Application for Employment

Application for Employment

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.
Applicant Name*
Today's date*

MonthDayYear
Date
Email Address*
example@example.com
Position(s) or type of work desired*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Secondary Number
Type of Employment Desired

Full TimePart TimeTemporary
Date you will be available to start work*

MonthDayYear
Date
Have you ever been employed by our organization?

YesNo
Have you applied for a position with our organization in the past?

YesNo
Are you related to any employee of our organization?

YesNo
If yes, name of employee and relation
Do you have any objection to working overtime if necessary?

YesNo
Do you have a valid Class E Driver License (if req’d by position)?

YesNo
Can you travel if required by this position?

YesNo
Are you legally authorized to work in the United States?

YesNo
Have you been convicted of a crime in the last 7 years?

YesNo
If yes, please explain (a conviction will not automatically disqualify an applicant for employment)
How were you referred to our organization?
References

Complete this section for three references (do not include relatives or employers):

	Name	Contact Number	Years Known
1.
2.
3.

Employment History

Please provide all employment information for your past four employers starting with the most recent.
May we contact your present employer?*

YesNot at this time*
Most Recent/Present Employer
Employer*
Position Held*
City*
State*
Contact Number*
Immediate Supervisor and Title*
Date Employed From*

MonthDayYear
Date
Date Employed To

MonthDayYear
Date
Salary*
Job Summary*
Reason for Leaving*

Voluntary (please explain below)Involuntary (please explain below)
Reason for Leaving*
*Before an offer of employment is extended, your current employer may be contacted.
Previous Employer
Employer
Position Held
City
State
Contact Number
Immediate Supervisor and Title
Date Employed From

MonthDayYear
Date
Date Employed To

MonthDayYear
Date
Salary
Job Summary
Reason for Leaving

Voluntary (please explain below)Involuntary (please explain below)
Reason for Leaving
Previous Employer
Employer
Position Held
City
State
Contact Number
Immediate Supervisor and Title
Date Employed From

MonthDayYear
Date
Date Employed To

MonthDayYear
Date
Salary
Job Summary
Reason for Leaving

Voluntary (please explain below)Involuntary (please explain below)
Reason for Leaving
Previous Employer
Employer
Position Held
City
State
Contact Number
Immediate Supervisor and Title
Date Employed From

MonthDayYear
Date
Date Employed To

MonthDayYear
Date
Salary
Job Summary
Reason for Leaving

Voluntary (please explain below)Involuntary (please explain below)
Reason for Leaving
Skills and Qualifications
Please summarize any job-related training, skills, licenses, certificates, and/or other qualifications.*
Education History

List school name, locations, years completed, course of study, and any degrees earned.

	School Name	Location	Course of Study	Years Completed	Degree Earned
1.
2.
3.
4.

Applicant Acknowledgement
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable local, state, or federal law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the American’s with Disabilities Act.

I understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination if I am employed, whenever it may be discovered. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

I understand that this form and the information contained herein is a public record and will be maintained at the Citrus County Tax Collector’s Office.
Signature*

Clear
Date*

MonthDayYear
Date
Veteran’s Preference

Complete the following fields and check the appropriate selection if you are claiming veteran’s preference.
Date of Entry

MonthDayYear
Date
Date of Discharge

MonthDayYear
Date
Branch of Service
A Veteran who has served on active duty in any branch of the U.S. Armed Forces, has received honorable discharge, and has established the present existence of a service-connected disability that is compensable under public laws administered by the U.S. Department of Veterans Affairs. REQUIRED DOCUMENTS: Must furnish a DD-214 listing military status, dates of service, and Character of Discharge. Disabled Veterans shall also furnish a document from the DOD or DVA certifying the service-connected disability and the rating.A Veteran who is receiving compensation, disability retirement benefits, or pension by reason of public laws administered by the U.S. Department of Veterans Affairs and U.S. DOD. REQUIRED DOCUMENTS: Must furnish a DD 214 listing military status, dates of service, and Character of Discharge. Disabled Veterans shall also furnish a document from the DOD or DVA certifying the service-connected disability and the rating.The spouse of a person who has total disability, permanent in nature, resulting from a service-connected disability and who, because of this disability, cannot qualify for employment, and the spouse of a person missing in action, captured in line of duty by a hostile force, or forcibly detained or interned in line of duty by a foreign government or power. REQUIRED DOCUMENTS: Must furnish DVA certification of total and permanent disability or ID card indicating such. Must also furnish marriage certificate and a statement indicating that the spouse is still married to the Veteran at the time of application. Spouse shall also submit proof that the disabled Veteran cannot qualify for employment because of the service-connected disability.A Veteran of any war as defined by Florida Statute subsection 1.0114 To be eligible for Veterans Preference as a veteran, an applicant must have served at least one day during a wartime period. Active Duty for Training may not be allowed for eligibility under this paragraph. ** See Below for Authorized Campaign Periods. REQUIRED DOCUMENTS: Must furnish a DD-214 listing military status, dates of service and Character of Discharge. DD-214 must indicate the qualifying campaign or expedition medal was authorized. ** See Below for Authorized Wartime PeriodsThe un-remarried widow or widower of a Veteran who died of a service-connected disability. REQUIRED DOCUMENTS: Spouse shall furnish a document form the DOD showing the death while on active duty status under combat-related conditions or the DVA certifying the service-connected death, and spouse shall further furnish evidence of marriage.The mother, father, legal guardian, or un-remarried widow or widower of a member of the U.S. Armed Forces who died in the line of duty under combat-related conditions, as verified by the U.S. Department of Defense. REQUIRED DOCUMENTS: Shall furnish a document form the DOD showing the death while on active duty status under combat related conditions or the DVA certifying the service-connected death and shall further furnish evidence of parental status or guardianship.A Veteran as defined in Florida Statue 1.0114 Active Duty for training may not be allowed for eligibility under this paragraph. REQUIRED DOCUMENTS: Must furnish a DD-214 listing military status, dates of service and Character of Discharge.A current member of any reserve component of the U.S. Armed Forces or the Florida National Guard. REQUIRED DOCUMENTS: A letter from Commanding Officer establishing dates of service is required.
**Authorized wartime periods:

World War II --12/7/41 - 12/31/46

Korean War -- 6/27/50 - 1/31/55

Vietnam War -- 2/28/61 - 5/7/75

Persian Gulf -- 8/2/90 - 1/2/92

Operation Enduring Freedom -- 10/7/01 - TBD

Operation Iraqi Freedom -- 3/19/03 - TBD

Note: Under Florida law preference in appointment and employment shall be given, by the state and its political subdivisions, first to those persons included in 1 and 2 above, and second to those persons included under 3 and 4 above. If any applicant claiming veteran's preference for a vacant position is not selected for the position, they may file a complaint with the Division of Veterans' Affairs, P.O. Box 31003, St. Petersburg, Florida 33731. A complaint shall be filed within 21 days after notice of a hiring decision. If a notice of a hiring decision is not given, a complaint may be filed at any time. Florida Statute 1.01(14)

1.01(14) Veterans Preference applies to all positions except those described in Florida Statute 295.07(4)(a)
Should be Empty:

Application for Employment

References

Employment History

Most Recent/Present Employer

Previous Employer

Previous Employer

Previous Employer

Skills and Qualifications

Education History

Applicant Acknowledgement

Veteran’s Preference