Page 1 of 7
CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
This application will only be considered active for 90 days from the date signed.
To be considered for employment after that date, a new application must be completed.
PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Drug Free Workplace
APPLICATION FOR EMPLOYMENT
1
THE CITY IS AN AT-WILL EMPLOYER
APPLICANTS
2
MAY BE TESTED FOR DRUGS IN ACCORDANCE WITH
THE FLORIDA DRUG FREE WORKPLACE PROGRAM
ALL PAGES MUST BE COMPLETED IN THEIR ENTIRETY.
DATE _________________________
Name
Last First Maiden Middle
Present address
Number Street City State Zip
How long
Home Phone ( ) Mobile ( ) Email
Are you 18 years of age or older? Yes No (If no, you will be required to provide authorization to work).
Can you perform the essential functions of the job you are applying for (with or without a reasonable accommodation)?
Yes No
If you need an accommodation please explain what you need. If you have questions about what essential functions are applicable to
the position, please ask the interviewer before you answer this question.
___________________________________________________________________________________________________________
Are you legally authorized to work in the United States? Yes No
(Proof of identity and employment eligibility will be required upon employment).
II. EMPLOYMENT INTERESTS
Position Desired
Date Available
Salary
Desired
Are you available to work overtime?
Yes No
Type of Employment Desired
Regular Full-Time
Temporary Part-Time
Days and hours available for work:
1
The City complies with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions
concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to
complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in
the same job category will be subject to the same medical questionnaire.
2
Applicants seeking a job which is considered a mandatory-testing position or safety sensitive position will be required to submit to a
pre-employment drug test.
CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Drug Free Workplace
Page 2 of 7
III. EDUCATION INFORMATION
School Level Name and Location of
School
Course of
Study
Circle last
grade
ltd
Did you
graduate?
Degree or
Diploma
High School
1 2 3 4
Y N
College/University
1 2 3 4
Y N
Post Graduate
1 2 3 4
Y N
Business/Trade Technical
1 2 3 4
Y N
IV. SKILLS - If Applicable for Position for Which You Are Applying
Typing speed ________wpm
Foreign Languages Yes No (indicate language and proficiency to speak, read and write)
Computer Skills (Indicate software used)
Other Skills
Do you have any experience, training, qualifications or special skills which you think make you especially suited for work at this City?
(Explain)
V. EMPLOYMENT INFORMATION (start with current or most recent employer). Account for all time periods including
unemployment, self-employment and military service. (Attach separate paper(s), if necessary.)
1
Company Name
Phone ( )
From Mo./Yr.
To Mo./Yr.
Street Address
City
State Zip
Starting Pay
$
Ending Pay
$
Job Title
Duties
Reason for leaving
(be specific)
Supervisor Name
May we contact this
employer?
Yes No
2 Company Name
Phon
e (
)
From Mo./Yr.
To Mo./Yr.
Street Address
City
State
Zip
Starting Pay
$
Ending Pay
$
Job Title
Duties Reason for leaving
Supervisor Name
May we contact this employer?
Yes No
3
Company Name
Phone (
)
From Mo./Yr. To Mo./Yr.
Street Address
City
State
Zip
Starting Pay
$
Ending Pay
$
Job Title
Duties
Reason for leaving
Supervisor Name
May we contact this employer?
Yes No
CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Drug Free Workplace
Page 3 of 7
CRIMINAL HISTORY
Your answers to these questions will be checked against local, state, and federal records. Failure to answer these questions
accurately is sufficient grounds to deny employment or for later dismissal if hired.
HAVE YOU EVER BEEN CONVICTED OF, PLED GUILTY OR "NO CONTEST" (NOLO CONTENDERE) TO A CRIME, HAD
ADJUDICATION WITHHELD OR PROSECUTION DEFERRED?
