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Home My WebLink AboutEmployment Application and cover sheetTown of Southold 53095 Main Road Southold, NY 11971 Telephone: 631-765-1800 Fax: 631-765-6145 APPLICATION FOR EMPLOYMENT Any candidate for non-competitive, part-time, temporary or provisional employment with the Town of Southold must complete and submit a Suffolk County Application for Employment to the Town so that the Town can determine whether the candidate is qualified for employment. The same Suffolk County Application for Employment is used for candidates to apply for and take competitive class examinations administered by Suffolk County Department of Civil Service. Please refer to Suffolk County Civil Service's website at http://www, co. suffolk.ny.us/civilservice/for more information concerning the administration of competitive class examinations. If you use the Suffolk County Application for Employment for competitive class examination purposes, please forward the application with the appropriate fee to Suffolk County Department of Civil Service/Human Resources, 725 Veterans Highway, North County Complex, Bldg. 158, PO Box 6100, Hauppauge, NY 11788-0099. To apply for non-competitive, part-time, temporary or provisional employment with the Town of Southold, please complete and return the Suffolk County Application for Employment only (?-ith no fe~) to the Town of Southold, Attention: Town Clerk's Office, PO Box 1179, Southold, NY, 11971. SUFFOLK COUNTY APPLICATION FOR EMPLOYMENT OPEN-COMPETITIVE EXAMINATIONS AND NON-COMPETITIVE APPOINTMENTS SUFFOLK COUNTY DEPARTMENT OF CIVIL SERViCE/HUMAN RESOURCES THIS IS FORM CS-205 PART A, 725 Veterans Memorial Highway, North County Complex, Bldg 158 YOU MUST ALSO COMPLETE P.O Box 6100 Hauppauge, NY 11788-0099 FORM CS-205 PART B. (631) 853-5500 Internet: www ce.suffolk ny. us/civilservice SUFFOLK COUNTY DOES NOT DISCRIMINATE AGAINST ANY APPLICANT BECAUSE OF RACE, CREED, COLOR, NATIONAL ORIGIN, HANDICAP, SEX, AGE, MARITAL STATUS OR SEXUAL PREFERENCE. 09-e101.07/02cb Unless otherwise stated in the examination announcement, THE APPLICATION PROCESSING FEE IS $25.00. A separate application is required for each examination identified by examination number) for which you are applying, Each application MUST be accompanied by a $25 NON-REFUNDABLE NON- TRANSFERABLE app cat on process ng ee, DO NOT SEND CASH. Make the check or money order payab e to the Suffo k County Department of C v l Service, Please indicate the examination title and the applicant's social security number on the face of the check or money order, This application is pad of your examination, Answer all questions fully and carefully in ink, Attach additional sheets if necessary to give detailed information. PLEASE PRINT: 1, EXACT TITLE OF EXAMINATION LAST NAME FIRST NAME M,I, SOCIAL SECURITY NUMBER MAILING ADDRESS LEGALADDRESS (Not a Post Office Box) CITY STATE ZIP CODE CITY STATE ZIP CODE 3, PLACE OF EXAMINATION Please check the examination center where you wish to be tested, [] SELBEN [] RIVERHEAD 4, DAYTIME TELEPHONE NUMBER (include area code) You may be contacted by prospective employers, ( ) 5. LEGAL RESIDENCE CODES Identifyeachofthedistrictsofwhichyouare a legal resident, not where you wish to be employed. If your legal residence changes, you must notify the Suffolk County Civil Service Department at once in writing. Complete the boxes with the correct codes for your legal residence. See last page of application for list of residence codes. cCOUNTY TOWN SCHOOL ~ILLAGE LIBRARY DISTRICT DISTRICT 6, GEOGRAPHIC ZONES Check one or more of the boxes below indicating the geographic zones in which you would be willing to accept an appointment, Your name will be certified only for job vacancies in the geographic zones you check, Zone 1 [] Riverhead, Southold, Shelter Island, Southampton, and East Hampton Townships Zone 2 [] Brookhaven Township Zone 3 [] Smithtown and Islip Townships Zone 4 [] Huntington and Babylon townships 7, Check appropriate box to the dght of each question: A. Have you ever been convicted of any crime (felony or misdemeanor)? YES NO [] [] B. Have you ever forfeited bail bond posted to guarantee your appearance in court to answer to any criminal charge? YES NO [] [] C. Were