Office of the State Attorney
10th Judicial Circuit
State Attorney Brian Haas
Serving Polk, Highlands, and Hardee Counties

State of Florida
Employment Application


Equal Opportunity Employer/Affirmative Action Employer
The State of Florida does not tolerate violence in the workplace.
POSITION APPLIED FOR
Position Title
Position Number
Counties of Interest
Date Available
Minimum Acceptable Salary
GENERAL INSTRUCTIONS HOW DO WE CONTACT YOU?
  • Please type or print in ink this application in its entirely.
  • Specify the position for which you are applying.
    (Note: A Separate application must be submitted for each vacancy. Photocopies are acceptable.
  • Submit your application to the office announcing the vacancy no later than the close of business on the announced deadline date
  • Sign your name in the Certification Section. All information you submit is subject to verification.
  • Notify the agency's hiring authority in advance if you require special disability accommodations to participate in the employment process
  • Information available at: http://jobs.myflorida.com/
 Name
 Email Address:
Mailing address:
 State:
County:
 City:
Zip Code:
 Home Phone:
 Cell Phone:
 Business Phone:

Education
HIGH SCHOOL
NAME/ADDRESS OF SCHOOL: Received: Diploma None Other, list:
COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL: (TRANSCRIPTS MAY BE REQUIRED)
NAME OF SCHOOL LOCATION DATES OF ATTENDANCE CREDIT HOURS EARNED MAJOR/MINOR COURSE OF STUDY TYPE OF DEGREE
EARNED
QTR SEM
YOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL:
JOB-RELATED TRAINING OR COURSE WORK: (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARMED FORCES, ETC.)
NAME OF SCHOOL LOCATION DATES OF ATTENDANCE CREDIT HOURS EARNED COURSE OF STUDY TRAINING COMPLETED?
CLASS CLOCK
Yes No
Yes No
Yes No
YOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL:


LICENSURE, REGISTRATION, CERTIFICATION EXAMPLES: Driver License, Teacher Certification, RN, LPN, PE, CPA, Etc.
LICENSE, REGISTRATION OR CERTIFICATION: NUMBER DATE RECEIVED EXPIRATION DATE STATE LICENSING AGENCY


PERIODS OF EMPLOYMENT

Describe your work experience in detail, beginning with your current or most recent job. Use a separate block to describe each position. Include military service (indicate rank) and job-related volunteer work if applicable. Indicate number of employees supervised. Provide an explanation of any gaps in employment. Resumes are acceptable for the description of duties and responsibilities only. All other information in this section must be completed.

1
Name of Present or Last Employer:
 Supervisor's Name:
Your job title:
Address:
Phone:
 Average hours worked per week:
 From:
To:
Currently Employed
Duties and Responsibilities

 Reason For Leaving:
Your name if different during employment:
2
Name of Present or Last Employer:
 Supervisor's Name:
Your job title:
Address:
Phone:
 Average hours worked per week:
 From:
To:
Currently Employed
Duties and Responsibilities

 Reason For Leaving:
Your name if different during employment:
3
Name of Present or Last Employer:
 Supervisor's Name:
Your job title:
Address:
Phone:
 Average hours worked per week:
 From:
To:
Currently Employed
Duties and Responsibilities

 Reason For Leaving:
Your name if different during employment:
4
Name of Present or Last Employer:
 Supervisor's Name:
Your job title:
Address:
Phone:
 Average hours worked per week:
 From:
To:
Currently Employed
Duties and Responsibilities

 Reason For Leaving:
Your name if different during employment:
5
Name of Present or Last Employer:
 Supervisor's Name:
Your job title:
Address:
Phone:
 Average hours worked per week:
 From:
To:
Currently Employed
Duties and Responsibilities

 Reason For Leaving:
Your name if different during employment:

KNOWLEDGE / SKILLS / ABILITIES (KSAs)
List KSAs you possess and believe relevant to the position you seek, such as operating heavy equipment, computer skills, fluency in language(s), etc

EXEMPTION FROM PUBLIC RECORDS DISCLOSURE
ARE YOU A CURRENT OR FORMER LAW ENFORCEMENT OFFICER, OTHER EMPLOYEE** OR THE SPOUSE OR CHILD OF ONE, WHO IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE UNDER §119.07(3)(k)1,F.S.?
**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 who responsibilities include revenue collection and Department		 NO
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 of Conviction:
HAVE YOU EVER HAD THE ADJUDICATION OF GUILT WITHHELD TO A CRIME WHICH IS A FELONY OR A FIRST DEGREE MISDEMEANOR?
YES NO
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.

