Q! MAX Ill REOUIRED\CTIY OR Vil.LAGE TOWN COUNIY �ATE MoJYr. MnNr.

List bcrc your actual, pcmwicm, kpl 1ddrm, for the last five '=PrcscDt ✓years. inclncting the dates (IDODth and ye.ir) that you lived there.

Consult officw umouncement co ensure that you meet anyresidency rcquitemems before filing.

fcee bid #I

�Ml AM'T P.A.# REC'D.BY I="" I =GEMENIS

CS-5087. 4/98 Rev. 8/01 I

("YES" answm so the mllowmg qucstsons IUllSt be explained under numt- 20)

7. Do you object to dus amaumaan 1,mmg inquiry about your ch:uacta and qll2hfirmons ftom yom- praa=tt anploya" □ Yes □ No

8. � you ever bad a drivers bcmsc suspended or m-okc:d" D Yes □ No

9. Have you �ed zny summc:ms for ttaffic viobtions wtthmthe pm three yean" □ Yes □No

10 Exa;,t for the ahon trnffic offenses. have yuu cm: hem � of any viobnan. nusdanc:anor, ar fdony? □ Yes □No

11 AR there miy auninaJ c1mJa pcndmg 11pmst you a! chis time" D Yes □No

tl. Were you eves-dismissed from c:mpJoymem for reasom other than mfuc:tioo in Sbffl C]Yes □No

NOTE: IF YOU WERE EVER FINGEKl'RL"'n'ED Oil INVESTIGATED BY TB1S C'OMMJSSJON, YOU MUST C1VE DETAILS (DATE A.''D l'OS1110N AJ'Pl.lED J'OR) UNDER• :ZO

13. DO YOU HAVE A UCENSEORCER.TIFJCATE lO PRACTICE A TRADE OR PROFESSION: (Jf Yes. mid if reqmrul for dm positilJcl{ ..... n, yoia mllSl lmdl a p!loCl:x:upy }O Yes D No

14. EDUCATION. I:'""' If---;,.....,.., ...... pmmm,1.._,..

Imust give details (Tule. dare completed. school/agency attended m.. 1:1' qpotion ! 211

A- Do you hzvc a High School or Eqinvalcncy Diplorm"

D Yes - Name a: Loanon of H.S. or issuing authority

D No - indicm gnide c:omplesc:d

B. Was prvof nu submittal to dus off=:? D Yes □ No

NOTE: When college td0ada11 Is nqulnd. H' aa1 alrrady aD file. yoa mmt � :,var KIIIIOI said aa offldal lnUlSatpt dlnllcdy m dm omce.

Tn,eofScbaol Name and Lac:aaon lhiaAcaided Fnm-To

,U.,,Nr \-1UA Nr,I

., CcllcF,

Unhocnily.

Pro!wui.J. T«=ical .ar Trade .

-

Complete tlus section ONLY rf you wub re dun vetctanS c:mbu AND if you mve not med vmrms credits rar appoinlmmt to :l pc,sition m NY St3!c since 1/lfSI

Far thepuipose ofcbimmg ven:rmsmdits 0:1 a civil savi= a� you m:m h:M: saved, or c:umntly sc:rvc. on active duty- for purposes other dim tr.lining • i,, the Annci! fom::s of the Umtc! Sias at :my ume clurrng the fnf!owing "tune of -..ar- perr.,ds:

WWI!· 12/7f4l - l21.31f46 -�-6/11&3-1211187 ICoR:.a • 6127/SO • 1/3 USS •Grtmda - 10f23J83 • l l/ll/83 Vietnam- 12122161 .: snns ·Pmmu • 1212£1.-'89 - 1 /3 J/9f}Pem:m Gulf - 8/2/90 - •urnr.cd II) l!ias: who m:cl'Cd c,,: =J r«.:.=.U.S Pubbc Health Service Navy or Mznne Cor;K �i{llfUfy �-

7129:45- 12/Jl/46 6127150 - 113152

In addition. you must {2) Be m Hcmcnbly Dlsdwpd Veser:m - or rele3Sed andc:r honorable�

(YOU must submJ1 proof via form #00214) OR.

(bl Be cunmtly OD active duty- for purposes o0er dtm tr.lining. (Proof� be by military ID or orders). You ,.,;n be nouficd later 35 to how to provi& proof or Honorable DisdmJe or rclcuc wdc:r boncnbJe conditions.

IS. Ha-we youm_ vctz::rms g-afiu for appomtmcu to a position m N.Y.5tltesmc:e 1/1/Sl?

□Ye:. Oo

(If so, you rmy not claim them again!)

16. Do you lll'ish 10 daim iqular vctcrms cmii1s? ClYcs ClNo

17. Do you 11/Uh to cl.um DISABLED Yelams credits? c:::Jycs CJNo (YOU ttm5t be l'CQ:MDJ payments from die U.S. Dept.ofVetcrms Affairs for a scmce-couoeaed disability med II I 0% or more. and iDcmn:d durinJ :a"'time of wu"' period listed abo\,:).

