Application for Qualifying Examination

New Jersey Civil Service Commission

INSTRUCTIONS: Please print or type. Answer all pertinent questions and ensure that all information FOR APPOINTING AUTHORITY
is accurate and complete. Sign your name in Block 9. USE ONLY
Return your completed application to your Personnel Office for approval. Name of Appointing Authority:
The Civil Service Commission will only accept Qualifying Applications that are
approved by and submitted directly from the Appointing Authority.
Address:
Appointing Authority: By signing and submitting this application, you are affirming
that the applicant’s representation of his or her job duties while employed by your
agency are true and accurate to the best of your knowledge and that any out-of-title Appointing Authority Signature:
work duties listed on this application were performed by the applicant and assigned
out of business necessity. Your affirmation also serves as your request that the
Civil Service Commission consider the applicant’s out-of-title work experience
when evaluating his or her eligibility for the title sought. Any false representations
regarding out-of-title work will result in denial of the application. c Lateral c Demotional
c Pre-Appointment Evaluation
Please note: Per N.J.A.C. 4A:4-7.6(c)4, A lateral title change pending examination
shall not be permitted when either a special reemployment or complete
Is this PAQ due to a classification
promotional list exists or when an appropriate representative of the Civil Service
determination?
Commission has received a request to conduct a promotional examination.
c Yes c No
1. Employee Identification Number: 2. Title of Qualifying Examination and Title Code:

3. Name and Address:

Last: First: M.I.:

Street:

City: State: Zip Code:

Email Address: County Daytime Telephone(including area code):

BACKGROUND DATA
4. Education (Indicates the highest level Diploma or Degree you have earned):
c High School Diploma or GED c (A) Associate’s Degree c (M) Master’s Degree
c (S) Some College but No Degree c (B) Bachelor’s Degree c (D) Doctorate

5. Check the county in which you prefer to take the examination. (Check one box only)
c (1) Camden c (2) Mercer c (3) Essex c (4) Monmouth c (6) Atlantic c (7) Bergen
6. ADA ASSISTANCE
c Check the box if you would like to contacted regarding auxiliary aid or reasonable accommodation in taking this examination in
accordance with the Americans with Disabilities Act.
EMPLOYMENT INFORMATION
7. Present Permanent Title and Appointment Date: Address:

Department/Agency: Name and Title of Immediate Supervisor:

Division, Bureau, or Institution: Telephone Number and Email Address of Immediate Supervisor:

* 8. Your Employee Identification Number will be kept confidential and used as your applicant I.D. number to identify correctly and track all of your records and
transactions associated with the application and testing process. Collecting this data is permissible under N.J.S.A. 11A:4-1, but its submission is voluntary. If
you do not provide the number, a unique number will be assigned to you. However, once assigned, you will be responsible for remembering it for any inquiries
you may have concerning your application or testing process.
9. SIGNATURE: I CERTIFY that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are
made in good faith. I understand that if my application is incomplete, it may be rejected. (WARNING: The NJ Civil Service Commission may refuse to examine,
or certify after examination, any applicant who makes a false statement of any material fact per N.J.A.C. 4A:4-6.2).
FOR CSC ONLY
NOTE: Your application may be released to the Appointing Authority for the purpose of verifying information with regard to your qualifications.

Signature____________________________________________________________________________ Date___________________________
DPF1-C Qual (page 1 of 2) Revised 10.02.2023 IMPORTANT-please complete page 2 of this application and keep a copy for your records
 Title of Qualifying Examination and Title Code: Employee Identification Number:

10. EDUCATIONAL SECTION - COLLEGE AND GRADUATE SCHOOL - List any colleges, universities, and graduate schools you have attended. If it is
required in the job announcement, be sure to attach a copy of your transcript or a list of courses, course descriptions, and credits completed. Foreign degrees/
transcripts must be evaluated by a recognized evaluation service.
What is the name and location of the What years What was your major course What type of Did you graduate? If NO, when Number of credits
college(s) you attended? did you of study? degree did will you earned?
attend? you earn? graduate?

From:
To:
 Y N _________
Month/Year

From:
To:
 Y N _________
Month/Year

11. OTHER SCHOOLS OR TRAINING COURSES - Include business, vocational, technical, or military schools you have attended, as well as any training
courses that are related to the title for which you are applying. If it is not a full-time curriculum, be specific as to the number of hours attended.
What is the name & location of school/facility where What classes did you take? What were the dates How many Did you complete
course(s)/training was held? you attended? hours per the program?
week did
you attend?

_________ _________  Y  N
Month/Year TO Month/Year

_________ _________  Y  N
Month/Year TO Month/Year

12. Use this space to describe any internships, licenses, certifications or registrations that you possess which are related to the position for which you are applying.
A. What type of license(s), certification(s), and/or registration(s) do you hold? C. What type of internship(s) have you completed?

Where was the internship(s) completed?

In which state(s) do you hold the license(s), certification(s), and/or registration(s)?
What were the dates of the internship(s)?

B. What was the original issue date of the license(s), certification(s), and/or registration(s)? How many hours per week did
you take part in the internship? _____________

What is the date of your current license(s), certification(s), and/or registration(s)? Was it part of a college curriculum? Y N

13. EMPLOYMENT RECORD - If you do not properly complete your application you may be declared ineligible. If you held different positions with the
same employer, list each position separately. Make sure you give full dates of employment (month/year), indicate whether the job was full or part time,
and the number of hours worked per week. Since your application may be your only “test paper,” be sure it is complete and accurate. Failure to complete
your application properly may cause you to fail. If more space is needed, attach separate sheets.

A
What is the name and address of your What is your title in this position? What duties do you perform in this position that are
current employer? relevant to the position for which you are applying?
_____________________________________
Is this position:
FULL TIME?
PART TIME?
(Average No. hrs. per wk.) - - - - - -
What dates have you been employed in this position?
How many staff members do you supervise?
From: _______________ To: ___________________
Month/Year Month/Year Professional Staff __________Support Staff ______________

B
What was the name and address of your What was your title in this position? What duties did you perform in this position that are
previous employer? relevant to the position for which you are applying?
_____________________________________
Was this position:
FULL TIME?
PART TIME?
What dates have you been employed in this position? (Average No. hrs. per wk.) - - - - - -

How many staff members do you supervise?

From: _______________ To: ___________________
Month/Year Month/Year Professional Staff __________Support Staff ______________

C
What was the name and address of your What was your title in this position? What duties did you perform in this position that are
previous employer? relevant to the position for which you are applying?
_____________________________________
Was this position:
FULL TIME?
PART TIME?
What dates have you been employed in this position? (Average No. hrs. per wk.) - - - - - -

How many staff members do you supervise?

From: _______________ To: ___________________
Month/Year Month/Year Professional Staff __________Support Staff ______________

DPF1-C Qual (page 2 of 2) Revised 10.02.2023 DID YOU INCLUDE ANY ATTACHMENTS TO THIS APPLICATION YES NO