State of Florida FOR OFFICIAL USE ONLY …

1 1 JOB-RELATED TRAINING OR COURSE WORK: (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARMED FORCES, ETC.)DATES OFCREDITTRAININGATTENDANCEHOURSCOURSE OF COMPLETED?NAME OF SCHOOLLOCATION(MONTH/YEAR)EARNEDSTUDYFRO M TOCLASSCLOCKYESNOPOSITION APPLIED FORFOR OFFICIAL USE ONLYA gency Authorized SignatureDate Class Code StatusAgency:_____Title:_____Position Number:_____ Date Available:_____Counties of Interest:_____Minimum Acceptable Salary:_____Where to Find Vacancy Information: On the Internet: Jobs and Benefits Centers - Consult your local telephone directory State Agency Personnel Offices Type or print in ink this application in its entirety.

2 Specify the position for which you are applying.(Note: A separate application must be submitted for eachvacancy. Photocopies are acceptable.) Submit your application to the office announcing the vacancy nolater than the close of business on the announced deadline date. Sign your name in the Certification Section (page 4). Allinformation you submit is subject to verification. Notify the agency's hiring authority in advance if you requirespecial disability accommodations to participate in theemployment NameSocial Security NumberYour Mailing AddressCityCounty State Zip CodeHome Phone Business Phone SUNCOM ( State Employees)E-mail AddressState of FloridaEMPLOYMENTEDUCATIONYOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL:_____HIGH SCHOOL:NAME / LOCATION OF SCHOOLRECEIVED:DiplomaOther (specify)NoneLICENSE, REGISTRATION OR CERTIFICATION:NumberDate ReceivedExpiration DateState Licensing AgencyHOW DO WE CONTACT YOU?

3 COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL: (TRANSCRIPTS MAY BE REQUIRED)DATES OFCREDITMAJOR / MINORTYPE OFATTENDANCEHOURSCOURSE OFDEGREENAME OF SCHOOLLOCATION(MONTH / YEAR)EARNEDSTUDYEARNEDFROMTOQTRSEMYOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL:_____GENERAL INSTRUCTIONSYOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL:_____LICENSURE, REGISTRATION, CERTIFICATION EXAMPLES: Driver License, Teacher Certification, RN, LPN, PE, CPA, Opportunity Employer/Affirmative Action EmployerThe State of Florida does not tolerate violence in the of Present or Last Employer:_____Address:_____Phone No.: (_____) _____Your Job Title:_____Supervisor s Name:_____FROM: _____/_____/_____ TO: _____/_____/_____ HOURS PER WEEK: _____ (_____)Duties and Responsibilities:_____Reason For Leaving:_____1 PERIODS OF EMPLOYMENTD escribe your work experience in detail, beginning with your current or most recent job.

4 Include military service (indicate rank) and job-related volunteer work, if applicable. Indicate number ofemployees supervised. Use a separate block to describe each position or gap in employment. If needed, attach additional sheets, using the same format as on the application. All informationin this section must be completed. Resumes may be attached to provide additional NAME IF DIFFERENT DURING EMPLOYMENTName of Next Previous Employer: _____Address:_____Phone No.: (_____) _____Your Job Title:_____Supervisor s Name:_____FROM: _____/_____/_____ TO: _____/_____/_____ HOURS PER WEEK: _____ (_____)Duties and Responsibilities:_____Reason For Leaving:_____2 MONTHDAYYEARMONTHDAYYEARYOUR NAME IF DIFFERENT DURING EMPLOYMENTName of Next Previous Employer: _____Address:_____Phone No.