CoJJece ahaadaa mm a ramp CRDtrr mmt be cmutld by u accredited nabnttaD semce. ud u •rlpua] npon sa1t by du!m to Wt office.

Tn,eof Did:,ou D=Dqpa:I Noaf l)pcof Wu Prmf'Subrnit=f Cacrser'Major Gradualc? Diplama c� Dcgrcc IO This OfJicc7

D.....;....i D--'-...1 v-,..._-, ,. "N,,,

11. EXPERIENCE: Dc:scribe here ml rdenu1 cxpclic:ncc ("mcluding YOhmtecr or milimy) smting with !he 111.0Sl m:em. Include III employmem for !he last five ye.as. a., wdl a imy �apaicncc prior to tb:1. (If aot emplO)":d during P=t er aD oflast 5 yrs, m �) In nddi!ioa, you MUST:

.,-

L l.hm'"Duties" dcsaibc work pmamlJy done by you. 4. If more 1h:m OllC title Ill SICDC employer, list IS� cmp!oymc:nt.2. Estimak SXJCCim&C of time SjXJll on aD work. �- If more space is needed, aUXh cdJa B tn. x 11 sbccts of piper. 3. Indicm size & type of wodd'mcc supemsm. if any, mid emm of sup=vimi. 6. TBlS SECTION MUST BE CO!\-D"IEIED EVEN IF A llESUME IS SUBMlTill>.

(a) Emplayl:r. N=daddic:ss Type of Business

In...:.-Yourtith:: ,_..wr ----:-

�) Employer- Nzmdaddzess lypeof Bo:sincss

1� IYaurtilk: -=l...c:mQI:

(c:) Employa--Nmrdllddiess lypeof Business

In...:-

IYourtide: 10r LaMng:

(d) Employa'. Namc'addrc:s.1 Type of Business

In-:-. Yoarlhl,c: l<.l'!!lUlll fOr l.eaTinat:

.

D=syouwortmtbce F-IU.nl'{r.l T,,BA,.Nr.\

I

D=csyouwomdtbm F.......tMft.Nr.l T,niMn.Nr.l

I

D::i:esyoa�thce FrmnlMoJYr. l T,.,-u,.JVr.\

I

D=syou�� frnnofMnJYr.\ T,.tMoNr.)

I

NOlE: Ymrcwk:zrirm_...� pro,:,::ad lllllil F«m CSX2.l arCSX2.2 is fikd. Sctmil .:ppupia: 1111m direaly aotmsallla:. (DoKOTsm::it fixm CSX 2.2 IO lppoi::tmg affim) Elcf., � � lfflClla1 i:umlioa mit... ....pojum:t o. eu · •m �

Hoars'Mlrbd Nmnc and tide of PtrWcck \'OUt

Hours woda:d Namcandtidco! PtrWeclc .

Homs worked Name and titJc: of PtrWedc vuur

.

Hours worm! Name and tidc or PcrWedt ...,.,r .

19 DECLARATION· I� mbJ,cctlO lbcpcmlb=s ofpc:rjmy. ihiialf ==em =de ci 6" sppfinrinn fmd=l!ial m:cxm a:s!= i:i q-ocax::p::iy1111 pqim) mc bc==ilaedb}'=emd111lhebcslcCm,boded;:•tn11:mdcm=.

(Applicant Sipature) (Date)

....

20. Use this space to c:xplam "yes" answers to questions 7-12, end for details of special courseworit, where rcquiicd.Do not use for additional informallon regarding experience. Rather. attach additional 8 1/2 x 11 sheets of paper for that purpose

·-~ ---- -- - -

.

.

APPOINTING AUTHORITY INFORMA110N

1. Name agd Address: County Depanment. Town. Village. School or Special Distm:t 3. lgrfsd1cticnw n-illgtlon: (per CS-4):

�

□C:,mi,etitive C Non-Competmve □ Labor □ Exempt

2. ( have reviewed !he qua!ifinmm:is Iist.cd above by !he applicant whose signature 4. Type or Appointment appears in imn 19, and I DIJllllDBle the applicant for appointmem to COMP.E11TIVE: □ Pan time

□ Provisional Appointment □ Seasonal

Tltle of Position Date Employment Begins D Provisional Promotion □ Full time

CJOthcr

C'.