No Yes
ARRESTS ARE NOT TO BE DISCLOSED. JUVENILE INFORMATION THAT IS CURRENTLY UNDER SEAL IS NOT TO BE
DISCLOSED. OTHER SEALED OR EXPUNGED RECORDS ARE NOT TO BE DISCLOSED SO YOU MAY CHECK NO IF ALL OF
THESE APPLY.
If yes, on the attached page 7, please explain number of conviction(s), nature of offense(s) leading to conviction(s) or pleas, how
recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. NOTE: An affirmative answer will
not automatically disqualify you from being considered as a candidate for employment but the information will be considered in relation
to the position that you are seeking. All requested information must be completed.
HAVE YOU EVER BEEN A DEFENDANT IN A CIVIL SUIT FOR AN INTENTIONAL TORT (assault, battery, false imprisonment,
invasion of privacy, intentional infliction of emotional distress, intentional wrongful death, etc.)?
No Yes
If yes, provide details, including type of tort, date(s), county and state and disposition(s):
COMPLETE IF REQUIRED FOR JOB APPLYING FO
R
DO YOU HAVE A DRIVER'S LICENSE? Yes No
What is your means of transportation to work?
Driver's license number State of issue
Expiration date
Have you had any accidents during the past three years? How many?
Have you had any moving violations during the past three years? How many?
REFERENCES
Please list two references (whom you have known for at least 2 years) other than relatives or previous employers.
Name Position
Company Address
Telephone( )
Name Position
Company Address
Telephone( )
CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Drug Free Workplace
Page 4 of 7
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space
below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are
applying or any other information you think would be helpful to us in considering you for employment, such as additional work
experience, special skills, articles/books published, activities, honors received, etc. (Please omit all information that would indicate
age, sex, sexual orientation, race, religion, color, national origin, genetics, disability or other protected characteristic.).
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been involuntarily discharged (terminated or asked to resign), or allowed to resign in lieu of termination from a
position? If so, explain the circumstances:
Are you currently employed? Yes No
If so, why do you wish to leave your current employment?
May we contact your present employer? Yes No
Have you ever applied or worked here before? If yes, provide dates:_______________________________
List any relatives or friends currently employed here:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
PLEASE PRINT ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Drug Free Workplace
Page 5 of 7
APPLICANT'S ACKNOWLEDGMENT
I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations,
omissions of facts or incomplete answers in any application or accompanying resume, letter of reference or other document will
disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of
facts in any application or accompanying resume, letter of reference, other document, or communication (written or oral) will be cause
for my dismissal at any time without prior notice. I hereby authorize investigation of all statements contained in this application. I
understand that if employed it is not for a definite period of time and that either the undersigned or the City may end the employment
relationship at any time, without specified notice or reason.
I acknowledge that this application will remain active for 90 days from this date. If I have not heard from the City at the conclusion of
this 90 day period, if I still wish to be considered for employment by the City, it is my responsibility to complete a new application. If
hired, I understand that this application becomes part of my official employment record.
I HAVE READ CAREFULLY, HAD THE OPPORTUNITY TO ASK QUESTIONS ABOUT, UNDERSTAND, AND VOLUNTARILY
AGREE TO THE ABOVE CONDITIONS OF ANY EMPLOYMENT THAT MAY BE OFFERED TO ME BY THE CITY.
NOTE: THIS APPLICATION IS NOT COMPLETE UNTIL THE ADDITIONAL ACKNOWLEDGMENTS ON PAGE 6 AND 7 ARE
COMPLETED, INITIALED AND SIGNED BY THE APPLICANT.
Signature:
Print Name:
Date:
FLORIDA DRUG FREE WORKPLACE PROGRAM
THE CITY IS A DRUG FREE WORKPLACE. IT IS A CONDITION OF EMPLOYMENT WITH THE CITY THAT ALL EMPLOYEES
REFRAIN FROM USING DRUGS AND ALCOHOL ON THE JOB. REFUSING TO SUBMIT TO A TEST FOR DRUGS OR ALCOHOL
CAN RESULT IN THE FORFEITURE OF ELIGIBILITY FOR MEDICAL AND INDEMNITY BENEFITS AND WILL RESULT IN
TERMINATION.
EQUAL EMPLOYMENT OPPORTUNITY POLICY
This City is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race,
color, religion, sex, sexual orientation, gender, national origin, citizenship, age, genetics, marital status, disability or other classification
protected by law. We assure you that your opportunity for employment with the City depends solely on your qualifications.
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CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
Page 6 of 7
VI. ACKNOWLEDGMENT
Please read carefully, initial each paragraph, and sign below
Initial
At-will. I agree that neither the acceptance of this application nor the subsequent entry into any type of employment
relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks,
benefit plans, policy statements, and the like as they may exist from time to time, or other City practices, shall serve to create
an actual or implied contract of employment for a definite term, or to confer any right to remain an employee of the City, or
otherwise to change in any respect the employment-at-will relationship between the City and the undersigned. Both the
undersigned and the City may end the employment relationship at any time, without specified notice or reason.
Initial
Application Disclosure and Release. I authorize investigation of all statements contained in this application. I understand
that the misrepresentation or omission of facts called for is grounds for dismissal at any time without any previous notice. I
hereby give the City permission to directly contact schools, previous employers (unless otherwise indicated), references, and
others with relevant information (excluding any medical information except post-offer if required for the position and as
permitted by law, or any information protected by law such as genetics, protected classifications, etc.) that may be useful to
the City in making a hiring decision and I hereby release the City and such persons and organizations from any liability as a
result of such contact. If employed, I also grant permission for the City to release information concerning my employment to
prospective employers and, I release the City from any legal liability in providing any information. If the City will use a third
party to obtain this information about me then I understand that separate Fair Credit Reporting Act (FCRA) Disclosures and
Consents for consumer reports and investigative consumer reports) will be required to be completed at the appropriate time
during the application process or during employment, and FCRA inquiries into any criminal history will be done only as
permitted by applicable Florida law, including the timing of making the inquiries.
Initial
CBA. The City and the International Union Police Associates, AFL-CIO and the Groveland City Employee Associates Local
6091 (the Union”) negotiated a collective bargaining agreement (“CBA”). The City approved the CBA but the Union did not
approve the CBA so it has not yet been ratified. If hired by the City and if my position falls under a ratified CBA I understand
that I should refer to the CBA for further information. I understand that nothing in the CBA as approved by the City affects the
right of the City to modify or amend its handbook at any time. I am hereby informed that per the terms of the CBA approved by
the City, in the event of a conflict, between the handbook and the CBA, the handbook (referred to as the Personnel Policy
Manual in the CBA
)
will prevail.
Initial
Driving. I understand that if driving is required for my position then a driver’s license check will be conducted in accordance
with applicable law (through a direct MVR or as part of the third party background check conducted under the FCRA). If
driving is a condition of my employment, then if employed I agree to immediately notify the City if my driver’s license is
suspended or revoked.
Initial
Public Records. If I become employed by the City I am aware that as a public employer the City must follow Florida’s public
records laws. I am aware that all e-mail sent to or from the City’s email address becomes part of the City’s public records, and
may include my personal email communications. Comments received by the City e-mail system can be read by anyone who
requests that privilege. In compliance with "Government in the Sunshine" laws, the City must make available, at request, any
and all information not deemed a threat to the security of law enforcement agencies and personnel. All City employees have
the obli
g
ation to compl
y
with Florida’s public records law.
Initial
Post Offer Medical Information and Release. I understand that if I am given a conditional offer of employment and if required
for my position (law enforcement) I will be required to accurately and truthfully complete a post offer medical questionnaire
and/or undergo a physical examination and I consent to the release to the City of any and all medical information, as may be
requested or required by the City in judging my capability to do the work for which I am applying. I understand that if
required, all entering employees in the same job category will be subject to the same medical questionnaire and/or
examination and all information will be kept confidential and in a separate file. All other medical examinations will be
requested and required as permitted by applicable laws such as the Americans with Disabilities Act (if applicable to the City).