you ever dismissed or discharged from any employment for reasons other than lack of work or funds? YES NO [] [] D. Did you ever resign from any employment rather than face dismissal? YES NO [] [] E. Did you ever receive a discharge fnom the An'ned Fomes of the United States which was other than honorable or which was issued under other than honorable circumstances? YES NO [] [] 10, Successful completion of an appropriate medical examination may be required. If you answered YES to any part of question 7 you MUST give specifics in the COMMENTS section below. None of the above circumstances represents an automatic bar to employment. Each case is considered and evaluated on individual merits in relation to the duties and responsibilities of the position for which you are applying. Background investigations may be conducted on all candidates considered for employment. A False statement may result in the disqualification of your application in accordance with the provisions of Section 50 of the Civil Service Law. A candidate appointed to a vacancy in the service of Suffok County shall be required to disclose, and a candidate appointed to any other vacancy in the civil service may be required to disclose, whether he/she is currently receiving any form of disability payment from New York State. THE FOLLOWING QUESTIONS ARE OPTIONAL, Are you a Saturday sabbath observer who, for religious reasons only, requests permission to take this examination after sundown on Saturday? Yes NO [] [] If you checked YES, you will be asked to provide verification. Do you need special accommodations to participate in this examination? YES NO [] [] If you checked YES, please descdbe the type assistance you request in the COMMENTS section below. COMMENTS (Attach additional sheets if necessary) CANDIDATE MUST SIGN DECLARATION ON LAST PAGE OF THIS APPLICATION FOR APPOINTING AUTHORITY'S USE FOR PROVISIONAL AND NON-COMPETITIVE APPOINTMENTS ONLY DEPARTMENT OR JURISDICTION DATE APPOINTED FOR CIVIL SERVICE USE ONLY ELIGIBLE INELIGIBLE TEST SCORE NOTES [] PENDING TRANSCRIPT VETS CREDIT [] PENDING NECESSARY TOTAL SCORE SPECIAL REQUIREMENT DATE YOUR ELIGIBILITY TO COMPETE IN THIS EXAMINATION WILL BE DETERMINED ON THE BASIS OF YOUR ANSWERS TO QUESTIONS 11 - 14. INCOMPLETE APPLICATIONS WILL BE DISAPPROVED. 11. EDUCATION A. Have you graduated from senior high school? If yes, complete name and location. Name of school: Location: B. If you have a high school equivalency diploma, indicate: [] YES [] NO Issuing Author~ C. If you did NOT graduate from high school, circle highest school year completed: 4 5 6 7 8 9 10 11 PLEASE ATTACH A COPY OF COLLEGE TRANSCRIPTS VERIFYING ALL COLLEGE LEVEL COURSE WORK FOR WHICH YOU CLAIM CREDIT. 12. DRIVER'S LICENSE: Circle the class of your New York State Motor Vehicle License: 1 2 3 4 5 6 A B C D E M Date of Expiration 13. LICENSES: If a license, certificate or other authorization to practice a trade or profession is a requirement for the pos~ion for which you are applying, complete the following question: Name of Trade or Profession Specialty License Number Granted by (licensing agency) I City or State Date License Fimtlssued Registered From: To: 14. DESCRIPTION OF EXPERIENCE Beginning with the most recent, describe below in detail ALL paid and volunteer employments relevant to the position sought. You are responsible for submitting an accurate and clear description of your experience. Omissions or vagueness will NOT be interpreted in your favor, if you have had military service which includes experience pertinent to the position(s), describe such experience as separate employment. IF YOUR TITLE OR DUTIES CHANGED MATERIALLY IN THE COURSE OF YOUR SERVICE IN ANY ONE ORGANIZATION. INDICATE SUCH CHANGE CLEARLY AND AS A SEPARATE EMPLOYMENT. (If more space is needed, attach 8¥,x11" sheets of paper) Under"Duties" for each employment describe the nature of the work personally performed by you, WITH ESTIMATED PERCENTAGE OF TIME SPENT ON EACH TYPE OF WORK. State size and kind of working force, if any, supervised by you and the extent of such supervision. ALL EXPERIENCE IS SUBJECT TO VERIFICATION. LENGTH OF EMPLOYMENT FIRM NAME ADDRESS CITY AND STATE A. MO. YR. MO. YR. PROM / TO / EARNINGS (Circle One) DUTIES: $ /WK/MO/YR TYPE QE BUSINESS YOUR EXACT TITLE Avera e no. of hrs. worked er week ~e~xclusive of overiimeI SUPERVlSOR'S TITLE SUPERVISOR'S NAME TELEPHONE NUMBER LENGTH OF EMPLOYMENT FIRM NAME ADDRESS CITY AND STATE B. MO. YR. MO. YR. FROM / TQ / EARNINGS (Circle One) DUTIES: $ /WK/MO/YR TYPE OF BUSINESS YOUR EXACT TITLE Average no. of hrs. worked per week (exclusive of overtime) SUPERVlSOR'S TITLE SUPERVlSOR'S NAME TELEPHONE NUMBER LENGTH OF EMPLOYMENT =IRM NAME ADDRESS CITY AND STATE C. MO. YR. MO. YR. FROM / TO / EARNINGS (Circle One) ~UTIES: $ /WK/MO/YR TYPE OF BUSINESS YOUR EXACT TITLE Average no of hfs worked per week (exclusive of overtime) SUPERVISOR'S TITLE SUPERVlSOR'S NAME TELEPHONE NUMBER LENGTH OF EMPLOYMENT =IRM NAME ADDRESS CITY AND STATE D. MO. YR. MO. YR. FROM / TO / EARNINGS (Circle One) ~UTIES: $ /WK/MO/YR TYPE OF BUSINESS YOUR EXACT TITLE Average no of hfs worked per week (exclusive of overtime) SUPERVISOR'S TITLE SUPERVlSOR'S NAME TELEPHONE NUMBER LENGTH OF EMPLOYMENT =IRM NAME ADDRESS CITY AND STATE E. MO. YR. MO. YR. FROM / TO / EARNINGS (Circle One) ~UTIES: $ /WK/MO/YR TYPE OF BUSINESS YOUR EXACT TITLE Avera e no of hfs worked er week ~e~xclusive of overtime~ SUPERVISOR'S TITLE SUPERVlSOR'S NAME TELEPHONE NUMBER BE SURE TO SIGN THE DECLARATION ON THE LAST PAGE BE SURE TO SIGN THE DECLARATION AT THE BOTTOM OF THIS PAGE UNSIGNED APPLICATIONS WILL BE DECLARED INELIGIBLE VETERANS' CREDITS Veterans' credits are granted on the following basis: DISABLED VETERANS: 10 points for Open-Competitive Exams 5 points for Promotional Exams NON-DiSABLED VETERANS: 5 points for Open-Compeeeve Exams 2.5 points for Promotional Exams These additional credits, which are combined with the final score obtained in the examination, may be granted only to PASSING CANDIDATES at the time of establishment of the eligible list. NON-DISABLED VETERANS In order to be eligible for additional credits as a non-disabled veterans, you must: 1. Have served on ACTIVE DUTY, other than active dub/for training purposes, with the Armed Forces of the United States during any of the following periods: WORLD WAR II - December 7, 1941 through and including December 31, 1946 KOREA - June 27, 1950 through and including January 31, 1955 VIETNAM - December 22, 1961 through and including May 7, 1975 LEBANON* - June 1, 1983 through and including December 1, 1987 GRENADA* - October 23, 1983 through and including November 21, 1983 PANAMA * - December 20, 1989 through and including January 31, 1990 PERSIAN GULF - August 2, 1990 - to the end of hostilities as yet undefined · To receive veterans' credits for service in these campaigns, an applicant must also have been the recipient of one of the following: Armed Forces Expeditionary Medal Navy Expeditionary Medal Marine Corps Expeditionary Medal 2. Have been honorable discharged or released under honorable conditions from such service. 3. Submit a photocopy of separation papers (i.e. FORM DD-214 or NAVPRS-553) from the Armed Forces of the United States before this eligible list is established. DISABLED VETERANS In order to be eligible for additional credit as a disabled veteran, in addition to meeting the requirements of items 1, 2 & 3 listed above, you must also complete ,FOR EACH TITLE, IF YOU DO NOT FORWARD THE PROPER DOCUMENTATION AS OUTLINED ABOVE, YOU Form VC-3,(Authorization for Disability Record), in duplicate and forward BOTH copies immediately to the Regional Office of the United States Veterans Administration where your application for disability pension is on file. The Veterans Administration will retain a copy for its files, and will return a copy to this Department for processing. Disabled veterans must have a war-incurred disability of at least ten percent (10%) certified by the Veterans Administration at the time of application for additional credits. 15, A. Do you claim additional credits as an honorably discharged war veteran for this examination? 