□TeQJpOlll)'

0;.411A fil...7ffiATEl GRADE STEP SALARY 3. EDPmJ2�:'NUlc: IF c:anctida1P is cmn:ntly emplayal by another goveri111«:otaJ jurisdiction in Nassau County give details under number 20, above. 1Til.E DEPARlMENT

6. tnATitt SIGNATIJRE OF APPO;-~ • U'IIU OFFICER NAME & 'JTIT� OF " · r " -I mn: • Q..-..-u 'loY (PRJN"n

CONFIDENTIAL SUPPLEMENT NASSAU COIJNTY CML SERVICE COMMISSION TO EXAMINATION APPLICATION 40 MAIN SlllE£T, H� N.Y. 11550 Yom appliattioo Rlllll1t be p.ucc.uc.d lly the C"ml Scnicc Coau:nissioo mml !his fonn bu been received. All questions mmt be� or applicatioD !!iJl.J!:!I be p,oocucd. PRINT IN 1NK. OR TYPE Campi= this lormandltllldl it1D }'Ol"'app!iarion fixm (CSX-I). PHOTOCOPY/FAXNOf ACCEPrABLE

ZI. Name (Last. Ptrst. Inldal) 24. 1be fi>lknring in.fmm:woD is needed m �wilh Fcdm11 requimnents. Your coaftdential mid'°°'l!lltmy reply will in DO\\� llfm:t your cmp�applialion.

21. Eu11m1111tioa f: A. RpcdEdmjtjJy;

TdJc: t. _ While (mKofHisp=aieorigiD)2._ Blad:(ootofffisp=corigin)3._ Hisp:mic(�ofn=)4. Olher

23. Dace orBinll: I I

111111m cby )'CD" B. Sex: C},lale 0Fcmu:

25. An: }1HI a. amen or the lJn=:d St=s? (Praor or citiz=sbip or alien swus m:ay be n:quin:d)

l6. SATURDAY RELIGIOUS QB.q;RVER, AND/OR ACTIVE MILITARY, Al'J)IOR SPECIAi. ACCOMMODATIONS; Most \\nlfl:n ICStS arc held oa Sllunbys. lfyau lll'C a rdigiom obscm:r and )'Oil c:mmot be lesied ou dw- nnr-l'UICed d:!!I: you mmt mmplete the appropriate lixm.. • Jr you 1R ICtin: in the Military )'OU must provide dl-olTllf'l!Tltion • A rasmmblc llmllllIDOdmon c:m be provided, fiJr pmoos \\itb a disability fmcfuding lcutpcmuy disability). IO tm a test. You must, ODD scpaate sheet of paper. dcsc:nuc the IICXOtlUDOCbtio you l:eed mid iDdudc de Cl llllCDtllion(jttstifialtion for )'Ollf request.• •\'ot I ARE RESPONSIBLE tD \\nte to the NIISS!U Camzly C"nil Scnicc Comrnissinn (Aaeation llecruimletlt) or call them as (S 16) S72-2702, DO bter t!rm lm'Ce d:a)°S afta' the mt cby fur fi1mg appliutions, for the nctlCSSmf ltliaagements. Failure to follow lhc,e imtnxtions m'lf prcdude m fi'oin providing to you the rcqu:stal msist:m=

AtrrHOBJZAVQS roe en EASE OE PERSQSAL rim>BMATJQS JO :rm: r-�'tM•' COUNT\' PVJL SEBYJCE COMHJSffl).'11

Appmm•sHzmc(J'lcaRl'ri:.I); ____________________ _

Appl9'2:ll'aSa=!SccurityNumbcr. ____________________ _

AD 1...1$1 Nalll!SBy\\'bidlAppticml fbsBem"-(Jllc:aePri::t): ____________ _

I bi:n:byllllhanzclbe rdaasc aflba:: &l!lowmg RCUds totx Nasai ComyCrril 5cm« c--· Ca.pajimad; Ed:l:axm-. Macar Vcbldc; Allllcd Scmca; OCdil; Om:R,f; �Tim; SClat= la::il.

Thia ubcaiu:iw d gi,,m 111i:baul arpd ID 111ilcdla' l2-Rallds 1R of a� pmm. or rmlidcolol =utt. l!ld I bi:n:by 11;1m: .a!I pnilc,p::serismg -of�pmaorcmf-dednl">\tllttofqoftbi:lllxM=iermk.

0a l,d,:!fof�my bms.� f s: •• s, -s-llld� lbadlyldd harmbs md rdcmc tbi: Nim:mCouatyCiril Scmcc Cornromioal!'ldlheO!muyofNama m=l!lm:tmm,amcsa!stim.lllils.�md dai:n. -mtklem 1111:owgrcqaity ldidill:af.-&S&mu!I or cd!cctmg l!i,cx m:anls.

