NYS Office of Parks, Recreation and Historic Preservation Employment Application - Free Download | Page 2
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NYS Office of Parks, Recreation and Historic Preservation Employment Application Page 2
NYS Office of Parks, Recreation and Historic Preservation Employment Application
Name Date
PERSONAL PRIVACY PROTECTION LAW NOTIFICATION
The information you are providing on this application is being requested for the
principal purpose of determining eligibility for initial and continued employment. The
information may also be used in administering employee benefit programs and will
be used in accordance with Section 96(1) of the Personal Privacy Protection Law.
Failure to provide the requested information may hinder your possible hiring and the
subsequent administration of your employee benefits.
THIS APPLICATION WILL BE KEPT ACTIVE FOR ONE YEAR. AFTER THAT, YOU MUST REAPPLY.
DO NOT WRITE BELOW
PLEASE CHECK OFF WHICH FORMS ARE ATTACHED
I-9 W-4 Retirement System Application/Declination
Working Papers (if necessary) IT2104 Designation of Benificiary (if Declining)
Dual Employment (if working for another state agency) Health Insurance Forms Retirement No.
Military Statement (Forward DD-214) Oath of Office Card Holiday Waiver Form
Veteran Yes No
Name
Address
Day Phone
to
Dates of Service
Member of NYS Retirement System Yes No
Evening Phone
Signed
Title
Date
Item No. Title
Location Date of Hire
D.O.B.
Driver’s License No.
Class
Expires
NOTIFY IN CASE OF EMERGENCY
An Equal Opportunity/Affirmative Action Agency
License Restrictions/Convictions
The following section to be completed ONLY after hire
Initial Appointment Date
(if previously employed with OPRHP)
E.C.
INTERVIEWER'S COMMENTS:
Please provide the name and contact information for three references:
BACKGROUND / REFERENCE CHECK AND RELEASE FORM
1. Name
Day Phone E-Mail Address
Address
3. Name
Day Phone E-Mail Address
Address
I, , hereby authorize the
New York Office of Parks, Recreation and Historic Preservation
to make such investigations and inquires of my employment and
background as may be necessary in arriving at an employment
decision. I hereby release those designated as references from all
liability in responding to inquiries in connection with my application.
Signature Date
(Print Name Here)
2. Name
Day Phone E-Mail Address
Address
Annual Salaried Positions
The information will be maintained by the Director of Personnel, Office of Parks,
Recreation and Historic Preservation, Albany, New York 12238, (518) 474-0453.
Hourly Wage (Temporary/Seasonal) Positions
The information will be maintained by the Regional Director (or his or her designee)
in the region(s) where you are applying for employment.
Social Security No.
The social security number will be used to verify eligibility for employment for those positions that require prior service with New York
State. Failure to provide your social security number at the time of application will not disqualify you from consideration, but you will
be required to provide it before any offer of employment can be made. Your social security number will not be given to the public, or
appear on any form or information request.
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