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

THIS FORM MUST BE COMPLETED AND RETAINED WITH THE CERTIFICATION.
Please enter on this form the names of all individuals on the certification who indicated willingness to accept the appointment, regardless of your intention to appoint or not to appoint.  The names must be listed on this form in the exact order (*) in which they appear on the certification.  The 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.	     											
	If you are making one appointment, selection must be made from among the above names.
	(1-3 inclusive)
4.	     											
5.	     											
	If you are making two appointments, selection must be made from among the above names.
	(1-5 inclusive)
6.	     											
7.	                                                                       											
	If you are making three appointments, selection must be made from among the above names.
	(1-7 inclusive)
8.	     											
9.	     	      										
	If you are making four appointments, selection must be made from among the above names.
	(1-9 inclusive)
10.	     											
11.	     											
	If you are making five appointments, selection must be made from among the above names.
	(1-11 inclusive)
12.	     											
13.	     											
	If you are making six appointments, selection must be made from among the above names.
	(1-13 inclusive)
14.	     											
15.	     											
	If you are making seven appointments, selection must be made from among the above names.
	(1-15 inclusive)
16.	     											
17.	     											
	If you are making eight  appointments, selection must be made from among the above names.
	(1-17 inclusive)
18.	     											
19.	     											
	If you are making nine  appointments, selection must be made from among the above names.
	(1-19 inclusive)
(*) Except for Public Safety certifications issued subject to NAACP or Castro federal consent decrees on which 
minorities must be moved up in compliance with the provisions of the consent decree.

		     	
Signature of Appointing Authority		Date	
			
     		     	
AGENCY OR MUNICIPALITY		CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT	OPEN COMPETITIVE LIST	CERTIFICATION DATE	

NAME OF CANDIDATE	SELECTED		NOT SELECTED	

20.	     	 										
21.	     	   										
	If you are making ten appointments, selection must be made from among the above names.
	(1-21 inclusive)
22.	     											
23.	     											
	If you are making eleven appointments, selection must be made from among the above names.
	(1-23 inclusive)
24.	     											
25.	     											
	If you are making twelve appointments, selection must be made from among the above names.
	(1-25 inclusive)
26.	     											
27.	     											
	If you are making thirteen appointments, selection must be made from among the above names.
	(1-27 inclusive)
28.	     											
29.	     											
	If you are making fourteen appointments, selection must be made from among the above names.
	(1-29 inclusive)
30.	     											
31.	     											
	If you are making fifteen appointments, selection must be made from among the above names.
	(1-31 inclusive)
32.	     											
33.	     											
	If you are making sixteen appointments, selection must be made from among the above names.
	(1-33 inclusive)
34.	     											
35.	     											
	If you are making seventeen appointments, selection must be made from among the above names.
	(1-35 inclusive)
36.	     											
37.	     											
	If you are making eighteen appointments, selection must be made from among the above names.
	(1-37 inclusive)
38.	     											
39.	     											
	If you are making nineteen appointments, selection must be made from among the above names.
	(1-39 inclusive)
40.	     											
41.	     											
	If you are making twenty appointments, selection must be made from among the above names.
	(1-41 inclusive)

		     	
Signature of Appointing Authority		Date	

     		     	
AGENCY OR MUNICIPALITY		CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT	OPEN COMPETITIVE LIST	CERTIFICATION DATE	

NAME OF CANDIDATE	SELECTED		NOT SELECTED	

42.	     											
43.	     											
	If you are making twenty-one appointments, selection must be made from among the above names.
	(1-43 inclusive)
44.	     											
45.	     											
	If you are making twenty-two appointments, selection must be made from among the above names.
	(1-45 inclusive)
46.	     											
47.	     											
	If you are making twenty-three appointments, selection must be made from among the above names.
	(1-47 inclusive)
48.	     											
49.	     											
	If you are making twenty-four appointments, selection must be made from among the above names.
	(1-49 inclusive)
50.	     											
51.	     											
	If you are making twenty-five appointments, selection must be made from among the above names.
	(1-51 inclusive)
52.	     											
53.	     											
	If you are making twenty-six appointments, selection must be made from among the above names.
	(1-53 inclusive)
54.	     											
55.	     											
	If you are making twenty-seven appointments, selection must be made from among the above names.
	(1-55 inclusive)
56.	     											
57.	     											
	If you are making twenty-eight appointments, selection must be made from among the above names.
	(1-57 inclusive)
58.	     											
59.	     											
	If you are making twenty-nine appointments, selection must be made from among the above names.
	(1-59 inclusive)
60.	     											
61.	     											
	If you are making thirty appointments, selection must be made from among the above names.
	(1-61 inclusive)
62.	     											
63.	     											
	If you are making thirty-one appointments, selection must be made from among the above names.
	(1-63 inclusive)

		     	
Signature of Appointing Authority		Date	

			
     		     	
AGENCY OR MUNICIPALITY		CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT	OPEN COMPETITIVE LIST	CERTIFICATION DATE	

NAME OF CANDIDATE	SELECTED		NOT SELECTED	

64.	     											
65.	     											
	If you are making thirty-two appointments, selection must be made from among the above names.
	(1-65 inclusive)
66.	     											
67.	     											
	If you are making thirty-three appointments, selection must be made from among the above names.
	(1-67 inclusive)
68.	     											
69.	     											
	If you are making thirty-four appointments, selection must be made from among the above names.
	(1-69 inclusive)
70.	     											
71.	     											
	If you are making thirty-five appointments, selection must be made from among the above names.
	(1-71 inclusive)
72.	     											
73.	     											
	If you are making thirty-six appointments, selection must be made from among the above names.
	(1-73 inclusive)
74.	     											
75.	     											
	If you are making thirty-seven appointments, selection must be made from among the above names.
	(1-75 inclusive)
76.	     											
77.	     											
	If you are making thirty-eight appointments, selection must be made from among the above names.
	(1-77 inclusive)
78.	     											
79.	     											
	If you are making thirty-nine appointments, selection must be made from among the above names.
	(1-79 inclusive)
80.	     											
81.	     											
	If you are making forty appointments, selection must be made from among the above names.
	(1-81 inclusive)
82.	     											
83.	     											
	If you are making forty-one appointments, selection must be made from among the above names.
	(1-83 inclusive)
84.	     											
85.	     											
	If you are making forty-two appointments, selection must be made from among the above names.
	(1-85 inclusive)