, .....,...,._, tt=t ti.: Na:mn ca=y C'i\il �Commission=>' mea,,: am m,cme t1=c n:can.is obt=ned punu:mi '° lhisa.t:luiz=iua"' ""urmcnUI rmplDyas. apca. dqmtwwta, imd lbc �l!s:rm!a itrdem IDmylladgraum. apcncncc. cad qmtt6r:ztmm C..-tbi: pcisilia;(s)of cmploymci;a v.t:idi l -=a �eadmymerilandfimenfilf pdmcmm,i= lhmbf a:mirizemcbrms:m!cmdmzft.

l an , lc•I ot=t lllll!iag anrzimd ia am &11hc■izabau ,lml bcdcmcd gr am:nal ID !mulct plob:bii die.,_, Coumy Cml Scmcr C e !IN D ftamobcamms � zmdlgr da::11;:rcts � me a m:na al public ruard..

AppllCGll'JSig=lme: ____________ _ D=: ___________ _

A PltaTOCOl'Y OF nos AUTHORJZATIOS \\1LL BE VALID AS A."- ORIGINAL THEREOF

l'iOTICE Tk l■r.n..dH wllkk b ...- ,-na■t III dm aadloriall■e IJ maaaltd ■-dff di« ■-tllerilJ IICf '9nli i. New Vert Clril 5crYb � 151(3), Ralr l.l ar th R■1ct alNI RcpbdHI el 1k N«w York Stale l>«pu1aall ef Chil Srmtt_ ■N Rak XJJ .rc- Rain eftu Name C .. afJ' Cril Srftla Creeehslee Tim i.r.miin will N .... ..._. l,y lk N-■ C-ty Owil Scmr- C.--ierie- •■Ill trill lor ldlbNI S.dttff■liM wlldlan-tllc appliralll peSRIICS Ck mpt.111: b■cqnnd, npmracc, ... qallfiadHI r« lk polldN(aJ ldltac ls lffidaa ... w.11,a ank .... lltJlal lar,-Wk seniu. Tlis ldtnmli■tl will � adlb:rd I■ acnrdaace widi rdn-■■t Stale nd Fcwnl Ins. F■ilmT ea pnmdr dih bifenallo■ -J' rad la ,-r l,d-c dbqallfld fn• tauac th nami•a..., .-ancr a.a .... -. ha! lad■c � hm tu dlplllr liltw ■pp■ulfc1t ta ck pasldN -■pt.

NOTE: SEE MEDICAL RELEASE (OVER)-REQUtRED FOR ALL EXA.\fS FOR NASSAU C<>Ul\TI' DEPARTME.'1175 A.'1> A..W POLICE OFFICDl EXA.,

CSX-2.1 REV. ,m

TO BE COMPLETED BY ALL APPLICANTS SEEKING EMPLOYMENT WITH THE COUNTY OF NASSAU (OR ANY POLICE OFFICER POSfflON}

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS TQmE NASSAU COUNTY CMLSERVICE COMMISSION

NOTICE .

No information will be sought pursuant to this nuthoriution until such time as a conditional offer of employment has been cxteoded to the applicant on behalf of the County of Nassau. This authoriZDlion does nol opply to potential employment with municip:llities other than the County of Nassau. The information which is sought pursuant to this authormtion is requested under the authority set forth in New York Civil Service Law §§SO(l), 50{4). end SS-a. Rule 3.2 of the Rules and Regulations oflhe New York State Department of Civil Service., nod Rule XII of the Rules of the Nassau County Civil Service Commission. This information is being sought to determine whether the applicant is uble to perform the job-Rlated functions of the position(s) to which he/she is seeking appointment. This information will be maintained and utilized by the N8SSllll County Civil Service Commission in accordance with relevant State and Federal laws. Failure to provide Ibis information may result in your disqualification from appointment to the position(s) soughL

Applicant's Name (Please Print): ______________________ _

Applkant's Social Security Numkr: _____________________ _

All Last Names by Which Applicant Has beca Known (Pase Print): ___________ _

1 hereby authorize the release to the Nasau County Civil Service Commission of all records pertaining to my physical and psychological health, including but not limited to medical records, hospital records, insurance iuords, x-rny and MRJ films and any other records or materials pertaining to nny diagnostic tests or proudures. intake sheelS, prescriptions, bills and invoices.

This BUlboriz.ation is given without regard to whether these rec.ords are of a public, private, or confidential nature. and I hereby waive all privileges arising out of the private or confidential nature of any of the above records.

On behalf of myself, my heirs. executors, administrators, successors, and assigns, I hereby hold harmless and release the Nassau County Civil Service Commission and the County of Nassau from all actions, causes of action. suits, damages. and claims whatsoever in law or equity which may arise as a result of collecting these records.

I undemnnd that the Nassau County Civil Service Commission may release and disclose the records obtnined pursuant to this authorization to governmental employers, agencies. departments, and the agents thereof as it relates to my ability to perform the duties of the position to which I am seeking appointment, and I hereby authori.zz: such release and disclosure.

Applicant's Signature: _______________ _

Date:

A PHOTOCOPY OF THIS AUnlORIZA TION MLL BEV ALID AS AN ORIGINAL HEREOF