town of lantana application for … · included with your application along with a completed town...

1 of 6 Revised 7/2014

TOWN OF LANTANA

APPLICATION FOR EMPLOYMENT Resumes may not substitute for the complete application. It is the responsibility of the applicant to

thoroughly and accurately complete the Application for Employment. Incomplete applications may

disqualify an applicant from consideration.

EOE, DFWP, VP, E-VERIFY

PLEASE PRINT OR TYPE

Position Applying For: __________________________________________________________________

PERSONAL INFORMATION

Name ____________________________________________________________________________________________

Last First MI

Present Address ____________________________________________________________________________________

Street City State Zip

Email Address _____________________ Telephone (H) ___________________ (C) _________________________

Are you legally eligible for employment in the USA? Yes No Are you of the legal age to work? Yes No

Were you previously employed with the Town of Lantana? Yes No If yes, when? ___________________________

Do you have any relative(s), either by blood or by marriage, employed by the Town of Lantana? Yes No

If “Yes” give name, relationship, and department __________________________________________________________

How did you hear about this position? ___________________________________________________________________

☐Palm Beach Post Newspaper

☐Craigslist

☐Other (please describe)

☐Town of Lantana Website

☐Town of Lantana Employee

☐Monster.com

☐Town Hall Posting

EDUCATION

School Name and Location of

School Course of Study

No of Years

Completed

Did you

Graduate?

Degree or

Diploma

High School

Certifications/

Business/Trade

College

Graduate/Ph.D.

MILITARY

Were you in the US Armed Forces? Yes No If “yes”, what Branch?

Do you wish to claim Veterans’ Preference? Yes No If “yes”, a copy of your DD214 must be

included with your application along with a completed Town Veterans’ Preference Form.


EMPLOYMENT HISTORY

List below present and past employment, full time and part time, beginning with your most recent.

If additional space is needed, please attach a separate page.

1

Employer: Phone:

Address: Supervisor:

Job Title: Ending Salary:

Responsibilities:

From: To: Reason For Leaving:

2

Employer: Phone:



Responsibilities:


3

Employer: Phone:



Responsibilities:


4

Employer: Phone:



Responsibilities:


I hereby give permission to contact the employers listed above concerning my prior work experience, and

to inspect my personnel file(s). ___________________________________________________________ SIGNATURE

If there is/are a particular employer(s) you do not wish us to contact, please indicate which one(s) and the

reason. ______________________________________________________________________________


Attached hereto is a job description for the position for which you have applied. Are you able to perform

these tasks without an accommodation? Yes No If No, please list accommodations needed.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

If you are known by any other name(s) at other employers listed under Employment History, please list

each of those names. ___________________________________________________________________

Have you ever been convicted, plead no contest, plead guilty, or had the adjudication of guilt withheld for

any criminal offense other than a minor traffic violation (i.e. speeding, parking, etc.)? Yes No

If yes, please explain: (An affirmative answer to the above does not constitute disqualification of

employment.)_________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Give the names of any organizations or professional groups of which you may be a member which have

any direct bearing on your qualifications for the position you are seeking.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

List any knowledge, skills, abilities, or qualifications you possess and believe relevant to the position you

seek, such as heavy equipment, computer skills, languages, etc. (Applicant should not list any information

that Federal and State law preclude obtaining in the pre-employment stage.)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever been discharged or forced to resign for misconduct or unsatisfactory performance?

Yes No If yes, please explain.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________


PLEASE READ AND INITIAL STATEMENTS BELOW

_______I certify that all information given on this employment application, related employment papers

and oral interviews is true and correct. I understand that the Employer will make a thorough investigation

of my work and personal history. I authorize the giving and receiving of any such information requested

by it. I understand that falsification of any information so given or other derogatory information

discovered as a result of this investigation will subject me to disqualification from consideration and/or

immediate dismissal. I agree to a post-offer physical examination if requested. If I am hired, I will

conform to the rules and regulations of the Employer.

_______I understand that the Employer makes every effort to maintain an atmosphere which will enable

employees to perform their work without sexual, religious, racial and/or ethnic harassment, intimidation

and/or without creating an offensive work environment. I understand that conduct and language can

constitute harassment and I agree not to engage in such conduct. I understand that if I violate this, I will

be subject to discipline up to and including discharge. I also understand that I do not have to, am not

expected to, and should not tolerate any such conduct. I further understand I have an affirmative

obligation to report such conduct, and that I will not be subject to any discipline for doing so. I may be

subject to discipline up to and including discharge for failing to disclose harassments.

_______In accordance to Florida Statute 440 as it relates to pre-employment drug testing of those in

“special risk” and/or “mandatory testing” positions , I hereby consent as a condition of employment to

have the Employer, or its authorized testing agent, perform a drug test for the purpose of determining the

presence of illegal drugs. In agreeing to this, I understand that if I fail the post job offer drug test the

Employer may withdraw my employment offer.

_______I further understand that, if hired, my failure to submit to, upon request, or to pass, any drug

and/or alcohol tests is grounds for immediate discharge.

_______I further agree that if I am under medication, it is my responsibility to provide the examining

physician or Human Resources of the Employer, a physician’s statement regarding any prescribed

medication or a copy of the prescription and its dates of use.

_______I have been assured that the results of the test will be provided only to the Employer and will be

held in strict confidence unless the Employer or its testing agent is required by law or court order to

divulge said information.

Signature _______________________________________Date _________________________

The Town of Lantana uses e-verify as part of a process to verify the work eligibility of all new hires. E-verify is an internet-based system that

compares an employee’s information to data from U S Department of Homeland Security and Social Security Administration records.


