Fillable EEO Designation Form DESOTO COUNTY BOARD OF COUNTY (Desoto County, Florida)

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EEO Designation Form DESOTO COUNTY BOARD OF COUNTY (Desoto County, Florida)

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_____________________
DESOTO COUNTY
BOARD OF COUNTY COMMISSIONERS
HUMAN RESOURCES DEPARTMENT
APPLICANT DEMOGRAPHIC RECORD
Equal
Opportunity
Employer
Equal Access
Employer
Drug-Free
Workplace
EEO Designation Form
It is the policy of DeSoto Board of County Commissioners to provide equal employment opportunity to all
individuals regardless of race, color, religion, sex, national origin, disability, age, veteran status, genetics or
any other legally protec
ted status. DeSoto BOCC will hold the information requested below in strict
confidence and will use such information for reporting purposes only as mandated by Title VII of Civil
Rights Act of 1964 as amended.
Completion of this form is voluntary; persons choosing not to submit information shall not be subject to
retaliation or reprisal of any kind. Please note, however, DeSoto BOCC will select a sex and race/ethnic
group based on visual insp
ection for those persons who decline to self-identify.
Please indicate the appropriate sex:
Male
Female
I do not wish to answer
Please indicate the appropriate race/ethnic group:
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe,
the Middle East or North Africa.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American or
other Spanish culture or origin, regardless of race
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black
racial groups of Africa.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the
original peoples of North
and South America (including Central America) and who maintain tribal
affiliation or community attachment.
Asian or Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the
original peoples of the Far East, South
east Asia or the Indian Subcontinents, including, for
example, China, India, Japan, Ko
rea, the Philippine Islands, and Samoa.
I do not wish to answer.
Applicant Name (please print)
Applicant Signature Date
Desotobocc/HR revised 2/22/2018
POSITION APPLIED FOR:
Requisition No: ___________
Position No: _____________
Job Title: _______________
This Page Intentionally Left Blank.
desotobocc/hr revised
2/22/2018
DESOTO COUNTY BOARD OF COUNTY COMMISSIONERS
HUMAN RESOURCES DEPARTMENT
EMPLOYMENT APPLICATION
Equal
Opportunity
Employer
Equal
Access
Employer
Drug-Free
Workplace
POSITION APPLIED
FOR:
Where to find Vacancy Information:
On the Internet at http://www.desotobocc.com
On the Internet at http://www.employflorida.com
DeSoto County Career Source Center
2160 NE Roan Avenue
Arcadia, Florida 34266
PH: (863) 993
-1008
Requisition
No:
Position
No:
Job Title:
Application
Instructions:
Submit your application to:
DeSoto County Career Source Center
Date
Available
to
Work:
Are
you a current DeSoto Board of County
2160 NE Roan Avenue
Commissioners
Employee? Yes No
Arcadia, Florida 34266
Are you a former DeSoto Board of County
PH: (863) 993-1008 Fax: (863) 993-1046
Commissioners
Employee? Yes No
Complete and submit a DeSoto County application form typed or
printed in ink neatly. A resume may be included as an attachment;
however, the application form must be completed in its entirety.
Incomplete applications will not be considered.
Specify the title, position, and requisition number of position applying
Where did you learn of this vacancy?
HOW DO WE CONTACT YOU?
for. (Note: A separate application must be submitted for each
vacancy. Photocopies with original signature are acceptable.)
Applicant must take appropriate measures to ensure that the application
Your Name
is received by DeSoto County Career Source Center by 5:00 p.m. on the
published closing date. Applications received after the closing date
will not be considered.
Email Address
Your Home Address
City County State Zip Code
Home Phone Work,
Business
or Cell Phone
CITIZENSHIP/AUTHORIZATION
TO WORK
Are you legally authorized to work in the U.S.?
"In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and
to complete the required employment eligibility verification form upon hire".
Yes
No
SELECTIVE SERVICE
REGISTRATION
If you are a male
between
the ages of 18 and 26, do you have proof of registration? Yes _ No N/A
RELATIVES
IN
BOARD
OF
COUNTY COMMISSIONERS EM
PLOYMENT
To your
knowledge,
do you have any relatives working for the DeSoto
County
BOCC?
Yes
No
Name of Relative(s)
EXEMPTION
FROM
PUBLIC RECORDS
DISCLOSURE
Are you a current or former law enforcement officer, other covered employee* or the spouse or child of a covered employee or
former employee who is exempt from public records under §119.07, Florida Statutes? _ 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; human resources, labor relations, or employee relations directors, and
their spouses and children; code enforcement officers and their spouses and children.
DRIVERS LICENSE
INFORMATION
State of Issuance:
For Human Resources Use Only:
Expiration Date:
License Class:
Reviewed by: Date:
desotobocc/hr revised
2/22/2018
DeSoto County
Board
of
County
Commissioners
Your
Name:_
EDUCATION – Circle Highest Grade Completed. You will be asked for more detailed information in the next section.
Grade School 1 2 3 4 5 6 7 8 High School 9 10 11 12 GED College 1 2 3 4 Graduate School 1 2 3 4
HIGH SCHOOL
Name: Location:
Received: _ Diploma Certificate of Completion GED None Highest grade completed:
COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL: (TRANSCRIPTS M AY BE
REQUESTED)
Add additional pages if necessary to provide all requested information.
NAME OF SCHOOL LOCATION
(CITY/STATE-ZIP/PHONE)
# C
REDIT HRS MAJOR/MINOR DEGREE EARNED
(qtr)
(sem)
(qtr)
(sem)
OTHER TRAINING/COURSE WORK: (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARM ED
FORCES, ETC.) Add additional pages if necessary to provide all requested information.
NAME OF SCHOOL LOCATION # HRS CERTIFICATE EARNED TRAINING COMPLETED
(CITY/STATE-ZIP/PHONE)
_ Yes No
Yes No
KNOWLEDGE/SKILLS/ABILITIES (KSAs). List KSAs an/or certifications you possess and believe relevant to the position
you seek, such as operating heavy equipment, computer skills, fluency in languages(s), supervisory or management
certifications, etc. (attach additional pages as necessary)
PRIOR TERMINATIONS:
Have you ever been discharged or forced to resign for misconduct or unsatisfactory performance?
No Yes
If yes, give details, including the name of employer and supervisor who terminated your employment and the reason you were
told you were terminated.
desotobocc/hr revised
2/22/2018
In o de o rece ve Veterans P e erence, documen a on substan ia ng you claim mus be
u n shed w h th s application** Check he app op ate b ock and a ach he equ ed
documen a on you a e c aim ng Ve erans Pre erence.
DeSoto County
Board
of
County
Commissioners
Your
Name:
PERIODS OF EMPLOYMENT: All employment information must be filled out in this section. Resumes and other
attachments will not
be accepted in place of filling out this section, but may be submitted as supplemental information.
Describe 10 years of work experience in detail beginning with your PRESENT or most recent job, and describe all periods of employment and periods of
unemployment if longer than six months. Be sure to provide complete information regarding each position. Use multiple pages to ensure that
10 years of
experience is shown.
IMPORTANT: Indicate supervisory responsibility and number of employee supervised.
For the purposes of the County, supervisory responsibility involved
having the authority, in the interest of the employer, to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward, or discipline other employees,
or responsibility to direct them or to adjust their grievances, or effectively to recommend such action, where the exercise of such authority requires the use of
independent judgment. Eligibility determinations are based on dates of employment, hours worked per week, and description of job duties and responsibilities.
1. Name of Present or Last Employer:
Address: Telephone Number ( )
Your Job Title: Supervisor’s Name and Title:
From: / / To: / / Number of Hours Worked Per Week Annual Salary
Supervisory Responsibility (see definition above): Yes No Number of employees supervised:
Your Name, if Different, During Employment: _
Duties and Responsibilities: _
Reason for Leaving:
2. Name of Previous Employer:
Address: Telephone Number ( )
Your Job Title: Supervisor’s Name and Title:
From:
/ / To: / / Number of Hours Worked Per Week Annual Salary
Supervisory Responsibility (see definition above): Yes _ No Number of employees supervised:
Your Name if Different During Employment: _
Duties and Responsibilities:
Reason for Leaving:
3. Name of Previous Employer:
Address:
Telephone Number ( )
Your Job Title: Supervisor’s Name and Title:
From: / / To: / / Number of Hours Worked Per Week: Annual Salary:
Supervisory Responsibility (see definition above): Yes
No
Number of employees supervised:
Your Name if Different During Employment:
Duties and Responsibilities: _
Reason for Leaving:
desotobocc/hr revised
2/22/2018
DeSoto County
Board
of
County
Commissioners
Your
Name:_
VETERANS’ PREFERENCE
CLAIM Check box if N/A
In order to receive Veterans’ Preference, documentation a (DD-214) substantiating your claim must be furnished with this application.