		     	
Signature of Appointing Authority		Date	

			
     		     	
AGENCY OR MUNICIPALITY		CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT	OPEN COMPETITIVE LIST	CERTIFICATION DATE	

NAME OF CANDIDATE	SELECTED		NOT SELECTED	

86.	     											
87.	     											
	If you are making forty-three appointments, selection must be made from among the above names.
	(1-87 inclusive)
88.	     											
89.	     											
	If you are making forty-four appointments, selection must be made from among the above names.
	(1-89 inclusive)
90.	     											
91.	     											
	If you are making forty-five appointments, selection must be made from among the above names.
	(1-91 inclusive)
92.	     											
93.	     											
	If you are making forty-six appointments, selection must be made from among the above names.
	(1-93 inclusive)
94.	     											
95.	     											
	If you are making forty-seven appointments, selection must be made from among the above names.
	(1-95 inclusive)
96.	     											
97.	     											
	If you are making forty-eight appointments, selection must be made from among the above names.
	(1-97 inclusive)
98.	     											
99.	     											
	If you are making forty-nine appointments, selection must be made from among the above names.
	(1-99 inclusive)
100	     											
101	     											
	If you are making fifty appointments, selection must be made from among the above names.
	(1-101 inclusive)
102	     											
103	     											
	If you are making fifty-one appointments, selection must be made from among the above names.
	(1-103 inclusive)
104	     											
105	     											
	If you are making fifty-two appointments, selection must be made from among the above names.
	(1-105 inclusive)
106	     											
107	     											
	If you are making fifty-three appointments, selection must be made from among the above names.
	(1-107 inclusive)

		     	
Signature of Appointing Authority		Date	

			
     		     	
AGENCY OR MUNICIPALITY		CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT	OPEN COMPETITIVE LIST	CERTIFICATION DATE	

NAME OF CANDIDATE	SELECTED		NOT SELECTED	

108	     											
109	     											
	If you are making fifty- four appointments, selection must be made from among the above names.
	(1-109 inclusive)
110	     											
111	     											
	If you are making fifty-five appointments, selection must be made from among the above names.
	(1-111 inclusive)
112	     											
113	     											
	If you are making fifty-six appointments, selection must be made from among the above names.
	(1-113 inclusive)
114	     											
115	     											
	If you are making fifty-seven appointments, selection must be made from among the above names.
	(1-115 inclusive)
116	     											
117	     											
	If you are making fifty-eight appointments, selection must be made from among the above names.
	(1-117 inclusive)
118	     											
119	     											
	If you are making fifty-nine appointments, selection must be made from among the above names.
	(1-119 inclusive)
120	     											
121	     											
	If you are making sixty appointments, selection must be made from among the above names.
	(1-121 inclusive)
122	     											
123	     											
	If you are making sixty-one appointments, selection must be made from among the above names.
	(1-123 inclusive)
124	     											
125	     											
	If you are making sixty-two appointments, selection must be made from among the above names.
	(1-125 inclusive)
126	     											
127	     											
	If you are making sixty-three appointments, selection must be made from among the above names.
	(1-127 inclusive)
128	     											
129	     											
	If you are making sixty-four appointments, selection must be made from among the above names.
	(1-129 inclusive)

		     	
Signature of Appointing Authority		Date	

     		     	
AGENCY OR MUNICIPALITY		CERTIFICATION NUMBER	
			
     		     	
DEPARTMENT	OPEN COMPETITIVE LIST	CERTIFICATION DATE	

NAME OF CANDIDATE	SELECTED		NOT SELECTED	

130	     											
131	     											
	If you are making sixty-five appointments, selection must be made from among the above names.
	(1-131 inclusive)
132	     											
133	     											
	If you are making sixty-six appointments, selection must be made from among the above names.
	(1-133 inclusive)
134	     											
135	     											
	If you are making sixty-seven appointments, selection must be made from among the above names.
	(1-135 inclusive)
136	     											
137	     											
	If you are making sixty-eight appointments, selection must be made from among the above names.
	(1-137 inclusive)
138	     											
139	     											
	If you are making sixty-nine appointments, selection must be made from among the above names.
	(1-139 inclusive)
140	     											
141	     											
	If you are making seventy appointments, selection must be made from among the above names.
	(1-141 inclusive)
142	     											
143	     											
	If you are making seventy-one appointments, selection must be made from among the above names.
	(1-143 inclusive)
144	     											
145	     											
	If you are making seventy-two appointments, selection must be made from among the above names.
	(1-145 inclusive)
146	     											
147	     											
	If you are making seventy-three appointments, selection must be made from among the above names.
	(1-147 inclusive)
148	     											
149	     											
	If you are making seventy-four appointments, selection must be made from among the above names.
	(1-149 inclusive)
150	     											
151	     											
	If you are making seventy-five appointments, selection must be made from among the above names.
	(1-151 inclusive)

		     	
Signature of Appointing Authority		Date