 Where?
 Date of Conviction:
CITIZENSHIP
ARE YOU A U.S. CITIZEN OR ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.? YES NO
NOTE: The State of Florida hires only U.S. citizens and lawfully authorized alien workers.
If a conditional offer of employment is made, you will be required to provide proof of citizenship or authorization to work in the U.S.
RELATIVES
TO YOUR KNOWLEDGE, DO YOU HAVE ANY RELATIVES WORKING IN THIS AGENCY? YES NO
SELECTIVE SERVICE SYSTEM REGISTRATION
IF YOU ARE A MALE BETWEEN THE AGES OF 18 AND 26, DO YOU HAVE PROOF OF REGISTRATION WITH THE SELECTIVE SERVICE SYSTEM OR EXEMPTION FROM SUCH REGISTRATION? 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.
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:

VETERANS' PREFERENCE CLAIM
Completion of the Veterans’ Preference section 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.
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.
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.
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 claim 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(14), F.S. Veterans’ Preference shall expire after an eligible person has been employed by any state or agency of a political subdivision of that 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 does not apply to retired-for-longevity military personnel when a competitive examination is used. However, retired military personnel with a compensable disability are eligible, regardless of whether a competitive examination is used. 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.
YOUR NAME: IF ELIGIBLE, WHICH VETERANS' PREFERENCE CATEGORY ARE YOU CLAIMING?
Have you ever been employed by any state or any of its political subdivisions (such as counties or cities) prior to the date on this application?

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.

 YES NO

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. 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.
a. Sex: Male Female
b. Date of Birth:
c. Race:
White Black Hispanic Asian or Pacific Islander Native American Other, list:
BACKGROUND RECORD

Due to the sensitive nature of all work processed through the State Attorney's Office, it is necessary for our office to investigate all eligible candidates. Police and driving records will be checked. Information concerning convictions or association with felons may disqualify an applicant. An applicant who falsifies the application by failing to give required information may be discharged.

Please provide us with the following additional information:

Have you ever been arrested, charged, convicted, pled nolo, or had a case diverted or nol-prossed for violation of any law or ordinance, including traffic violations?

YES NO

If YES, describe the nature of the offense(s). Show date, location, disposition and court. Include prison and suspended sentences, probation served and convictions during military service.



Have you ever filed for bankruptcy?

YES NO

If yes, when?


Are there any other issues in your background that would potentially jeopardize the handling or processing of sensitive information or that, as an employer, we would want to know about?

YES NO



Note: A “YES” answer to any of these questions will not automatically bar you from employment. The nature, severity and date of the offense in relation to the position for which you are applying are considered.
INFORMATION FOR PERSONAL BACKGROUND INVESTIGATION
List the names of the people you have worked for, giving addresses and telephone numbers. Please give exact location of home or business

NAME:
 ADDRESS:
 PHONE:
NAME:
 ADDRESS:
 PHONE:
NAME:

 ADDRESS:
 PHONE:

List personal references, giving addresses and telephone numbers.

NAME:
 ADDRESS:

 PHONE:
NAME:
 ADDRESS:

 PHONE:
NAME:
 ADDRESS:

 PHONE:

Have you ever worked as a volunteer?

YES NO

If YES, list the agency and the person you worked for along with any duties you performed.
Name and address of parents:

Mother: PHONE:

Father: PHONE:

How long have you lived at the present address?
Years:

If less than 2 years please give previous address.
Your Name: Date: