FORM NYS-APP (7/2023 L)
www.cs.ny.gov

NON-REFUNDABLE PROCESSING FEEAPPLICATION FOR NYS EXAMINATIONSApplication Processing
New York State Department of Civil Service
Albany, NY 12239

Send
Completed
Application to:

Read Instructions on Page 3 First - Please Print Clearly
If applicable, please complete additional information on page 4.

Announced
Test Date:
Exam No(s).

M
A
X
E
L
L
N
A
O
I
T
A
CI
LPP
E
A
R
A
S
E
E
YFL
TN
E
RRU!
CDEVIWA

If you are a NYS employee in a position represented by CSEA and you are applying for an OPEN-COMPETITIVE examination,
you are not required to submit a processing fee under current negotiated agreements. Check the box “I am applying for anOPEN-COMPETITIVE examination and my fee is paid by my union because I am a NY State employee represented by CSEA in
Negotiating Units 02, 03, 04 or 47. (State employees represented by PEF are required to pay the Application Processing Fee.)”
Refunds will not be issued to employees covered by the agreements if they submit a fee.
FEE WAIVER: No fee is due if you are unemployed and primarily responsible for the support of a household. Do notenclose any payment with your application. Check the box, “I am unemployed and primarily responsible for the support of ahousehold.”
No fee is due if you are determined eligible for Medicaid, or receiving Supplemental Social Security payments, or PublicAssistance (Temporary Assistance for Needy Families/Family Assistance or Safety Net Assistance) or are certified Job Training
Partnership Act/Workforce Investment Act eligible through a state or local social service agency. Do not enclose any payment
with your application. Check the box, “I am receiving public assistance.” All claims are subject to verification. Those notsupported by appropriate documentation are grounds for barring or rescinding an appointment.    Titles(s)Last Name

Refer to the front of the exam announcement for the required processing fee. Enclose a check or money order for the total
amount required, made payable to the New York State Department of Civil Service. DO NOT SEND CASH. If your application
is disapproved, the fee will not be refunded. Check the box, “I have enclosed the fee.”     First Name    MIMailing Address:  No., Street, Apt., or P.O. Box
City or Post Office           State      Zip CodeNo fee is due if you are a Veteran discharged under honorable conditions from the Armed Forces of the United States or New
York State. Check the box, “I am applying for an OPEN-COMPETITIVE examination and I am a Veteran.”

Check OneI have enclosed the fee.      (Enclose a check or money order payable to       the NYS Department of Civil Service).       DO NOT SEND CASH.
(The Fee will NOT BE REFUNDED
if your application is DISAPPROVED.)

Email Address # 1  Email Address # 2

I am applying for an OPEN-COMPETITIVE examination and myfee is paid by my union because I am a NY State employee
represented by CSEA in Negotiating Units 02, 03, 04 or 47. (Stateemployees represented by PEF are required to pay the Application
Processing Fee.)I am unemployed and primarily responsible for the support of ahousehold.
I am receiving public assistance.
I am applying for an OPEN-COMPETITIVE examination and I
am a Veteran.

Social Security NumberHome Phone

FEE WAIVER: No Fee Is Due Because:Day Phone

I affirm under penalties of perjury that all statements made on this application (including any attached papers) are true. I understand that allstatements made by me in connection with this application are subject to investigation and verification and that a material misstatement or fraud
may disqualify me from appointment and/or lead to revocation of my appointment. I understand the application processing fee(s) paid with thisapplication is non-refundable. I understand and will comply with the mandatory COVID-19 vaccination/testing policy and mask requirement for
any in-person examinations administered at a New York State test center.

XELIGIBILITY FOR EMPLOYMENTYou must be legally eligible to work in the United States atSignature of Applicant      Date
Please print any other last name by whichtime of appointment and throughout your employment withyou are or have been known.
New York State.  If appointed, you must produce documentsthat establish your identity and eligibility to work in the UnitedStates, as required by the Federal Immigration Reform andControl Act of 1986, and the Immigration and Nationality Act. It is the policy of the State of New York to provide for and promote equal opportunity employment, compensation, and other terms and conditions

For Civil Service Use OnlyWGU

Vof employment without unlawful discrimination on the basis of age, race, color, religion, disability, national origin, gender, sexual orientation,veteran or military service member status, marital status, domestic violence victim status, genetic predisposition or carrier status, arrest and/orcriminal conviction record, or any other category protected by law, unless based upon a bona fide occupational qualification or other exception.
It is the policy of New York State Department of Civil Service to provide qualified persons with disabilities equal opportunity to participate in andreceive the benefits, services, programs and activities of the Department, and to provide such persons reasonable accommodations andreasonable modifications as are necessary to provide such equal opportunity, including accommodations in the examination process. Further, itis the policy of the Department to provide reasonable accommodations for religious observance or practice.