1. [] YES, AS A NON-DISABLED VETERAN 2. [] YES, AS A DISABLED VETERAN 3. r-I NO. If you checked YES, complete 15B and C: B. Have you previously used veterans' credits to receive a permanent competitive class appointment in the service of the State of New York or any civil division within the State? [] YES [] NO If you check YES complete the information in 15D below. CIVIL SERVICE LAW LIMITS THE USE OF VETERANS' CREDITS TO ONE PERMANENT COMPETITIVE CLASS APPOINTMENT WITHIN NEW YORK STATE. C. With the exception of the federal service, have you ever been employed by a governmental agency outside the Suffolk County (e.g. New York Cib/, New York State, Office of Court Administration, or another county within New York State?) [] YES [] NO If you checked YES complete the information in 15D below: D. Government Name Length of Employment From To Department Your Official Title(s) (Attach additional sheets if necessary) WILL NOT BE GRANTED VETERANS' CREDITS, ONCE THE ELIGIBLE LIST IS ESTABLISHED, VETERANS' CREDITS CANNOT BE GRANTED, LEGAL RESIDENCE CODES - Lindenhurst Vd3 Deer Park S~308 Sachem S~220 Connetquot LdO COUNTY Lloyd Harbor Vd4 East Hampton Sd03 Sag Harbor S~118 Copiague NAME CODE Nissequogue Vd 5 East Islip S-208 Sagaponack S-119 Deer Park Ld2 Suffolk Couniy C-1 Nodh Haven Vd 6 East Modches S~209 Sayville S~221 East Islip Ld3 Other C-0 Nodhpoff Vd 7 Eastooff S~104 Shelter island S~120 Halt Hollow Hills Ld4 Ocean Beach Vd8 East Quogue Sd05 Shorehan>Wading River Sd21 Harbodields Ld5 TOWNS Old Field Vd9 EIwood S~307 Smithtown S~315 Hauppauge L~34 Babylon T-01 Patchogue V-20 Fire Island School S-210 Southampton S-122 Huntington L-16 Brookhaven T-02 Poquott V-21 Fishers Island Sd08 South Country S-222 Islip L-17 East Hampton T-03 POd Jefferson V-22 Greenport Sd 07 South Haven S-223 Lindenhurst L-18 Huntington T-04 Qungue V-23 Half Hollow Hills S-308 South Huntin¢on S-316 Longwood L-21 Islip T-05 Sag Harbor V-24 Hampton Bays S-108 South Manor S-224 Mastic-Mor~hes-Shirley L-19 Harbodields S-309 Southold Sd23 Middle Country L-20 Riverkead T-06 Saltaire V-25 Hauppauge S-211 Springs Sd24 Montauk L-33 Shelter Island T-07 Shoreham V-26 Huntington S-310 Three Village S-225 North Babylon L-22 Smiththwn T-08 Southampton V-27 Islip S-212 Tuckahoe Sd25 Northpod L-23 Southampton T-09 Village of the Branch V-28 Kings Park S-311 Wainscoa Sd26 Patchogue-Medford L-24 Southold T-10 Westhampthn Beach V-29 Laurel Sd09 West Babylon S-317 Sachem L-25 Other V-00 Lindenhurst S-312 West Islip S-226 Sayviile L-26 INCORPORATED VILLAGES Little Flower Sql0 Westhampton Beach Sd27 Shoreham-Wading River L-27 NAME CODE SCHOOL DISTRICTS Longwood S-214 West Manor S-228 Smithtown L-28 Amiiyviile V~01 Amaganseti S-101 Matfftuck - Cutchogue Sql1 William Floyd S-227 South Huntington L-29 Asharoken V~02 Amityville S-301 Middle Country S-213 Wyandanch S-318 West Babylon L-32 Babylon V~03 Babylon S-302 Miller Place S-215 West Islip L-30 Belle Terre V~04 Bay Shore S-201 Montauk Sql2 LIBRARIES Wyandanch L-31 Mt. Sinai S-216 NAME CODE Other L-00 Bellpo ff V~05 Baypo ff-Blue Point S-202 New Suffolk Sq13 Ami~yville L~01 Brightwaters V~06 Breniwood S-203 Nodh Babylon S-313 Babylon Public L~02 Dering Harbor V~07 Bridgehampton Sd02 Noflhport · E. Northport S-314 Bay Shore · Brighiwaters L~03 East Hampton V~08 Center Mor~hes S-204 Oysterponds S-114 Baypott · Blue Point L~04 Greenpod V~09 Central ISlip S-205 Patchogue-Medford S·217 Brenlwood L~05 Head-of-the-Harbor V·10 Cold Spdng Harbor S-303 Pod Jefferson S·218 Center Moriches L~06 Huntington Bay V·11 Commack S-304 Quogue S·115 Isiandia V·30 Comsewogue S-206 Remsenberg · Speonk S·116 Central Islip L~07 Lake Grove V·12 Connetquot S-207 Riverhead S·ll7 Commack L~08 Copiague S-305 Rocky Point S·219 Comsewogue L~09 DECLARATION: I declare, subject to the penalties of perjury that the statements made in this application (including statements made in any accompanying papers) have been examined by me and to the best of my knowledge and belief are true and correct. I fudher request and authorize any former or present employer, military records center, police, parole, and probation agencies, and former school to provide to the Suffolk County Department of Civil Service any and all information including, but not limited to information as to my character, habits, work ability, and/or education. In consideration of compliance with this request, I hereby release and discharge said institutions from any claims, liabggies, or damages. X DATE SIGNATURE OF APPLICANT State former name or any other name(s) by which you were known. 09-0101.07/02cb