Please answer all questions. Resumes are not accepted in lieu of completion of this application. NOTE: This application was designed to use with several types of jobs/positions. Some questions may not be completely applicable to the job/position you are seeking, however we ask that you answer all questions. This application will remain active for ninety (90) days. Any applicant wishing to be considered for employment beyond ninety (90) days should reapply.

PERSONAL

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L / Last Name First MI Nickname / Date:
Street Address / Position Applying For:
City State Zip / Home Phone
( )
Have you applied here before? Have you ever been employed with us?
__ Yes __ No ___ Yes ___ No
When ______If Yes, when? ______/ Business or Msg. Phone
( )
When will you be available to begin work? / E-Mail Address
Some positions require incumbents to drive agency vehicles. Do you have a
valid Driver’s License?
___ Yes ___ No In what state are you licensed now? ______
/ Driver’s License Number
Are you available for full-time work? ___ Yes ____ No
Are you available for part-time work? ___ Yes ____ No
Are you available for temporary work? ___ Yes ____ No
Do you use tobacco products? ___ Yes ____ No

Are you now employed? __ Yes __ NoAre you on a layoff? __ Yes __ No Are you subject to recall? __ Yes __ No

May we contact your present employer? __ Yes __ NoPrevious employers? __ Yes __ No

Please identify any exceptions and reasons for not contacting prior employers: ______

Have you ever been dismissed or forced to resign from any employment? __ Yes __ No

Have you ever been, or are you presently, a named party in any legal action(s) alleging professional negligence? __ Yes __ No

Do you have any pending complaints with the Florida Bar or any other professional regulatory board or governing body? ___Yes __No

Has your professional license/certification ever been revoked or suspended by a professional regulatory board or governing body? __ Yes __ No

If YES to any of the above, please explain: ______

Do you have any friends or relatives who work for the Office of the Public Defender? __ Yes __ No

Name:______Relationship: ______

Name:______Relationship: ______

Did a current Public Defender employee refer you for employment? __ Yes__ __ No If YES, employee’s name:

______

If NO, how did you hear about this opening? ______

EDUCATION

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N / HIGH SCHOOL:
NAME/LOCATION OF SCHOOL: / RECEIVED: _____ Diploma _____ Other (specify) _____None
______
COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL: (Transcripts may be required)
NAME OF SCHOOL / LOCATION
City, State / Dates of Attendance
Month/Year / Credit
Hours Earned / Major/Minor Course of Study / Type of Degree Earned
From / To / Qtr / Sem
OTHER JOB-RELATED TRAINING OR COURSE WORK:
NAME OF SCHOOL / LOCATION
City, State / Dates of Attendance
Month/Year / Credit
Hours
Earned / Course of Study / Training
Completed?
From / To / Class / Clock / Yes / No
Other Skills: List any other job related skills training or qualifications/certifications that support your application:
Honor received or membership in professional/civic organizations: (exclude those which may disclose your race, color, religion, national origin, marital status or disability)
In order to permit a check of your work and educational records, should we be made aware of any change of name or assumed name that you previously used? ___ Yes ___ No
If yes, identify names and relevant dates:

EMPLOYMENT HISTORY

Please give accurate, complete full-time and part-time employment record for the last ten years. Account for all time periods including unemployment, self-employment, and military service (attach separate paper(s) if necessary). Resumes are not accepted in lieu of completion of this segment of the application.

1 / Current or most recent employer: / Telephone:
( )
Address: / Employed (state month and year)
From: To:
Name of Supervisor: / Pay $______per hr mth yr
Start: Last:
State job title and describe work performed: / Reason for leaving:
2 / Previous employer: / Telephone:
( )
Address: / Employed (state month and year)
From: To:
Name of Supervisor: / Pay $______per hr mth yr
Start: Last:
State job title and describe work performed: / Reason for leaving:
3 / Previous employer: / Telephone:
( )
Address: / Employed (state month and year)
From: To:
Name of Supervisor: / Pay $______per hr mth yr
Start: Last:
State job title and describe work performed: / Reason for leaving:
4 / Previous employer: / Telephone:
( )
Address: / Employed (state month and year)
From: To:
Name of Supervisor: / Pay $______per hr mth yr
Start: Last:
State job title and describe work performed: / Reason for leaving:
5 / Previous employer: / Telephone:
( )
Address: / Employed (state month and year)
From: To:
Name of Supervisor: / Pay $______per hr mth yr
Start: Last:
State job title and describe work performed: / Reason for leaving:
KNOWLEDGE / SKILLS / ABILITIES (KSAs)
List KSAs you possess and believe are relevant to the position you seek, such as operating special 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 §119.07, F.S.? / ___Yes ___ No
**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 §119.07, F.S.].
BACKGROUND INFORMATION*
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR A FIRST DEGREE MISDEMEANOR? / ___Yes ___ No
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? / ___Yes ___ No
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? / ___Yes ___ No
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. By signing below, I acknowledge that I will be subjected to a background investigation, including a criminal background check.
/ ___Yes ___ No
___Yes ___ No
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 Florida state government for employment purposes. This consent shall continue to be effective during my 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 of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith.
SIGNATURE: ______DATE: ______
YOUR NAME: ______DATE: ______
______
POSITION TITLE FOR WHICH YOU ARE APPLYING: ______POSITION NUMBER: ______
VETERANS’ 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 or 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 DD214 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 §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 number from Verterans’ Preference Information section above.)
/ ______
HAVE YOU EVER BEEN EMPLOYED BY ANY GOVERNMENTAL ENTITY WITHIN THE STATE OF FLORIDA: / ____Yes ____ No
ARE YOU A RESIDENT OF THE STATE OF FLORIDA? / ____Yes ____ No
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.

CUT ALONG DOTTED LINE

EEO SURVEY
Although the following information is not mandatory, it is requested to aid the State of Florida in its commitment to Equal Employment 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.
POSITION TITLE FOR WHICH YOU ARE APPLYING: ______
POSITION NUMBER: ______
SEX: ___MALE ___FEMALE
DATE OF BIRTH: ______
RACE (Check Only One):
___WHITE (Non-Hispanic) ___BLACK (Non-Hispanic) ___HISPANIC ___ ASIAN OR PACIFIC ISLANDER
___NATIVE AMERICAN ___OTHER (Specify)______

DRIVING RECORD INFORMATION REQUEST

Name: ______

Name as it appears on Driver’s License (please print): ______

Driver’s License Number: ______Expiration Date: ______

Date of Birth: ______State of Issuance: ______

Reason for Inquiry (check one):

______Applicant for Employment______Periodic Inquiry______Other

In cooperation with the Office of the Public Defender in their investigation of the backgrounds of prospective and current employees, I hereby request that any of my past or present employers, or certification/licensure agencies or individuals, provide to the representative of the Office of the Public Defender whatever information is requested concerning my driving history/record. I understand this information may be used in conjunction with employment decisions but will be kept confidential.

Requesting Supervisor/Manager: ______

Return Inquiry to: ______Location: ______

EMPLOYEE SIGNATURE: ______Date: ______

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