Notice to Applicant Regarding Veterans’ Preference

For the purposes of appointments, retention, reinstatement, reemployment and promotions, Veterans'

Preference ensures that veterans and eligible family members of veterans are given consideration at each

step of the selection process. However, preference does not guarantee that a veteran or the eligible family

members of a veteran will be the candidate selected to fill the position. Effective July 1, 2014, per Florida

Statute 295.07, the following groups are now eligible for Veterans’ Preference:

1. Disabled veterans who have served on active duty in any branch of the Armed Forces

and who presently have an existing service connected disability which is compensable

under public laws administered by the Department of Veterans’ Affairs (DVA) or are

receiving compensation, disability retirement benefits, or pension by reason of public

laws administered by the DVA or the Department of Defense; or

2. The spouse of a veteran:

a. who has a total and permanent service-connected disability and who, because of this

disability, cannot qualify for employment; or

b. who is missing in action, captured in line of duty by hostile forces, or detained or

interned in line of duty by a foreign government or power; or

3. A veteran of any war who has served at least one day during the war time period as

defined in subsection 1.01(14) Florida Statutes or who has been awarded a campaign or

expeditionary medal. Active duty for training is not allowed for eligibility under this

section; or

4. The un-remarried widow or widower of a veteran who died of a service-connected

disability, or

5. The mother, father, legal guardian, or un-remarried widow or widower of a service

member who died as a result of military service under combat-related conditions as

verified by the U.S. Department of Defense; or

6. A “veteran” as defined by section 1.01m (14) Florida Statutes as a person who served in

the active military, naval, or air service and who was discharged or released under

honorable conditions only or who later received an upgraded discharged under honorable

conditions. Active duty for training is not allowed for eligibility under this section; or

7. A current member of any reserve component of the US Armed Forces or the Florida

National Guard.

Those wishing to claim Veterans’ Preference must furnish a DD-214 or military discharge papers, or

equivalent certification from the DVA, listing military status, dates of service and Character of Discharge.

Disabled veterans must also furnish a document from the Department of Defense, the DVA, or the

Department certifying that the veteran has a service connected disability.

**Documentation must be provided in order to establish eligibility for Veterans’ Preference. Certain

categories of preference may require additional documentation to be submitted by the applicant. Human

Resources will contact the applicant should additional documentation be required.

An individual must file a complaint within 21 calendar days from the date after receiving notice of the hiring decision made by the hiring agency.

If no notice is given then the individual must file a complaint within three (3) months of the date the application is filed with the employer.


VETERANS’ PREFERENCE FORM

Your

Name:

Position you are

applying for:

VETERANS’ PREFERENCE: Completion of the Veterans’ Preference section is made on a

voluntary basis and kept confidential in accordance with the Americans with Disabilities Act..

Documentation substantiating your claim must be furnished at the time of application.

Check the appropriate block:

Disabled veteran who has served on active duty in any branch of the Armed Forces and who presently

has an existing service connected disability which is compensable under public laws administered by the

Department of Veterans’ Affairs (DVA) or are receiving compensation, disability retirement benefits, or

pension by reason of public laws administered by the DVA or the Department of Defense.

The spouse of a veteran:

a. who has a total and permanent service-connected disability and who, because of this disability, cannot

qualify for employment; or

b. who is missing in action, captured in line of duty by hostile forces, or detained or interned in line of

duty by a foreign government or power.

A veteran of any war who has served at least one day during the war time period as defined in

subsection 1.01(14) Florida Statutes or who has been awarded a campaign or expeditionary medal.

The un-remarried widow or widower of a veteran who died of a service-connected disability.

The mother, father, legal guardian, or un-remarried widow or widower of a service member who died

as a result of military service under combat-related conditions as verified by the U.S. Department of

Defense.

A “veteran” as defined by section 1.01m (14) Florida Statutes as a person who served in the active

military, naval, or air service and who was discharged or released under honorable conditions only or who

later received an upgraded discharged under honorable conditions.

A current member of any reserve component of the US Armed Forces or the Florida National Guard.

I acknowledge that I have read and understood the rights expressed in this notice.

Applicant’s Signature___________________________ Date _________________

For additional resources or information regarding Veterans’ Preference:

Visit: http://floridavets.org/benefits-services/employment/

Call: (727) 319-7462

FDVA Headquarters: 11351 Ulmerton Rd. Suite 311-K Largo, FL 33778-1630

PERSONAL HISTORY

QUESTIONNAIRE

Lantana Police Department 500 Greynolds Circle

Lantana, Florida 33462

Position Applied for:

Police Officer (Florida Certified Only) Dispatcher

Police Officer (Out of State Certified Only) (State:)___________ Reserve Police Officer

Police Officer (Not Certified) Other ________________

Last Name First Name Middle Name

Street Address Apartment No.

City County State Zip Code

Residence Telephone (Area Code) Business Telephone (Area Code)

Social Security Number Driver’s License Number State

Date of Birth (Month/Day/Year) Town of Lantana will use information concerning ethnicity, sex, age and disability for affirmative action purposes only, consistent with and pursuant to its obligation under federal

law. We are an equal opportunity employer/drug free workplace.

Where did you hear about this position?

Race/Ethnicity Photo American Indian

Asian

Black (Non-Hispanic)

Haitian

Hispanic

White (Non Hispanic)

Other

Revised: 3/15/2004

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NOTICE:

Please read and follow these instructions exactly. Your ability to complete this document as requested will be evaluated and used as one basis for employment decisions. This document, when completed, will be used by the Lantana Police Department as an investigative aid. Retention of this personal data will remain in the files of the Town of Lantana as required by state statute.

REQUIREMENTS:

1. Candidates applying for the position of Police Officer or Reserve Officer must be twenty-one (21) years of age at the date of application and have a high school diploma or a Florida recognized G.E.D.;

2. In the absence of proof of successful high school completion or General Education Development (G.E.D.) tests, the Florida Police Standards and Training Commission will recognize an Associate’s Degree, or transcript verification of successful completion of two (2) years of college work from any state recognized accrediting association, or grant exemption to those individuals who hold a certificate issued prior to December 31, 1974 by the United States Armed Forces Institute (U.S.A.F.I.) denoting that holder has successfully completed high school equivalency examinations.; 3. The remaining tests include a voice stress analysis and/or a polygraph, a background investigation, a psychological test, interview with the Chief of Police and a drug screening and medical test. Failure to pass any portion of the requirements will result in being eliminated from any further consideration for the particular testing cycle. Candidates must be available for all the tests as scheduled. All tests can not be scheduled or accomplished in one day.

IMPORTANT! You will be denied employment if you:

1. Are not a United States Citizen;

2. Do not have corrected vision to a standard of 20/40;

3. Have ever been convicted of, or plead no contest, as an adult, of any felony or a misdemeanor involving perjury or false statements;

4. Have been dishonorably discharged from the military;

5. Have ever used any illegal substance, but not limited to Marijuana, Cocaine, Heroin, LSD, Quaalude, Hashish, PCP, GHB, etc; or within the last five years used any prescription drugs or steroids not prescribed by a physician.

6. Have ever illegally sold or distributed any narcotic, drug or similar substance, including marijuana;

7. Misrepresent, falsify or omit any information on the application;

8. Have an unacceptable driving history, which would be indicative of a pattern of poor driving behavior, with particular regard to recent experience and seriousness of respective violations;

9. Have an unstable work history or a pattern of unreliable work practices including frequent or serious disciplinary actions from previous employers.

I understand that any of the above circumstances will disqualify me from consideration for a position of ____________________ with the Lantana Police Department. I further attest, after carefully reviewing these stipulations, that I do, to the best of my knowledge, qualify for the aforementioned position. I understand that by making this claim, any information which surfaces to the contrary during my pre-employment processing or during my actual employment with the Lantana Police Department, will result in my immediate termination of employment or consideration of employment. __________________________________________ Applicant’s Signature

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INSTRUCTIONS: (PLEASE READ CAREFULLY) 1. Hand print clearly, in black ink and in your own handwriting. 2. Answer every question. If a question does not apply to you, so state with N/A. 3. Any unanswered, incomplete or omitted questions may result in rejection of your application or dismissal. 4. If the space available is insufficient, use a separate sheet of 8 ½ x 11 paper and precede each answer with the

number of the referenced block. 5. Do not misstate or omit any material fact since the statements made herein are subject to verification to

determine your qualifications for employment. 6. Answer all questions accurately and completely. Do not make exaggerated, false or misleading statements

as they may cause your rejection or dismissal. 7. Each and every question has a purpose. Do not fail to answer each question completely, even if you feel it is

“not important.” SPECIAL INSTRUCTIONS: If you have expunged or sealed records, read this section before completing the Personal History Questionnaire.

Florida State Statute (FSS) 943.058 – Criminal History Record Expunction or Sealing “When all criminal history records have been sealed or expunged, the subject of such records may lawfully deny or fail to acknowledge the events covered by the expunged or sealed records, except in the following circumstances:”

a) When the person who is the subject of the record is a candidate for employment with a

criminal justice agency. This exception requires by law that you as an applicant for employment with a criminal justice agency (such as the Lantana Police Department) may not lawfully deny or fail to acknowledge the events in any expunged or sealed records. “I have read and I understand all the above instructions. I also understand that I will be asked to take a Voice Stress Test (lie detector) examination to determine the authenticity of the information provided in this questionnaire”.

Signature Date

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VETERAN’S PREFERENCE (Based upon Honorable Discharge)

Date

Print Name: Signature:

Do you claim veteran’s preference? Yes No (If No, proceed to question 1. If Yes, check the appropriate status below)

(Chapter 295, Florida Statutes, excludes non-disabled retired military persons from veteran’s preference)

A. Based on active duty during wartime or Vietnam era

B. As a veteran with a compensable service-connected disability

C. As the un-remarried spouse of a veteran who was killed in action or who died of a service-connected disability

D. As the spouse of a veteran who cannot qualify for employment because of a total and permanent service-connected disability or the spouse of a person missing in action, captured or forcible detained by a foreign power

Have you claimed and been employed through veteran’s preference since October 1, 1987? Yes No

If Yes, give name of employer:

If No, you must submit current documentation of your veteran’s preference status to receive preference.

Please attach a copy of your documentation to this application.

Branch of Service Entry Date Date of Honorable Discharge

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 Veteran’s Affairs, P.O. Box 1437, 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.

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LANTANA POLICE DEPARTMENT

PERSONAL HISTORY QUESTIONNAIRE

The following types of information are examples of what will be collected: employment and educational histories, military, insurance, credit and financial information, motor vehicle and police records, information about your abilities, family, character, lifestyle, and organization memberships. Information will be obtained by letter, by telephone and by personal interview with both primary and secondary sources. This information is used as one basis for employment decisions.

PERSONAL INFORMATION

2. Alias(es), Nickname, Maiden Name, or other changes in name (include official document(s) concerning any changes in

name)

4. U.S. Citizen

Yes No

Native

Yes No

Naturalized Certificate No. If derived, parent Certificate No.

Date, Place and Court: ___________________________________________________________________________

5. Height Weight Color of Eyes Color of Hair Scars, tattoos, and/or distinguishing marks

Description/Location of tattoos:

6. Place of Birth (City, County, State) (Include a copy of birth certificate)

8. With whom do you reside? __________________________________________________________________________

9. Marital Status: Single Married Engaged Separated Divorced

10. If married, are you living with your spouse? Yes No

If not, state reasons: _____________________________________________________________________________

11. Spouse Fiancee Life Partner (if applicable):

Name Employer

Address Address

Phone ( ) Phone ( )

Date of Birth / /

- 5 -

12. Information concerning previous marriages (List all marriages): (Include copies of all marriage certificate(s), separation agreement(s) or divorce decree(s), if applicable)

Date Married

Where performed Spouse’s Name (Wife’s maiden name)

Date of Separation/Divorce

Social Security Number

/ / / / - -

/ / / / - -

/ / / / - -

13. List all your children, stepchildren and adopted children and give the following information:

Name Birthdate Birth Place Address Resides With Supported By

/ /

/ /

/ /

/ /

14. Are you subject to court ordered support payments for the benefit of a minor child? Yes No

Give details:

15. If you claim income tax exemptions for support of dependents other than your spouse and children, provide the following information:

Name Address (Street, City, State) Relationship Percent of Support Provided

16. List in the order given, showing relationship, parents, guardians, stepparents, parents-in-law, brothers and sisters, even if deceased. Include any others you have resided with or with whom a close relationship existed or exists:

Relationship Name Present Address (if living) Phone Birthdate

Father ( ) / /

Mother (Maiden) ( ) / /

( ) / /

( ) / /

( ) / /

( ) / /

( ) / /

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17. List all residences for the past TEN YEARS, beginning with your present address.

From: / To: / Own Rent Family

Street Address:

City: County: State: Zip:

Landlord’s Name: Landlord’s Phone No.

Landlord’s Address:

City: State: Zip:

Local Police Dept. Phone No.


Street Address:




City: State: Zip:



Street Address:




City: State: Zip:



Street Address:




City: State: Zip:



Street Address:




City: State: Zip:


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EDUCATION

18a. List all junior high and high schools attended (Include copies of high school or GED diplomas):

Name Location Dates Attended

From To

Years Completed

Graduated

Yes No

/ /

/ /

/ /

/ /

/ /

18b. GED (if applicable) / /

18c. List information below for all colleges or universities attended (Include an official transcript from any institution awarding you a degree or certificate):

Name and Location Dates Attended From To

Credit Hours

GPA Degree Received

Year Received

/ /

/ /

/ /

/ /

18d. List other schools or training (trade, vocational, business or military):

Name and Location Dates Attended

From To

Courses Studied Certificate

Yes No

/ /

/ /

/ /

18e. Were you ever expelled or suspended from ANY SCHOOL or ever disciplined by any school official? Yes No

If yes, give particulars:

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FOREIGN LANGUAGE

19. List all foreign languages and indicate your knowledge of each:

Language Reading Speaking Understanding Writing

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

Excellent Good Fair

SPECIAL QUALIFICATIONS AND SKILLS

20a. Indicate any special skills/qualifications (i.e. Radar, Traffic Homicide, Scuba Diving):

20b. Indicate special skills that you possess regarding personal computers and applicable software programs:

Typing: Approximate number of words per minute:

MILITARY

21a. Have you ever served in the U.S. Military, Military Reserve, National Guard or Coast Guard, including R.O.T.C.?

(If YES, INCLUDE A PHOTO COPY OF DD214; If NO, proceed to question 22)

Yes No

21b. Branch of service Unit or Ship

21c. What is your service number?

21d. Highest rank held?

21e. How many periods of active military service have you had?

- 9 -

21f. List all medals and decorations awarded to you as a member of the armed forces:

21g. What type of discharge? Honorable Dishonorable General Honorable Conditions Other

21h. Give date and location of entrance to active duty:

21i. Give date and location of discharge:

21j. Give period or periods of active military service:

From / To / From / To /

From / To / From / To /

21k. Are you currently a member of a National Guard or Reserve Unit? Yes No

State Regiment Unit Rank

21l. What is your present draft classification? (Not applicable for age 27 or above)

Date of classification? / / Selective Service Number:

Draft board number and location:

21m. Were you ever court-martialed, tried on charges, or were you the subject of a summary court, deck court, captain’s mast or company punishment, Article 15 or any other disciplinary action while a member of the armed forces? Yes No

If yes, explain:

21n. List any disciplinary action taken against you in the National Guard or other reserve unit:

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EMPLOYMENT

22a. Are you now or have you ever been engaged in any business as an owner, partner, or corporate member? Yes No

If yes, give details:

22b. Were you ever discharged, terminated, fired or forced to resign because of misconduct or unsatisfactory service for other than medical reasons (except military)? Yes No

If yes, explain, give name and address of employer, approximate date and reasons for each case:

22c. Please list the number of sick hours used in the last year to date:

Explain any use:

22d. Please list the number of sick hours used in the last five (5) years to date:

Explain any use:

22e. Have your employers always treated you fairly? Yes No If not, explain:

22f. Please list any disciplinary action received in the last five (5) years:

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22g. Do you object to working nights or shift work? Yes No

22h. Have you ever received unemployment insurance or other Federal, State or local benefits or assistance? Yes No

Type of Assistance Local Office Address For how long?

22i. Are you currently under contract with your employer? Yes No

22j. List all jobs you have held in the last TEN YEARS. Place your present or most recent job FIRST. Include military service in proper time sequence and also all periods of unemployment. List all part-time, temporary, seasonal, voluntary jobs and periods of unemployment If you were self-employed, provide copies of tax returns. .

