City Of Lake Alfred, Florida
155 E. Pomelo St.
Lake Alfred, FL 33850

The City of Lake Alfred is an Equal Employment Opportunity Employer. No person shall, on the basis of race, color, creed, religion, sex, national origin, age, sexual orientation, marital status, gender identity, genetic information, handicap or disability, veteran status, or any other protected status under applicable law, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity under the jurisdiction of the City of Lake Alfred.

Please answer each question completely and accurately. If a question does not apply, please mark "N/A" on the appropriate line. Please type or print clearly in ink and complete all information.

*Please attach a copy of your DD-214 form (including Special Additional Information, #23-30) to your application prior to interview.

VETERAN'S PREFERENCE: If you have been honorably separated from the armed forces for service during any war or any campaign or expedition for which a campaign badge or service medal has been authorized and have served more than 180 days in active wartime service, then you are allowed veteran's preference consideration in accordance with the provisions of Chapter 295, Florida Statutes. You must furnish proof of claim (DD-214 form or VA letter) for the veteran's preference consideration prior to the interview.

If yes, please identify the public entity(ies), position(s) held, and dates of employment below. Attach additional pages if necessary.

Personal and Background Information is used by the City of Lake Alfred in establishing your eligibility to work in the United States (via Federal I-9 form); in verifying your identity for various forms of background, credit, criminal activity, worker's compensation, medical history, and licensing checks; in furnishing information to various local, state, and federal agencies; in establishing social security deductions if necessary; and in setting up various means of compensation accounts, deferred compensation accounts, pension accounts, etc.

The position you are applying for may require drug testing, background screening, or a valid Florida driver's license of a particular class, with or without endorsements, and a safe driving record. Failure to state accurate information or falsification of any of the information requested herein may result in disqualification for employment consideration.

* A conviction will not automatically disqualify an applicant. Factors considered include the nature of the offense, time elapsed, relevance to the position, and evidence of rehabilitation.

WORK HISTORY:
Begin listing with present/last employer and list ALL employers for the past ten years. If necessary, use blank sheets and attach them to this form:

*Please list high school, night school, etc. if equivalency diploma (GED).

All offers of employment are contingent upon successful completion of the City's pre-employment process, which may include:

• Background investigation
• Criminal history review
• Motor vehicle record review (if applicable)
• Employment and education verification
• Drug screening (for safety-sensitive or special-risk positions)
• Post-offer medical examination to determine the ability to perform essential job functions

Failure to successfully complete the required pre-employment screening may result in withdrawal of the employment offer.
The City may review publicly available information relevant to an applicant's qualifications and suitability for employment, including publicly accessible online content.

READ THIS APPLICATION AND YOUR ANSWERS CAREFULLY BEFORE SIGNING BELOW:

I certify that all statements made in this application and on any attachments are true, complete, and accurate to the best of my knowledge and belief. I understand that any omissions, falsifications, misstatements, or misrepresentations may result in immediate disqualification from employment consideration and, if hired, termination of employment.

I understand that the City of Lake Alfred may investigate all information provided in this application as permitted by law, including but not limited to criminal history records, driving history, prior employment, educational background, licensing verification, and personal and professional references.

If I have been employed by a federal, state, county, municipal, or other public-sector entity within the preceding ten (10) years, I authorize the City of Lake Alfred to obtain and review my personnel records from such employer(s). I understand that refusal to execute any required authorization may result in disqualification from employment consideration. I further understand that failure to disclose prior public-sector employment within the preceding ten (10) years may result in disqualification or termination of employment if discovered after hire.

I acknowledge that certain positions classified at Grade 15 or above and/or designated as exempt under the Fair Labor Standards Act (FLSA) may require completion of a leadership strengths assessment as part of the interview process. If selected for final interview consideration for such a position, I agree to complete the required assessment. Completion of the assessment does not guarantee employment.

I consent to the release of information about my employment history, qualifications, and fitness for employment by employers, schools, law enforcement agencies, and other relevant entities to authorized representatives of the City of Lake Alfred. This consent shall remain effective during my employment if I am hired.

I acknowledge, affirm, and agree that employment with the City of Lake Alfred shall be subject to and governed by the City of Lake Alfred Personnel Manual and Employee Handbook (the "Manual"), as amended from time to time, and applicable law; and, by executing this application (see below), I further acknowledge and agree that I have received a copy of and/or received access to the Manual.

By executing this application (see below), I voluntarily acknowledge and agree to strictly adhere to the conditions, policies, procedures, processes, requirements and rules set forth in the Manual, as may be amended from time to time by the City; and I further acknowledge, affirm, and agree that nothing in this application or in any subsequent communication shall create a right and/or entitlement to employment with the City (i.e., this application is not a contract and/or guarantee of employment).

I understand that applications submitted for City employment are public records under Florida law (Ch. 119, F.S.).

If offered employment, I agree to submit to any required pre-employment physical examination, drug test, and background screening as a condition of employment.

I hereby authorize the City of Lake Alfred to request, obtain, and review my personnel records from any public-sector employer listed above for employment evaluation purposes.

This authorization includes, but is not limited to, access to:

• Employment history and dates of service
• Performance evaluations
• Disciplinary records
• Attendance records
• Training and certification documentation
• Separation records
• Any other job-related documentation maintained in my personnel file

I understand that:

1. This authorization applies only to public-sector employment within the preceding ten (10) years.
2. Refusal to execute this authorization will result in disqualification from further employment consideration.
3. Failure to disclose prior public-sector employment may result in disqualification or termination if discovered after hire
4. The City Manager retains discretion to determine whether to proceed with employment if records are unavailable, incomplete, delayed, or redacted.
5. Any records received may become part of the confidential recruitment file and, if hired, may be incorporated into my personnel record consistent with applicable records retention laws.

This authorization is valid for the duration of the recruitment process for the position listed above.

Equal Employment Opportunity Statistic Survey
Applicant, New Hire, or Employee Self-Identification Survey

I received, read, and understand the instructions and information provided with this voluntary survey.

Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual's terms and conditions of employment, because of such individual's race, color, religion, sex, or national origin.

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS SURVEY

Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual's terms and conditions of employment, because of such individual's race, color, religion, sex, or national origin.

The City of Lake Alfred (City) is an equal opportunity, affirmative action employer. The City has established and maintains an Equal Employment Opportunity Plan (EEOP) for the City.

This employer is subject to certain governmental recordkeeping, nondiscriminatory, and affirmative action recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, this employer invites applicants and employees to voluntarily self-identify their race/ethnicity, veterans' status, disability and gender. Use: pre-offer, post-offer/pre-employment, and current employee invitation

Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement.

For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported in the seven categories identified. The definitions for each category have been established by the federal government. If you choose to voluntarily self-identify, you may mark only one of the boxes presented.

This employer is a Government subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A "disabled veteran" is one of the following:

• A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
• A person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

City of Lake Alfred

EEO Statistics Survey

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

Government employers must reach out to, hire, and provide equal opportunity to qualified people with disabilities.* This survey is a method of measuring the City's efforts. Therefor, the survey asks you to tell us if you have a disability or if you ever had a disability. Completing this survey is voluntary. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for the City, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

• Blindness
• Deafness
• Cancer
• Diabetes
• Epilepsy

• Autism
• Cerebral palsy
• HIV/AIDS
• Schizophrenia
• Muscular dystrophy

• Bipolar disorder
• Major depression
• Multiple sclerosis (MS)
• Missing limbs or partially missing limbs

• Post-traumatic stress disorder (PTSD)
• Obsessive compulsive disorder
• Intellectual disability
• Impairments requiring the use of a wheelchair

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

* - Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.