hereby elect to give up my additional credits on the eligible list indicated above. I understand that this election is final and cannot be changed for this particular examination eligible list. However, this does not affect my right to claim additional credits in other examinations.

This section is for use by an eligible who is using additional credits to obtain a permanent or contingent permanent appointment or promotion.

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In accepting appointment to the position shown above, I certify that I have not, since January 1, 1951, previously received a permanent appointment or permanent promotion as a result of the use of additional credits as a disabled war veteran, in the service of the State or any of its political subdivisions, including County, Town, City, Village, School District or Special District in New York State.

I further recognize that all statements made by me in support of my claim for additional credits are subject to investigation and verification and that any material misstatement or fraud in this claim may result in this appointment being rescinded and in my disqualification.

- U.S. citizen or alien lawfully admitted for permanent residence.
- Qualifying Active Service Dates (and Campaign) Honorable Discharge or release under honorable circumstances from the Armed Forces of the United States.
- New York State residence at time of appointment.

PURPOSE: (1) To provide a positive indication of use or waiver of ALL claimed veteran credits; (2) to provide positive verification of eligibility for claimed veteran credits; and (3) to enhance the accuracy of veteran’s information in central personnel records.

All eligibles who have claimed veteran credits and who receive permanent or contingent permanent appointment from an eligible list in which they have claimed veteran credits MUST either waive or use the credits. No permanent or contingent permanent appointment of such eligible will be accepted by the local civil service agency in the absence of this waiver or acknowledgment of use.

1 – 4. Enter information as called for in appropriate boxes.
3. Date of Appointment is to be completed if appointment is made.
5. Veteran Claim: Enter NDV for non-disabled veteran; DV for disabled veteran.
6. Examination Number: Enter exam number from eligible list.
7. Certification Number: Enter number as indicated on the certification, if applicable.
8 – 9. Enter information as called for in appropriate boxes.
10 – 11. Score and Relative Standing With Veteran Credits: Enter eligible’s score as it appears on list and the eligible’s relative standing (rank on the eligible list) among those eligibles willing to accept appointment to this position (see number 4) based upon the score entered in number 10.
12 – 13. Score and Relative Standing Without Veteran Credits: Enter eligible’s score minus additional veteran credits (from list) and the eligible’s relative standing (rank on the eligible list) among those eligibles willing to accept appointment to this position. (Eligibles who have not declined or indicated unwillingness to accept appointment to the position must be considered as willing to accept appointment.) This form should not be used for temporary appointments since temporary appointments do not affect veteran credits.

Section 2 - Election To Give Up Additional Credits: This waiver must be signed by all eligibles who elect to waive their claim of veteran credits, regardless of whether or not they are subsequently appointed from this list to this position. In fairness to all eligibles, the full consequences of such waiver should be clearly stated to the eligible before the waiver is executed.

Section 3A - Acknowledgment Of Use Of Additional Credits: This acknowledgment must be signed by all eligibles who require the additional credits to be reachable for appointment to this position and who are to be appointed. If the eligible does not require the additional credits in order to be reachable, such eligible should be clearly so advised.

Section 3B - Verification of Eligibility For Veteran Credits: This verification must be completed whenever an appointment is made of an eligible who has veteran credits, whether using or waiving such credits. Include a copy of the DD-214 or other supporting documentation.

1. U.S. citizen or an alien lawfully admitted for permanent residence at the time of application for veteran credits.
2. Service in the Armed Forces of the United States or the U.S. Public Health Service during any of the following periods (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 a call as provided by law on a full-time active duty basis other than active duty for training purposes) during any of the following Time of War periods.

In the Armed Forces: - August 2, 1990 until the Persian Gulf Hostilities end
- February 28, 1961 to May 7, 1975
- June 27, 1950 to January 31, 1955
- December 7, 1941 to December 31, 1946

Or earned the armed forces, navy, or marine corps expeditionary medal for service in:
- (Panama) December 20, 1989 to January 31, 1990
- (Lebanon) June 1, 1983 to December 1, 1987
- (Grenada) October 23, 1983 to November 21, 1983

Or in the U.S. Public Health Service:
- June 26, 1950 to July 3, 1952
- July 29, 1945 to September 2, 1945

3. Honorable Discharge or release under honorable circumstances.
4. Resident of New York State at time of appointment.

1. Same documents as for U.S. Immigration and Naturalization Service Employment Eligibility Verification Form I-9. (Enter Document Name)
2. Report of Separation and Honorable Discharge and/or Certificate of Service. Military forms NAVPERS-533; NAVMC-78; WDAGO-53; 55; WDAGO-53, 98; DD 214. If eligible’s name is different from that shown, require marriage certificate or other appropriate legal document to verify name. (Enter form number(s), service serial number and dates of active service. If expeditionary medal, enter campaign name.)
3. Same documents as for requirement 2 above.
4. Various documents acceptable: NYS Driver’s License, NYS Tax Records, utility bills, etc. No specific minimum time period required prior to date of appointment. (Enter County of residence.)

If the eligible fails to meet any of the above requirements, he or she may not be appointed if the use of veteran credits is necessary in order for the eligible to be reachable. You should indicate the deficiency in the appropriate area of the eligibility requirements, attempt to secure a copy of that documentation which is offered, and forward the copy with this form and a brief explanatory memorandum to the Yates County Personnel Office IMMEDIATELY. The covering memorandum should indicate why you believe the claim to be deficient and your assessment regarding the likelihood of any fraud having been committed.

Questions about use of veteran credits for appointment to State government may be directed to the Yates County Personnel Officer by calling 315-536-5112 or in the mail at
417 Liberty Street
Penn Yan, NY 14527