FORM NYS-APP (7/2023 L)
www.cs.ny.gov

Application for NYS Examinations

Page 2

YOUR EDUCATION: Read the exam announcement for educational requirements, if any. If specialized coursework is required,attach a copy of the transcript or a list of the required courses and the number of credit hours you completed.
Do you have a High School or
Yes If yes, Name and Location of High Schoolor Issuing Governmental Authority:
Equivalency Diploma?
No
Quarter
Type of Major Subject
College, University, Professional or Semester
Did You
DegreeCredits
HoursDegreeor Type ofGraduate Expected
Technical Schools
Received
Received Received
Course
MO.
YR.
Yes
Name
No

Address (City, State)
NameYes
NoMO.

YR.

Address (City, State)
LICENSE OR CERTIFICATION: Complete the following if a license, certificate or other authorization to practice a trade orprofession is required on the announcement(s).
Trade or Profession
License Number Date License Registration
If you are not
MO.
YR.
MO.
YR.
First Issued
currently licensed,
check this box:
FROM
TOSpecialty
Granted by (licensing agency)
DESCRIBE YOUR EXPERIENCE: Beginning with your most recent, list all employment, military service, or volunteer experiencethat shows you meet the minimum qualifications for the examination(s). We cannot interpret omissions or vagueness in your favor.
You are responsible for an accurate and clear description of your experience. Do not send your resume. Under 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.
LENGTH OF EMPLOYMENT
MO.
YR.
MO.
YR.

FROM

TO
TYPE OF BUSINESSFIRM NAME

ADDRESSCITY AND STATEADDRESSCITY AND STATE

DUTIES:YOUR EXACT TITLE
NAME OF YOUR SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week
(exclusive of overtime):LENGTH OF EMPLOYMENTMO.
YR.
MO.
YR.
FROMTOTYPE OF BUSINESSFIRM NAME

DUTIES:YOUR EXACT TITLE
NAME OF YOUR SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week
(exclusive of overtime):

BE SURE TO READ THE REQUIRED QUALIFICATIONS ON THE EXAMINATION ANNOUNCEMENT(S)ALL STATEMENTS ARE SUBJECT TO VERIFICATIONFORM NYS-APP (7/2023 L)
www.cs.ny.gov
LENGTH OF EMPLOYMENTMO.
YR.
MO.
YR.
FROMTOTYPE OF BUSINESS

Application for NYS Examinations
FIRM NAMEADDRESSPage 3CITY AND STATE

DUTIES:YOUR EXACT TITLE
NAME OF YOUR SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week
(exclusive of overtime):(Attach additional 8 ½” x 11” sheets if necessary.)

INSTRUCTIONSEXAMINATION APPLICATION

Use this form to apply for all New York State Civil Service examinations (the five-digit examination number). Read each examannouncement carefully to be sure that you meet the Minimum Qualifications.
You may list up to four exam numbers on one application, as long as they are all being held on the same date.
Unless the exam announcement has different instructions, mail your application to Application Processing, NYS Department ofCivil Service, Albany, NY 12239.

ADMISSION TO EXAMINATION

We usually review your application before the test to be sure that you appear to qualify. Generally we will advise you if we need more
information. You may be admitted to the test pending a full review of your application. If you take the test but your application isdisapproved later, you will not receive a test score. If your application is disapproved, we will notify you of the reason.
If you are applying for a written test and you do not receive an admission notice from us at least three days prior to the test date,
immediately call (518) 474-6470 in the Albany area, or toll free at 1-877-697-5627.

PLACE OF EXAMINATION
AlbanyAmsterdam
Binghamton
Buffalo
Fredonia
Hicksville

Unless the exam announcement states otherwise, written tests areheld in the following locations, although some may not be open forevery examination. You will be assigned to the nearest OPEN
location based on the postal ZIP code for your mailing address.
Oral tests are usually held in Albany only.

KingstonMiddletown
New York City (Manhattan)
NyackPort Jefferson
Poughkeepsie

Rochester
Saranac Lake
Syracuse
Utica
Watertown

EXTRA CREDITS FOR VETERANS

Answering questions in this section means that you are requesting extra credits as either a non-disabled veteran or a disabledveteran. All veterans are encouraged to answer questions in this section of the application to ensure that appropriate points areadded to passing examination scores. Veterans who answer “YES” to questions 1 AND 2 may receive tentative credits as a nondisabled veteran; candidates who also answer “YES” to question 3 may receive tentative disabled veteran credits. If you previously
used non-disabled veteran credits to obtain a permanent appointment to a position in New York State or Local Government, andsubsequent to appointment, were certified as a disabled veteran, you may be eligible to receive additional disabled veteran credits by
answering “YES” to BOTH questions 5a AND 5b in this section. NOTE: All veterans claiming extra credit will be required to produce
eligibility documentation which will be verified at time of interview. Candidates found ineligible for such credit will have the points
subtracted from their examination score(s). If it is determined that veteran credits do not increase one’s reachability for appointment
from an eligible list, the use of veteran credits for such appointment will be waived, and veteran credits can be claimed for future civil
service examinations until such time as they are used to receive a permanent appointment as provided by the New York State
Constitution.