From Name of Employer Part Time Full Time Job Title

/ / To Date Street Address Phone No. Description of Duties

/ / ( ) - Begin Salary City, State, Zip Code Name of Supervisor

$ Salary End Why did you leave? Name of Co-Worker

$ From Name of Employer Part Time Full Time Job Title








$

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22j. From Name of Employer Part Time Full Time Job Title




















$

- 13 -

VEHICLE OPERATOR’S LICENSE (Driver’s, Chauffeur’s, etc.)

23a. Can you operate a motor vehicle? Yes No

Do you now or did you ever possess a valid driver’s license from the state of Florida? Yes No

Driver’s Lic. # Date Issued / / Restrictions:

23b. Did you ever possess a driver’s license issued by any state other than Florida? Yes No

If yes, provide the following information: Driver’s Lic. # State

Date Issued / Restrictions: Current Yes No

23c. Was your license ever suspended or revoked? Yes No If yes, give reasons, date and length of suspension:

23d. Was your license ever restored? Yes No If yes, give details:

23e. Have you ever been refused a driver’s license by any state? Yes No If yes, give details:

23f. Has your driver’s license ever been restricted due to traffic offense convictions or placed on negligent operator’s probation? Yes No If yes, give details:

23g. Have you ever been involved in a motor vehicle accident? Yes No If yes, give complete details for each accident whether collision, non-collision or hit and run:

Date / Police Investigation? Yes No

Location

Cause of Accident (for example: ran red light, careless driving, etc.)

Were you charged with a violation? Disposition:

- 14 -

23g. Date / Police Investigation? Yes No

Location




Location




Location



23h. List below all traffic citations you have received: (include parking tickets) Location

(Street, City, State)

Approximate Date

Nature of Violation Penalty or

Disposition

/

/

/

/

/

/

/

/

23i. List all vehicles you currently own or operate:

Year Make Model Tag Number Own Lease

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MOTOR VEHICLE INSURANCE

24a. Do you presently have automobile liability insurance? Yes No If no, give details:

24b. If you presently have automobile insurance, list the following information:

Name of Company Policy Number Name of Agent Address Phone Number

List the dates of coverage: From / To /

List your present policy coverage:

24c. If you have been insured by this company for less than three (3) years, list the previous insurance company:

Name of Company Policy Number Name of Agent Address Phone Number

List the dates of coverage: From / To /

From / To /

24d. Have you ever had automobile insurance refused, withdrawn or revoked? Yes No


ARREST, DETENTION AND LITIGATION (Show all arrests including juvenile delinquent and traffic arrests):

25a. Have you ever been arrested or detained by ANY law enforcement agency? Provide police and court records, if available. (Include any arrest in which the records were expunged or sealed in accordance with F.S.S. 943.058)

Crime Charged: Police Agency:

Date / / Disposition of Case

Crime Charged: Police Agency:

Date / / Disposition of Case

25b. Have you ever been placed on probation, parole or community control? Yes No


- 16 -

25c. Have you ever been required to pay a fine? Yes No If yes, give details:

25d. Have you ever been reported as a missing person or runaway? Yes No

If yes, give complete details, including police jurisdiction, date and outcome:

25e. If you have been fingerprinted by a law enforcement agency for any reason, give details below. Your answers will be checked with the FBI and other agencies.

Agency Date / Purpose




25f. Have you ever been advised of your Miranda rights? Yes No If yes, give details:

25g. Have you ever been the subject of a police investigation? Yes No

If yes, give details including police department and date:

25h. Has any member of your immediate family ever been arrested or convicted of a criminal offense? Yes No

If yes, give particulars below:

Name Relationship Offense Where Arrested Date

/

/

/

- 17 -

25i. Have you or your spouse ever sued anyone (civil court plaintiff)? Yes No

If yes, give details and provide copies:

25j. Have you or your spouse ever been sued by anyone (civil court defendant)? Yes No

If yes, give details and provide copies:

FINANCIAL INFORMATION

26a. Do you have a savings account? Yes No Account Number Amount

Name of Bank City and State

26b. Do you have a checking account? Yes No Account Number Amount

Name of Bank City and State

26c. Do you own or are you buying your own home? Yes No

Amount invested Company City and State

Present mortgage balance Monthly mortgage payment

Insurance coverage Company City and State

26d. Do you own or are you buying other real estate? Yes No

Type of real estate Amount invested

Bank or Company City and State

26e. What income other than salary do you have at the present time?

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26f. List spouse’s occupation, place of employment and salary

26g. Have you ever had accounts placed in the hands of a collection agency? Yes No


26h. Have you ever filed for bankruptcy? Yes No

If yes, give details, including date and court filed:

CONTROLLED SUBSTANCE USE

27a. Have you ever possessed, smoked or ingested by any means, marijuana without legal authorization? Yes No

If yes, how many times and when was the last time you used marijuana (explain the circumstances)?

27b. Have you ever possessed, injected, inhaled, swallowed or ingested by any other means, any illegal drugs without legal authorization? Yes No

If yes, how many times and when was the last time you used any illegal drugs (explain the circumstances)?

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CHARACTER REFERENCES: (Do not include relatives, former employers or persons living outside the United States or its territories). List only character references who have definite knowledge of your qualifications for the position for which you are applying. Do not repeat the names of supervisors. List four (4) characters.

28a. Name of Character Reference

Years Known

Address (Street/City/State/Zip)

Business Phone

Residence Phone

28b. Are you acquainted with any members of the Lantana Police Department? Yes No If so, whom?

NEIGHBOR REFERENCES: List four (4) neighbors over the past three (3) years.

28c. Name of Neighbor Reference

Address (Street/City/State/Zip)

Residence Phone

PAST AND/OR PRESENT MEMBERSHIP IN ORGANIZATIONS

29a. Name/Address/Phone No. Type (Social, Fraternal, Unions,

Professional, Academic, Etc.)

Office or Position

held

Membership From

Membership To

29b. SUBVERSIVE ORGANIZATIONS:

1. Are you now or have you ever been a member of an organization that advocates the superiority of one racial group over another?

Yes No

2. Are you now or have you ever been a member of any organization, association, movement, group or combination of persons which advocates the overthrow of our constitutional form of government, or which has adopted the policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States or which seeks to alter the form of government of the United States by unconstitutional means?

Yes No

3. Are you now or have you ever been affiliated or associated with any organization of the type described above, as an agent, official, or employees?

Yes No

4. Are you now associating with, or have you associated with individuals, including relatives, who you know or have reason to believe are or have been members of any of the organizations identified above?

Yes No

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29b.

5. Have you ever been engaged in any of the following activities of any organization of the type described above: Contributions(s) to, attendance at or participation in any organizations, social, or other activities of said organizations or of any projects sponsored by them; the sale, gift, or distribution of any written, printed or other matter, prepared, reproduced or published, by them or any of their agents or instrumentalities?

Yes No

If YES to any of the answers above, describe the circumstances. Attach sheets for a full detailed statement. If associated with any of these organizations, specify nature and extent of associations with each, including office or position held. Also include dates, places and credentials now or formerly held. If associations have been with individuals who are members of these organizations, then list the individuals and the organizations with which they were or are affiliated.

CIVIL SERVICE

30a. List below EVERY Law Enforcement Agency to which you have applied?

Agency Approx. Date Applied Position Applied For Present Status

30b. Are you now on any eligibility list? Yes No If yes, give details:

30c. Were you ever rejected for any government position? Yes No If yes, give details:

30d. Is there anything not mentioned herein which may reflect upon your suitability to perform the duties which may be required of you in a law enforcement capacity or which might require further explanation?

Yes No If yes, give details:

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31. The following is to be executed PRIOR to submission:

I hereby swear or affirm that there are no misrepresentations or omissions in or falsifications of the above statements and answers to questions. I am aware that should investigation disclose such misrepresentations, falsifications or omissions, my application will be rejected and I will be disqualified from applying in the future for any position in the service of the Lantana Police Department, or if after my acceptance for employment, subsequent investigation should disclose misrepresentations, falsifications or omissions, it will be just cause for immediate dismissal.

Date Signature of Applicant

Subscribed and sworn to before me this day of ,

By Check one: Personally Known Produced Identification

(Name of Affiant) Type of Identification Produced:

Notary Public, State of Florida at Large Notary Public (Print Name)

My Commission expires ,

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FORMS WHICH MUST ACCOMPANY A POLICE DEPARTMENT APPLICATION

Note: All attached copies must be clear and sharp. Enlarge when necessary to insure details are readable.

Please check off the forms you have attached and indicate N/A if not applicable in your case:

1. Birth Certificate

2. Copy of High School Diploma or equivalency certificate (including GED grade scores)

3. Notarized Release of Liability and FDLE Release of Information Form 58

4. Copy of DD214, if applicable

5. Copy of current driver’s license

6. Copy of Social Security card

7. If you are a certified Police Officer, a copy of your Police certification

8. A photocopy of your Naturalization Certificate, if applicable

9. Documentation of all name changes from birth name

10. College transcripts

11. Credit History Report List of other forms attached (college degrees, certificates, etc.):

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AGILITY WAIVER AND RELEASE FORM For and in consideration of the Town of Lantana, Florida, permitting the undersigned to apply for a position with the Lantana Police Department, and whereas the undersigned knows and understands that prior to being accepted for employment by the City of Lantana said City may require the undersigned to take certain physical fitness or agility tests in order to determine whether the undersigned is physically capable of carrying out the duties of a Police Officer, and whereas the undersigned knows and understands that such a rigorous physical fitness and agility test could result in injury to the undersigned, I, ___________________________________ do hereby waive all claims for any injuries which I may receive or sustain during or as a result of the physical fitness and agility tests; and I further do hereby release the Town of Lantana, its Officers, employees, and agents from any and all liability, for any and all injuries which I may receive or sustain during or as a result of the aforesaid physical fitness and agility tests. I further understand and agree that I am assuming the risk of any and all injuries which I may receive or sustain during or as a result of the physical fitness and agility tests. I further understand and agree that this Waiver and Release is binding on me, my dependents, heirs, personal representatives, successors and assigns.

Any and all medical, hospital and other expenses that may be incurred by me or by any person in my behalf in connection with an injury or injuries which I may receive or sustain during or as a result of the aforesaid physical fitness and agility tests are the sole and separate obligation of myself; and the Town of Lantana and its agents, officers, employees, successors and assigns are hereby released and discharged of and from any and all liability therefore.

Print Name

Signature

SWORN AND SUBSCRIBED before me by the above-named applicant this day of ,

NOTARY PUBLIC

My commission expires:

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POLICE OFFICER EMPLOYMENT WAIVER

I, _______________________________, thoroughly understand that I am being considered for employment as a Police Officer and must successfully complete Administrative Application Review, Voice Stress Analysis (truth verification), Background Investigation, a Psychological Evaluation, Chief of Police Interview and Medical Examination. I understand that should unfavorable information be developed, I will be denied employment. I am seeking employment on the basis that I know that no unfavorable information will be developed by the Lantana Police Department with the exception of what I have indicated on my application and has been explained by me in detail as outlined in the personal history process. I understand that the Lantana Police Department has no funds available to reimburse any expenses I may incur in seeking this position. I recognize that the time required to process and select Police Officer applicants is time consuming and no promises or commitments are expected as to a time when a hiring decision and/or actual hiring will take place. I understand that certain non-exempt portions of the Background Investigation, Psychological Evaluation and Medical Examination may become available for inspection by the public pursuant to the public records law. I understand and agree to the contents of this statement. I acknowledge I will serve a one year probationary period, if employed, that begins with completion of required State of Florida certification as a law enforcement officer. I acknowledge that during the probationary period that my employment may be terminated at the discretion of the Chief of Police.

Signature

Date

- 25 -

AUTHORIZATION TO RELEASE INFORMATION To Whom It May Concern:

I hereby authorize any representative of the Lantana Police Department bearing this release, or copy thereof,

to obtain any information in your files pertaining to my employment records, educational records, or

departmental background investigations/information including, but not limited to, achievement, attendance,

personal history, and disciplinary records; medical records, after a conditional offer of employment; credit

records; and criminal history records. I hereby direct you to release any and all information upon request of

the bearer. This release is executed with full knowledge and understanding that the information is for the

official use of the Lantana Police Department. Consent is granted for the Lantana Police Department to

furnish such information, as is described above, to third parties in the course of fulfilling its official

responsibilities. I hereby release you, as the custodian of such records, and employer, educational institution,

physician, hospital or other repository of medical records after a conditional offer of employment, credit

bureau or consumer reporting agency, including its officers, employees, or related personnel, both

individually and collectively, from any and all liability for damages of whatever kind, which may at any time

result to me, my heirs, family or associates because of compliance with this authorization and request to

release information, or any attempt to comply with it. Should there be any questions as to the validity of this

release, you may contact me as indicated below.

Full Name (Signature)

Full Name (Printed Name)

Date

Current Address

Telephone Number

Subscribed and sworn to before me this day of ,

By Check one: Personally Known Produced Identification

(Name of Affiant) Type of Identification Produced:

Notary Public, State of Florida at Large Notary Public, Print Name

My Commission expires ,

Florida Department of Law Enforcement

AUTHORITY FOR RELEASE OF INFORMATION

(Background Investigation Waiver) Incorporated by Reference in Rule 11B-27.0022(2)(a), F.A.C.

Effective: 8/9/2001 Pursuant to Original – Employing Agency 1 of 1 Commission-Approved Revisions: 12/16/10 Sections 943.134(2)(a) and (4), F.S. Form Effective Date: 3/2013

CJSTC 58

To: Concerned Person or Authorized APPLICANT’S NAME: Representative of Any Organization, Institution or Repository of Records DATE OF BIRTH:

LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER:

AGENCY REQUESTING BACKGROUND INFORMATION: Town of Lantana Police Department

ADDRESS: 500 Greynolds Circle Lantana FL 33462

Having made application for certification or employment as a law enforcement, correctional, or correctional probation officer within the state of Florida, I hereby authorize for one year, from the date of execution hereof, any authorized representative of a Florida criminal justice agency or a Regional Criminal Justice Selection Center bearing this release to obtain any information pertaining to my employment, credit history, education, residence, academic achievement, personal information, work performance, background investigations, polygraph examinations, any and all internal affairs investigations or disciplinary records, including any files that are deemed to be confidential and/or sealed.

I also authorize release of any criminal justice records of arrests, citations, detentions, probation and parole records, or any police reports or other police records in which I may be named for any reason, including any files that are deemed to be juvenile and confidential. I hereby direct you to release this information upon the request of the bearer, whether in person or by correspondence. I further authorize the bearer to make copies of these records.

This release is executed with the full knowledge and understanding that these records and information are for the official use of a Florida criminal justice agency or Regional Criminal Justice Selection Center in fulfilling official responsibilities, which may include sharing the records or information with other criminal justice agencies, Regional Criminal Justice Selection Centers or the State of Florida or release to third parties as may be required by Florida public records laws. I hereby release you, as the custodian of such records, and employer, educational institution, physician, hospital or other repository of medical records, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. A copy of this form will be as effective as the original.

I hereby authorize the National Records Center, St. Louis, Missouri, or other custodian of my military record to release information or copies from my military personnel and related medical records, including a copy of my DD 214, Report of Separation, or other official documents from the United States Military denoting discharge status or current active military status to:

Town of Lantana Police Department 500 Greynolds Circle Lantana FL 33462

Section 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former or current employees states: An employer who discloses information about a former or current employee to a prospective employer of the former or current employee upon request of the prospective employer or of the former or current employee, is immune from civil liability for such disclosure of its consequences, unless it is shown by clear and convincing evidence that the information disclosed by the former or current employer was knowingly false or violated any civil right of the former or current employee protected under chapter 760, Florida Statutes. Pursuant to Sections 943.134(2)(a) and (4), F.S., Chapter 2001-94, Laws of Florida, disclosure of information is required unless contrary to state or federal law. Civil penalties may be available for refusal to disclose non-privileged legally obtainable information.

Applicant’s Signature Date

Applicant’s Address

OATH

Pursuant to Section 117.05(13)(a), Florida Statutes

STATE OF COUNTY OF

Sworn to (or affirmed) and subscribed before me this

day of , year , By

Signature of Notary Public – State of Florida

Print, Type, or Stamp Commissioned name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced

This OrganizationParticipates in E-Verify

This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s Form I-9 to confirm work authorization.

IMPORTANT: If the Government cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact DHS and/or the SSA before taking adverse action against you, including terminating your employment.

