Mr./Mrs./Ms. Last First Middle/Maiden
Board of Interest or position to which you are seeking appointment
Street City State Zip Code
Home Phone Work Phone Cell Phone Email
Date of Birth Place of Birth
Social Security Number
Driver’s License Number Issuing State
Have you ever used or been known by any other legal name Yes No
If “Yes” please explain
Are you a United States Citizen Yes No
If “No”, please explain
If you are a naturalized citizen, please list date of naturalization
How long have you been a continuous resident of Florida:
Are you a registered Florida voter? Yes No
If “No”, please list which state you are registered to vote:
Pursuant to s. 760.80, F.S. the following information is required for appointment to commissions, boards,
councils, etc. and is used to file a statistical report annually:
Gender: Male Female Do you have a Disability: Yes No
Please check “minority person” as designated in s.760.80(2), F.S.:
African-American Hispanic-American Asian-American Native-American American Woman
Job Title:
Current Employer:
Employer Address
Street City, State Zip Code
Employer contact Phone Email
Are you or have you ever been a member of the United States armed forces? Yes No
Have you ever been arrested, charged, convicted, or indicted for violation of any federal, state, county, or
municipal law, regulation, or ordinance? (Exclude trac violations for which a fine or civil penalty of $150 or
less was paid? Yes No
If “Yes”, please explain and list below
Has probable cause ever been found that you were in violation of Part III, Chapter 112, F.S., the code of Ethics
for Public Ocers and Employees? Yes No
If “Yes”, please give details
Supervisor Name Job Title Business
Your Former
Job Title
Your Former
Job Title
Education Institution and Location Dates Attended Certificates/Degrees Received
Branch Date of Service Type of Discharge
Date Nature of Violation Disposition
Date Location Nature Disposition
Have you ever been suspended from any oce by a Governor of a state Yes No
If “Yes” please provide details:
Title of Oce Date of suspension
Reason for suspension Result
Do you know of any reason why you will not be able to attend full to the duties of the oce or position to which
you have been or will be appointed? Yes No
If “Yes”, explain
Please List 3 non-relative references who are familiar with you professionally/academically
As a general matter, applications for all positions within state government are public records, which may
be viewed by anyone upon request. However, there are some exemptions from the public records law for
identifying information, including but not limited to present law enforcement ocers and their families, victims
of certain crimes. If you believe an exemption from the public records law applies to your submission, please
check this box.
Yes, I assert that identifying information provided in this application should be excluded from inspection
under public records law. Please indicate what section of Florida Statutes provides this in your particular
Florida Statute:
If you need additional guidance as to the applicability of any public records law exemption to your situation,
please contact the oce of the attorney general: PL 01, the Capitol, Tallahassee, Florida 32399, (850) 487-1963.
By checking this box, you consent to a background check including but not limited to criminal history review,
calling former employers and references, and any other individuals who may have information relevant to your
employment history.
Mailing Address Phone Number Email