Recruitment Application Form

Employment Application
AN EQUAL OPPORTUNITY EMPLOYER/ AN AFFIRMATIVE ACTION EMPLOYER DRUG FREE WORKPLACE
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Are You a U.S. Citizen?*

YesNo
Driver's License Number*
State of Issue*
Employment Desired:
Position Applying For*
Date You Can Start*

MonthDayYear
Date
Salary Desired ($)*
Have You applied here before?*

YesNo
Education:
High School*
Name of High School Attended
Number of Years Attended*
Graduated?*

YesNo
College
Name of College/University Attended
Number of Years Attended
Area of Study/Degree
Graduated?

YesNo
Graduate School
Name of Graduate School Attended
Number of Years Attended
Area of Study/Degree
Graduated?

YesNo
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Area of Study/Degree
Graduated?

YesNo
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Current Salary ($)*
Reason for Leaving?*
Start Date*

MonthDayYear
Date
May We Contact?*

YesNo
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Previous Salary ($)*
Reason for Leaving?*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Previous Employer
Name of Previous Employer
Position
Previous Salary ($)
Reason for Leaving?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
References:
Reference 1
Name of Reference
Relationship
Years Acquainted
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference 2
Name of Reference
Relationship
Years Acquainted
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference 3
Name of Reference
Relationship
Years Acquainted
Email
example@example.com
Phone Number
Please enter a valid phone number.
Resume

Cancelof
Knowledge/Skills/ Abilities (KSAS)
List KSAs you possess and believe relevant to the position you seek, such as operating heavy equipment, computer skills, fluency in language(s), etc.
Exemption From Public Records Disclosure
ARE YOU A CURRENT OR FORMER LAW ENFORCEMENT OFFICER, OTHER EMPLOYEE'' OR THE SPOUSE OR CHILD OF ONE, WHO IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE UNDER SEC. 119.07, F.S.?*

YesNo
Other covered jobs include correctional and correctional probation officers, firefighters, certain judges, assistant state attorneys, state attorneys, assistant and statewide prosecutors, personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement, and certain investigators in the Department of Children and Families (see Sec. 119.07, F.S.].
Background Information
Have you ever been convicted of a felony or a first degree misdemeanor?*

YesNo
If "yes", what charges?
Where convicted?
Date of conviction?
Have you ever pled nolo contendere or pled guilty to a crime which is a felony or a first-degree misdemeanor?*

YesNo
If "yes", what charges?
Where?
Date?
Have you ever had the adjudication of guilt withheld for a crime which is a felony or a first degree misdemeanor?*

YesNo
If "yes", what charges?
Where?
Date?
Note

A "Yes" answer to these questions will not automatically bar you from employment. The nature, job-relatedness, severity and date of the offense in relation to the position for which you are applying are considered.
Citizenship
Gadsden County hires only U.S. citizens and lawfully authorized alien workers. If a conditional offer of employment is made, you will be required to provide identification and proof of citizenship or authorization to work in the U.S. Are you a U.S. citizen or are you legally authorized to work in the U.S.?*

YesNo
Relatives
To your knowledge, do you have any relatives working for Gadsden County?*

YesNo
Selective Service System Registration
All males between the ages of 18 and 26 must be registered with the Selective Service System or be exempted. IF YOU ARE A MALE BETWEEN THE AGES OF 18AND 26, DO YOU HAVE PROOF OF REGISTRATION WITH THE SELECTIVE SERVICE SYSTEM OR EXEMPTION FROM SUCH REGISTRATION?*

YesNo
Veteran's Preference Information

Completion of the Veterans' Preference section below is made on a voluntary basis and kept confidential in accordance with the Americans with Disabilities Act. Listed below are the four Veterans' Preference categories:

1. A veteran with a service-connected disability who is eligible for receiving compensation, disability retirement, or pension under public laws administered by the U.S. Department of Veterans' Affairs and the Department of Defense, or

2. The spouse of a veteran who cannot qualify for employment because of a total and permanent disability, or the spouse of a veteran missing in action, captured, or forcibly detained by a foreign power, or

3. A veteran of any war who has served on active duty for one day or more during a wartime period, excluding active duty for training, and who was discharged under honorable conditions from the Armed Forces of the United States of America, or

4. The unremarried widow or widower of a veteran who died of a service-connected disability.

A D0214 or comparable document which serves as a certificate of release or discharge must be furnished at the time of application. In addition, applicants claiming categories 1,2, or 4 above must furnish supporting documentation in accordance with the provisions of Rule 55A-7.013, F.A.C. Wartime periods are defined in Sec. 1.01, F.S. Veterans' Preference shall expire after an eligible person has been employed by the state or an agency of a political subdivision of the state. Under Florida law, preference in appointment shall be given by the state to those persons in categories 1 and 2 and then those in categories 3 and 4. Veterans' Preference is only available to Florida residents.
If an applicant claiming Veterans' Preference for a vacant position is not selected, he/she may file a complaint with the Florida Department of Veterans' Affairs, P.O. Box 31003, St. Petersburg, Florida 33731-8903. A complaint must be filed within 21 days of the applicant receiving notice of the hiring decision made by the employing agency or within 3 months of the date the application is filed with the employer if no notice is given.
Veterans' Preference Claim -IF ELIGIBLE, WHICH VETERANS' PREFERENCE CATEGORY ARE YOU CLAIMING? (Please indicate the number from Veterans' Preference Information section above.)
Enter Number in Box
Have you ever been employed by any governmental entity within the state of Florida?*

YesNo
Are you a resident of the state of Florida?*

YesNo
Note: If you are claiming Veterans' Preference you must meet the criteria and substantiate your claim by furnishing a DD 214 (Certificate of Release or Discharge from Active Duty) and any other required supporting documentation with your application.
EEO Survey
Although the following information is not mandatory, it is requested to aid Gadsden County in its commitment to Equal Opportunity and Affirmative Action. Refusal to answer will not result in adverse treatment of any applicant. Applicants who believe they have been discriminated against may file a complaint with the Florida Commission on Human Relations, Building F, Suite 240, 325 John Knox Road, Tallahassee, Florida 32303.
Birth Date

MonthDayYear
Position title for which you are applying?
Sex

MaleFemale
Race

White (Non Hispanic)Black (Non Hispanic)HispanicAsian or Pacific IslanderNative AmericanOther
CERTIFICATION
I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel staff and other authorized employees of Gadsden County government for employment purposes. This consent shall continue to be effective during my employment if I am hired. I understand that applications submitted for county employment are public records except as exempted above. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete and made in good faith.
Date

MonthDayYear
Date
Signature*

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Employment Application

Personal Information:

Employment Desired:

Education:

Current Employment:

Previous Employment:

References:

Knowledge/Skills/ Abilities (KSAS)

Exemption From Public Records Disclosure

Background Information

Note

Citizenship

Relatives

Selective Service System Registration