Albany, NY 12239

Instructions:

The agency human resources office completes Part 1. The Director of Human Resources or Director of Personnel must sign the attestation.

The completed signed form and required documentation should be faxed or emailed to your Staffing Services Representative.

The agency will be notified of a determination by the Staffing Services Representative within 2 business days of receiving the completed form.

If you have questions about this form, please contact your Staffing Services Representative.

Part 1- To be completed by agency human resources office (Please print or type)

Agency/Agency Code:

Appointment Title/Title Code:

Location/Location Code:

List No.:

Candidate Name:

Appointment Type:

Advanced placement

70.4 transfer

Advanced placements and 70.4 transfers require an attestation the candidate has demonstrated they meet the minimum qualifications for appointment. Please provide:

Candidate’s completed NYS-APP.

Additional supporting documentation demonstrating the candidate’s qualifications such as college degrees and/or transcripts.

Attestation

Advanced placement - This candidate meets the advanced placement minimum qualifications and is reachable on the eligible list, and appointment from the list is in order.

70.4 transfer - This candidate meets the requirements, including the minimum qualifications, for 70.4 transfer.

Name (Please print or type):	Title:
Signature:	Date:	Phone Number:

Part 2- To be completed by the Department of Civil Service

Approved/Disapproved

Justification:

Staffing Services Representative	Date: