REMARKS:
ALL STATEMENTS ARE SUBJECT TO VERIFICATION. MISREPRESENTATIONS MAY CONSTITUTE CAUSE FOR
DISQUALIFICATION OR DISCHARGE. IT IS A CRIME PURSUANT TO SECTION 210.45 OF THE NEW YORK STATE
PENAL LAW, PUNISHABLE AS A CLASS “A” MISDEMEANOR, TO KNOWINGLY MAKE A FALSE STATEMENT
HEREIN.
Background Investigation: Applicants may be required to undergo extensive investigation of criminal history and
background, which will include a fingerprint check, to determine suitability for appointment. Costs related to such investigation
may be borne by the applicant. Failure to meet the standards of investigation may result in disqualification.
For County employment: You may be required to submit to a pre-employment drug test. Your appointment may be
conditioned on such test result.
THIS AFFIRMATION AND AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION MUST BE COMPLETED:
By my signature below, I hereby authorize the Orange County Department of Human Resources, the County of Orange, and/or
its respective Departments, Offices or Agencies to request verbal records or written verification of any or all information
contained herein. I further authorize a review and full disclosure of all records concerning me whether said records are of a
public, private or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of
records.
I further release the Orange County Department of Human Resources, the County of Orange, and/or its respective
Departments, Offices or Agencies, and their respective officers and/or employees from any and all liability which may be
incurred as a result of collecting such information. Further, my signature below certifies I have read and fully understand the
“Affirmation and Authorization for Release of Personal Information” and have acknowledged that a photocopy of this
Application for Examination/Employment containing this release will be valid as an original thereof, even though said
photocopy does not contain an original writing of my signature. I affirm that all statements made on this application (including
any attached paper) are true under the penalties of perjury.
_____________________________________ _________________ ___________________________________________
SIGNATURE OF APPLICANT DATE PLEASE PRINT ANY OTHER NAME BY WHICH
YOU ARE OR HAVE BEEN KNOWN
CHECK TO MAKE SURE THAT ALL APPLICABLE QUESTIONS HAVE BEEN ANSWERED. AN INCOMPLETE
APPLICATION MAY RESULT IN DISAPPROVAL. A RESUME MAY NOT BE SUBMITTED IN LIEU OF COMPLETING THE
APPLICATION.
The New York State Human Rights Law prohibits discrimination in employment because of age, race, creed, color, national
origin, sexual orientation, military status, sex, disability, genetic predisposition or carrier status, or marital status. Accordingly,
nothing in this application form should be viewed as expressing, directly or indirectly, any limitation, specification, or
discrimination as to age, race, creed, color, national origin, sexual orientation, military status, sex, disability, genetic
predisposition or carrier status, or marital status in connection with employment in the municipal service of the County of
Orange.
ORANGE COUNTY GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
9/12/2013