EOANF-HRD

Department Information

City or Town of:(Required)

Department:(Required)

Date of Submission:(Required)

Type of Emergency Employment : To the Personnel Administrator: Under Civil Service Law, I hereby(Required)

Report the emergency employment*

Request permission to renew the emergency employment**

Candidate Information

Name(Required)

First Middle Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Last four of Social Security Number(Required)

Please enter a number less than or equal to 9999.

Position to be Appointed

Position Title(Required)

First date of employment(Required)

Anticipated duration of emergency employment. Please indicate if this is in hours or days.(Required)

Reason (Definite reasons must be stated in order to have emergency approved)

Duration of Emergency Employment

*Original emergency employment may not exceed a period of 30 days within 60 consecutive days following the date of appointment.

**Emergency employment may be renewed for one additional period in the same twelve month period, only after the expiration of the original 60-day period.

In departments, institutions and hospitals the functions of which are connected with the public safety or public health, emergency employment may be renewed for a second period in the same twelve-month period.

Emergency employment only in the position of LABORER may be renewed immediately after the original emergency employment for a period not to exceed 15 days, in which event emergency employment may not be further renewed in the same twelve-month period.

Intermittent or part-time employment should be reported on an hourly basis but in no case shall such employment exceed 240 hours in the 60-day period immediately following the date of the original appointment, renewal or renewals as the case may be.

If more than one appointment has been made to the position, please ensure to submit an emergency appointment for each individual.

Name, Title(Required)

By typing my name, I confirm that the information provided is true and accurate, and I agree to the terms stated above.

Email(Required)