Employers may not use E-Verify to pre-screen job applicants and may not limit or influence the choice of documents you present for use on the Form I-9.

To determine whether Form I-9 documentation is valid, this employer uses E-Verify’s photo matching tool to match the photograph appearing on some permanent resident cards, employment authorization cards, and U.S. passports with the official U.S. government photograph. E-Verify also checks data from driver’s licenses and identification cards issued by some states. If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the employment eligibility verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 800-255-7688, 800-237-2515 (TDD) or at www.justice.gov/crt/osc.

N O T I C E: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States.

E-Verify Works for Everyone For more information on E-Verify, please contact DHS: 888-897-7781

www.dhs.gov/E-VerifyThe E-Verify logo and mark are registered trademarks of Department of Homeland

Security. Commercial sale of this poster is strictly prohibited.

Esta organización participa en E-Verify

Este empleador proporcionará a la Administración del Seguro Social (SSA, por sus siglas en inglés) y, de ser necesario, al Departamento de Seguridad Nacional (DHS, por sus siglas en inglés) la información incluida en el Formulario I-9 de todo empleado nuevo con el propósito de confirmar su autorización de trabajo.

IMPORTANTE: Si el gobierno no puede confirmar que usted tiene autorización para trabajar, el empleador debe suministrarle las instrucciones por escrito y darle la oportunidad de ponerse en contacto con DHS o SSA antes de sancionarlo de cualquier forma o finalizar la relación laboral.

Los empleadores no pueden utilizar E-Verify para realizarpreselecciones de solicitantes y no pueden limitar ni influenciar la selección de los documentos que usted presente para su inclusión en el Formulario I-9.

Para determinar si los documentos incluidos en el Formulario I-9 son válidos, este empleador utiliza la técnica de comparación fotográfica para comparar la fotografía que aparece en las Tarjetas de Residente Permanente, Tarjetas de Autorización de Empleo y pasaportes de los EE. UU. con la fotografía oficial del gobierno de los EE. UU. Asimismo, E-Verify verifica los datos incluidos en licencias de conducir y tarjetas de identificación emitidas por algunos estados. Si considera que su empleador ha infringido sus responsabilidades en virtud de este programa o lo ha discriminado durante el proceso de verificación de la elegibilidad de empleo por su origen nacional o estatus de ciudadanía, comuníquese con la Oficina del Consejero Especial llamando al 800-255-7688, 800-237-2515 (para personas con impedimentos auditivos) o visitando www.justice.gov/crt/osc.

E-Verify funciona para todos

Para obtener más información sobre E-Verify, comuníquese con DHS al:

888-897-7781

www.dhs.gov/E-Verify

A V I S O: La ley federal exige a todos los empleadores que

verifiquen la identidad y la elegibilidad de empleo de todas las personas contratadas en los Estados Unidos.

El logotipo y la marca de E-Verify son marcas registradas del Departamento de Seguridad Nacional. Queda estrictamente prohibida la venta comercial de este afiche.

http://www.justice.gov/crt/osc

http://www.dhs.gov/E-Verify

IF YOU HAVE THE RIGHT TO WORK, Don’t let anyone take it away.

If you have the legal right to For assistance in your own language: UEmployers cannot terminate you work in the United States, there are Phone: 1-800-255-7688 or Cbecause of E-Verify without giving laws to protect you against (202) 616-5594 you an opportunity to resolve the discrimination in the workplace. For the hearing impaired: problem. TTY 1-800-237-2515 or I You should know that – (202) 616-5525 E In most cases, employers cannot

require you to be a U.S. citizen or E-mail: [email protected] In most cases, employers cannot a lawful permanent resident. deny you a job or fire you because Or write to: of your national origin or If any of these things have U.S. Department of Justice – CRT citizenship status or refuse to happened to you, contact the Office of Special Counsel – NYA accept your legally acceptable Office of Special Counsel (OSC). 950 Pennsylvania Ave., NW documents.

Washington, DC 20530 Employers cannot reject documents

because they have a future expiration date.

.S. Department of Justice ivil Rights Division

Office of Special Counsel for mmigration-Related Unfair mployment Practices

www.justice.gov/crt/about/osc

SI USTED TIENE DERECHO A TRABAJAR, no deje que nadie se lo quite.

Si usted tiene el derecho a Los empleadores no pueden trabajar legalmente en los Estados despedirlo debido a E-Verify, sin Unidos, existen leyes que lo darle una oportunidad de resolver el protege contra la discriminación problema. en el trabajo. En la mayoría de los casos, los Usted debe saber que: empleadores no pueden exigir En la mayoría de los casos, los que usted sea ciudadano

empleadores no pueden negarle un estadounidense o residente legal empleo o despedirlo debido a su país permanente. de origen o estatus migratorio, o negarse a aceptar sus documentos Si usted se ha encontrado en alguna válidos y legales. de estas situaciones, contacte a la Oficina del Consejero Especial

Los empleadores no pueden (OSC). rechazar documentos por que tienen una fecha de vencimiento futura.

Para ayuda en su propio idioma: Teléfono: 1-800-255-7688 o 202-616-5594 Para las personas con discapacidad auditiva: TTY 1-800-237-2515 o 202-616-5525 E-mail: [email protected] O escriba a: U.S. Department of Justice - CRT Office of Special Counsel- NYA 950 Pennsylvania Avenue, NW Washington, DC 20530

Departamento de Justicia de EE.UU. División de Derechos Civiles Oficina del Consejero Especial Para Prácticas Injustas en el Empleo Relacionadas a Inmigración

www.justice.gov/crt/about/osc

town of lantana application for … · included with your application along with a completed town...

Documents