Check the appropriate answer and attach the required documentation if you are claiming Veterans’ Preference.
1.
2.
3.
4.
5.
6.
7.
____ Disabled Veterans who have served on active duty in any branch of the Armed Forces and who presently have an existing
service-connected disability which is compensable under public laws administered by the DVA or are receiving
compensation, disability retirement benefits, or pension by reason of public laws administered by the DVA and the
Department of Defense.
_____ The spouse of a Veteran: a.) who has a total and permanent service-connected disability and who, because of this
disability, cannot qualify for employment; or b) Who is missing in action, captured in line of duty by a hostile force, or
detained or interned in line of duty by a foreign government or power.
_____ A Veteran of any war, who has served at least one day during that war time period as defined in subsection 1.01
(14) or who has been awarded a campaign or expeditionary medal. Active duty for training shall not be allowed for
eligibility under this paragraph.
_____ The unremarried widow or widower of a Veteran who died of a service-connected disability.
_____ The mother, father, legal guardian, or unremarried widow or widower of a service member who died as a result of military
service under combat-related conditions as verified by the U.S. Department of Defense.
_____ A Veteran as defined in section 1.01m (14) Florida Statutes. “Active Duty for Training” may not be allowed under this
paragraph. The term “veteran” is defined as a person who served in the active military, naval, or air service and
who was discharged or released therefrom under honorable conditions only or who later received an upgraded discharge
under honorable conditions.
_____ A current member of any reserve component of the U.S. Armed Forces or the Florida National Guard.
Note: 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' fairs Division
n of Benefits and Assistance - Veterans' Preference Post Office Box 31003 St. Petersburg, FL 33731. While the DVA stands ready to assist preference-eligible applicants
who are seeking public employment opportunities, Chapter 55A-7, Florida Administrative Code (FAC), requires the department to accept only those complaints for positions
that have been filled and the petit ion filed in a timely manner. Any applicant seeking veterans’ preference in employment in the state of Florida who is not selected for the
job and is so notified must file the co pliant with the DVA against the agency or political subdivision within twenty- one calendar days from the date the hiring decision is
received or within three months of the date the application is filed with h the employer if no notice is given.
CRIMINAL HISTORY INFORMATION – A CRIMINAL HISTORY INFORMATION SCREENING WILL BE CONDUCTED ON THE TOP
APPLICANT
. IF YOUR ANSWERS TO THE QUESTIONS BELOW DO NOT ACCURATELY AND COMPLETELY REFLECT YOUR CRIMINAL
HISTORY
, YOU MAY BE ELIM INATED FROM FURTHER CONSIDERATION FOR THE VACANCY.
If you are not sure or cannot remember what happened in a criminal case(s), contact the appropriate county, state, or federal agency so that you can
report accurate information on your criminal history. A “Yes” answer to any question(s) will not automatically bar you from employment. The nature,
job- relatedness, severity and date of the offense(s) in relation to the duties of the position for which you are applying are considered.
1. Have you ever been convicted of a felony or a first-degree misdemeanor?
2. Have you ever had the adjudication of guilt withheld for a felony or first-degree misdemeanor?
Yes No
Yes No
If you answered “Yes” to one of the above questions and have a conviction or adjudication of guilt withheld, please
complete the following information regarding each and every felony and/or first degree misdemeanor:
C
HARGE DATE OF DISPOSITION COUNTY/STATE
CERTIFICATION
I understand that omissions, falsifications, misstatements, or misrepresentations of the information provided by me 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 provide
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 organization to investigators, personnel staff, and
other authorized employees of the County government for employment purposes. This consent shall continue to be effective during my
employment if I am hired. I understand that applications are submitted for County employment are public records except as noted in the
previous section. I certify that to the best of my knowledge and belief that all of the statements contained herein and on any attachments are
true, correct, complete, and made in good faith. I further understand that if I am selected to fill a safety-sensitive position, I will be required
to successfully pass a pre-employment drug test prior to appointment.
Signature: Date:
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EEO Designation Form DESOTO COUNTY BOARD OF COUNTY (Desoto County, Florida)

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Completed 12 August 2021

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