Please use your own stationery

DEPARTMENTAL PROMOTIONAL CERTIFICATION

Requisition Number:	<Insert Name>					Date:	<Insert Date>	

	<Insert AA Name>	
	<Insert Address>	
	<Insert City/Town MA>	

LOCATION:  city/town name

<Insert # of vacancies and position type>
Selection must be 1 of the first 3 highest who will accept

NAME OF ELIGIBLE CANDIDATES

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		<Insert Tie - Tie End>			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

Requisition Number:	<Insert #>					Date:	<Insert Date>	

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

					REPORT ON CERTIFICATION	
								DECLINE		WILLING TO	
								APPT	ACCEPT APPT.	
									
							SIGNATURE OF APPLICANT	
<Insert Name>		< >			

		Signature of Appointing Authority:  		

		Please Type or Print:		
							NAME	

		Please Type or Print:		
							TITLE