FORM 16-II (PAR.09) 			
	CERTIFICATION AND REPORT SUPPLEMENT		
     		     	
AGENCY OR MUNICIPALITY	DEPARTMENTAL PROMOTIONAL LIST	CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT		CERTIFICATION DATE	

THIS FORM MUST BE COMPLETED AND RETAINED WITH THE CERTIFICATION.
Please enter on this form the name(s) of all individuals on the certification who indicated willingness to accept the appointment, regardless of your intention to appoint or not to appoint.  The name(s) must be listed in the exact order in which they appear on the certification.  This form should be retained with the original signed certification by the Appointing Authority and available to the Human Resources Division for audit purposes.

NAME OF CANDIDATE								SELECTED		NOT SELECTED
1.	     											
2.	     											
3.	     											
	Your first appointment must be made from among the above names.
	(1-3 inclusive)
4.	     											
5.	     											
	Your second appointment must be made from among the above names.
	(1-5 inclusive)
6.	     											
7.	                                                                       											
	Your third appointment must be made from among the above names.
	(1-7 inclusive)
8.	     											
9.	     	      										
	Your fourth appointment must be made from among the above names.
	(1-9 inclusive)
10.	     											
11.	     											
	Your fifth appointment must be made from among the above names.
	(1-11 inclusive)
12.	     											
13.	     											
	Your sixth appointment must be made from among the above names .
	(1-13 inclusive)
14.	     											
15.	     											
	Your seventh appointment must be made from among the above names.
	(1-15 inclusive)
16.	     											
17.	     											
	Your eighth appointment must be made from among the above names.
	(1-17 inclusive)
18.	     											
19.	     											
	Your ninth appointment must be made from among the above names.
	1-19 inclusive)

20.	     											
21.	     											
	Your tenth appointment must be made from among the above names.
	(1-21 inclusive)

Signature of Appointing Authority							      Date                         

FORM 16-II (PAR.09) PROM			
	CERTIFICATION AND REPORT SUPPLEMENT		
     		     	
AGENCY OR MUNICIPALITY	DEPARTMENTAL PROMOTIONAL LIST	CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT		CERTIFICATION DATE	

NAME OF CANDIDATE							SELECTED		NOT SELECTED
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)

	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)
	     											
	     											
If you are making           appointments, selection must be made from among the above names.
(1-        inclusive)

	Signature of Appointing Authority							      Date