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Telecommuting Pilot Program Application

Personal Privacy Protection Law Notification

The information you are providing will be used to determine your eligibility to participate in the Telecommuting Pilot Program. This information will be retained by your agency. Failure to provide the requested information may result in a delay in processing or denial of your application.

It is the responsibility and the intent of the State of New York to fully comply with the provisions of article 6-A of the Public Officer’s Law, the Personal Privacy Protection Law. The Personal Privacy Law protects you from the random collection of personal information by state agencies. The law enables you to access and/or correct information on file which pertains to you. It also regulates disclosure of personal information to persons authorized by law to have access for official use.

  • 1Application> 2Supervisor's Approval
  • Please check one: *
    Please check one:
  • Name: Name: *
  • Emergency contact information: (voluntary) Emergency contact information: (voluntary)
  • Phone (Emergency Contact) Phone (Emergency Contact) - -
  • Are you currently serving a probation period? *
    Are you currently serving a probation period?
  • Do you have a state-issued Laptop? *
    Do you have a state-issued Laptop?
  • Do you have a personal computer (PC)? *
    Do you have a personal computer (PC)?
  • Attestation:
    I am in receipt of, have read and agree to adhere to the Telecommuting Pilot Program.
    Attestation:
    I am in receipt of, have read and agree to adhere to the Telecommuting Pilot Program. *
  • Draw or Type
    I understand this is a legal representation of my signature. Clear
  • Click on the "Continue" button below to begin Supervisor's approval.

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