Initial
FDLE Consent. I hereby consent to the City obtaining a public criminal history records check on me at the City’s expense and
I understand the report will be run by the Florida Department of Law Enforcement through its public records check process.
Initial
Drug Testing. I understand that if I have applied for a positon which is considered a mandatory-testing position (for example
one requiring operating machinery or driving) or safety sensitive position (law enforcement) I will be required to submit to a
pre-employment drug test. If I have questions on whether the positon I have applied for is one that requires a pre-
employment drug test I may contact the City Human Resource Manager for more information.
Initial
FCRA. If I am conditionally offered a position then I understand that separate federal Fair Credit Reporting Act disclosures and
acknowledgments will be provided to me and required to be signed by me as the applicant so the City can obtain consumer
reports and investigative consumer reports on me which will be provided by a third party and that my offer is conditioned on a
successful background check.
Initial
I HAVE READ CAREFULLY, HAD THE OPPORTUNITY TO ASK QUESTIONS ABOUT, UNDERSTAND, AND
OLUNTARILY AGREE TO THE ABOVE CONDITIONS OF ANY EMPLOYMENT THAT MAY BE OFFERED TO ME B
THE CITY.
Signature:
Print Name:
Date:
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CITY OF GROVELAND EMPLOYMENT APPLICATION
(excluding Firefighter applicants)
Page 7 of 7
CONFIDENTIAL CRIMINAL CONVICTION DISCLOSURE
[THIS PAGE TO BE REMOVED BY THE CITY AND PLACED IN A SEPARATE CONFIDENTIAL FILE]
Applicant’s Name: ___________________________ Position applying for:________________________
PLEASE READ THIS STATEMENT CAREFULLY: A PAST CRIMINAL CONVICTION WILL NOT
AUTOMATICALLY DISQUALIFY YOU FROM BEING CONSIDERED AS A CANDIDATE FOR
EMPLOYMENT. THE FOLLOWING INFORMATION WILL BE CONSIDERED IN RELATION TO THE
POSITION THAT YOU ARE SEEKING: THE NATURE OF THE CRIME(S) FOR WHICH YOU WERE
CONVICTED AND THEIR RELATIONSHIP TO THE POSITION FOR WHICH YOU ARE APPLYING,
THE, NUMBER OF OFFENSES, THE TIME ELAPSE SINCE THE OCCURRENCE OF THE
OFFENSE(S), YOUR AGE AT THE TIME OF THE OFFENSE(S), THE SERIOUSNESS OF THE
OFFENSE, ANY INFORMATION YOU PROVIDE REGARDING YOUR REHABILITATION AND/OR
GOOD CONDUCT, AND ANY PUBLIC POLICY CONSIDERATIONS OF THE STATE OF FLORIDA TO
ENCOURAGE EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF A CRIMINAL OFFENSE,
AS WELL AS THE CITY’S NEED TO COMPLY WITH ANY FEDERAL, STATE AND LOCAL LAW
REQUIREMENTS. ALL REQUESTED INFORMATION MUST BE COMPLETED.
ARRESTS ARE NOT TO BE DISCLOSED. JUVENILE INFORMATION THAT IS CURRENTLY UNDER
SEAL IS NOT TO BE DISCLOSED. OTHER SEALED OR EXPUNGED RECORDS ARE NOT TO BE
DISCLOSED.
Please identify all criminal convictions below (excluding information as explained above). For each
conviction provide the date of the offense, details Explain: number of conviction(s):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Provide any other information you want the City to consider, such as your rehabilitation and/or good
conduct, etc. : [attach separate page if necessary]
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature of applicant: _____________________________________
Printed Name: ___________________________________________
Date: ______________________
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