5 : (_____) _____Your Job Title:_____Supervisor s Name:_____FROM: _____/_____/_____ TO: _____/_____/_____ HOURS PER WEEK: _____ (_____)Duties and Responsibilities:_____Reason For Leaving:_____3 MONTHDAYYEARMONTHDAYYEARYOUR NAME IF DIFFERENT DURING EMPLOYMENT3 Name of Next Previous Employer:_____Address:_____Phone No.: (_____) _____Your Job Title:_____Supervisor s Name:_____FROM: _____/_____/_____ TO: _____/_____/_____ HOURS PER WEEK: _____ (_____)Duties and Responsibilities:_____Reason For Leaving:_____4 MONTHDAYYEARMONTHDAYYEARYOUR NAME IF DIFFERENT DURING EMPLOYMENTName of Next Previous Employer:_____Address:_____Phone No.: (_____) _____Your Job Title:_____Supervisor s Name:_____FROM: _____/_____/_____ TO: _____/_____/_____ HOURS PER WEEK: _____ (_____)Duties and Responsibilities:_____Reason For Leaving:_____5 MONTHDAYYEARMONTHDAYYEARYOUR NAME IF DIFFERENT DURING EMPLOYMENTName of Next Previous Employer:_____Address:_____Phone No.

6 : (_____) _____Your Job Title:_____Supervisor s Name:_____FROM: _____/_____/_____ TO: _____/_____/_____ HOURS PER WEEK: _____ (_____)Duties and Responsibilities:_____Reason For Leaving:_____6 MONTHDAYYEARMONTHDAYYEARYOUR NAME IF DIFFERENT DURING EMPLOYMENT If needed, attach additional sheets, using the same format as on the application. Resumes may be attached to provide additional am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment consideration and, if I amhired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law.

7 I consent to the release of informationabout my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations toinvestigators, personnel staff, and other authorized employees of Florida State government for employment purposes. This consent shall continue to be effective duringmy employment if I am hired. I understand that applications submitted for State employment are public records except as exempted above. I certify that to the best ofmy knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good : _____ DATE: _____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), FROM PUBLIC RECORDS DISCLOSUREARE YOU A CURRENT OR FORMER LAW ENFORCEMENT OFFICER, OTHER EMPLOYEE** OR THE SPOUSEOR CHILD OF ONE, WHO IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE UNDER , YES NO**Other covered jobs include.

8 Correctional and correctional probation officers, firefighters, certain judges, assistant State attorneys, State attorneys, assistant andstatewide prosecutors, personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or childsupport enforcement, and certain investigators in the Department of Children and Families [see , ].BACKGROUND INFORMATIONHAVE YOU EVER BEEN CONVICTED OF A FELONY OR A FIRST DEGREE MISDEMEANOR? YES NOIf YES , what charges?_____Where convicted?_____Date of Conviction:_____HAVE YOU EVER PLED NOLO CONTENDERE OR PLED GUILTY TO A CRIME WHICH IS AFELONY OR A FIRST DEGREE MISDEMEANOR? YES NOIf YES , what charges?

9 _____Where?_____Date: _____HAVE YOU EVER HAD THE ADJUDICATION OF GUILT WITHHELD FOR A CRIME WHICH IS AFELONY OR A FIRST DEGREE MISDEMEANOR? YES NOIf 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 State of Florida hires only citizens and lawfully authorized alien workers. If a conditional offer of employment is made, you will be required to provideidentification and proof of citizenship or authorization to work in the YOU A CITIZEN OR ARE YOU LEGALLY AUTHORIZED TO WORK IN THE YES NORELATIVESTO YOUR KNOWLEDGE, DO YOU HAVE ANY RELATIVES WORKING IN THIS AGENCY?

10 YES NOSELECTIVE SERVICE SYSTEM REGISTRATIONAll males between the ages of 18 and 26 must be registered with the Selective Service System or YOU ARE A MALE BETWEEN THE AGES OF 18 AND 26, DO YOU HAVE PROOF OF REGISTRATIONWITH THE SELECTIVE SERVICE SYSTEM OR EXEMPTION FROM SUCH REGISTRATION? YES NODP-E-16 Rev. 12/98 YOUR NAME:_____POSITION TITLE FOR WHICH YOU ARE APPLYING:_____POSITION NUMBER: _____VETERANS PREFERENCE INFORMATIONC ompletion of the Veterans Preference section below is made on a voluntary basis and kept confidential in accordance with the Americans with Disabilities below are the four Veterans Preference veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement, or pension under public laws administered bythe Department of Veterans Affairs and the Department of Defense, 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.