ADDITIONAL EXAMINATION CREDITS PURSUANT TO CIVIL SERVICE LAW SECTION 85-a

If you are a child or sibling of a firefighter, police officer, emergency medical technician, or paramedic who was killed in the line ofduty in the service of New York State, you may be entitled for additional examination credits pursuant to Civil Service Law Section
85-a. For further information, please contact the Department of Civil Service at (518) 473-6437.

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION

The information which you are providing on this application is being requested pursuant to Section 50.3 of the New York State Civil
Service Law for the principal purpose of determining the eligibility of applicants to participate in the examination(s) for which theyhave applied. This information will be used in accordance with Section 96(1) of the Personal Privacy Protection Law, particularly
subdivisions (b), (e), and (f). Failure to provide this information may result in disapproval of the application. This information will bemaintained by the Director, Division of Staffing Services, Department of Civil Service, Albany, New York 12239; telephone (518) 4736437. For further information, relating only to the Personal Privacy Protection Law, call (518) 457-9375. (For examination
information, call (518) 457-2487 or toll free at 1-877-697-5627.)

FORM NYS-APP (7/2023 L)
www.cs.ny.gov
TESTING ACCOMMODATIONS:Application for NYS Examinations
All accommodation requests will be subject to verification.

Page 4

RELIGIOUS OBSERVANCE OR PRACTICE: Most written tests are held on Saturdays. If you cannot be tested on Saturday due to a religious observance or practice, you must check the box next tothe question below. If you check this box, the Department of Civil Service will schedule your test for the Sunday following the test date. Sunday tests are generally administered in Albany, Buffalo,and New York City. (If you need something other than a Sunday test date due to a religious observance or practice, please use “Other Accommodations” below).
I require a Sunday test date due to a religious observance or practice.
REASONABLE ACCOMMODATIONS FOR INDIVIDUALS WITH DISABILITIES: Reasonable Accommodations are provided for persons with disabilities who wish to take a test. If you need a test
accommodation due to disability, please check the box below.
I require a reasonable accommodation due to a disability.
OTHER ACCOMMODATIONS: Requests for Testing Accommodations may also be requested as needed due to pregnancy, for nursing mothers, or for other circumstances that may impact yourability to be tested without accommodation. If you will need a test accommodation for such other reasons, or if you need something other than a Sunday test date due to a religious observance orpractice, please check the box below.
I require a test accommodation, other than a Sunday test day, for reasons other than a disability.

EXTRA CREDITS FOR VETERANS – See page 3 for specific instructions and information relating to Veteran Credits
COMPLETE THIS SECTION ONLY IF YOU: Wish to claim Veteran Credits, AND have not used DISABLED veteran credits for a permanent appointment to a position in New York State or Local
Government.
1. Yes

NoDo you expect to receive or have you already received a discharge which was honorable or release under honorable circumstances from the Armed Forces of the UnitedStates; or have you applied to or been approved by the New York State Department of Veterans’ Services as a veteran pursuant to the Restoration of Honor Act? The“Armed Forces of the United States” means the Army, Navy, Marine Corps, Air Force and Coast Guard, including all components thereof, and the National Guard when in
the service of the United States pursuant to call as provided by Law, on a full-time active duty basis other than active duty for training purposes.

2. YesNo

Are you now serving, or have you served, on a Federal active duty basis other than active duty for training purposes?

3. YesNo

Are you a United States citizen or a non-citizen lawfully admitted for permanent residence?

4. YesNo

Do you have a service connected disability rated at 10% or more by the U.S. Department of Veterans Affairs?

5a. YesNo

Have you USED NON-DISABLED veteran credits for a permanent appointment to a position in New York State or Local Government?

5b. YesNo

If you answered "Yes" to "5a" above, you must answer “5b”:
After you were permanently appointed using non-disabled veteran credits, were you subsequently certified as having a service connected disability rated at 10% or moreby the U.S. Department of Veterans Affairs?

New York State Residency Requirement for Extra Credits as a Veteran or Disabled Veteran: You will be required to provide proof of current New York State residency at time ofappointment.

ADDITIONAL QUESTIONS FOR OPEN-COMPETITIVE* APPLICANTS ONLYCertain job titles, including many law enforcement positions (such as Correction Officer, Parole Officer, and Park Patrol Officer) and direct patient care positions (such as Mental Health Therapy Aideand Secure Care Treatment Aide), are also subject to agency criminal history background investigations, as required by law. Applicants should read the official examination announcement for more
specific information.
If you answer YES to either of these questions, you MUST provide a detailed explanation in the REMARKS section provided below, including employer information, position, reasonsand dates:
Were you ever discharged from any employment except for lack of work, funds, disability or medical condition?
No
1. YesREMARKS:

2. Yes

NoDid you ever resign from any employment rather than face a dismissal?

* An examination open to the general public.

(Attach additional 8 ½” x 11” sheets if necessary)