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Application Fee Waiver Request & Certification Form

  1. Examination Information
  2. I request that my application fee(s) for the examination(s) listed below be waived in accordance with Section 50.5(b) of the State Civil Service Law.
  3. Check the Box(es) That Apply to You
    Note: Individuals who can be claimed as a dependent on any other person’s tax return are not eligible for application fee waiver as head of household.
  4. Affirmation
    have read the above portion of Section 50.5(b) of the Civil Service Law relating to the waiver of application fees and certify that I am qualified to receive such waiver for the reasons indicated above. I understand that my claim for application fee waiver may be investigated and I may be disqualified from the listed civil service examination(s) if I make any false statement regarding my eligibility for application fee waiver.
  5. By typing your name into this field you authorize Yates County to consider this an electronic signature.
  6. Leave This Blank:

  7. This field is not part of the form submission.