4
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 ___________________________________
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 (Check Only One):
WHITE BLACK HISPANIC ASIAN or PACIFIC ISLANDER NATIVE AMERICAN
OTHER (Specify) ______________________________________________________________________________________
LAW ENFORCEMENT BACKGROUND
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.? YES NO
**Other covered jobs include: correctional and correctional probation officers, firefighters, certain judges, assistant state attorneys, state attorneys,
assistant and statewide prosecutors, and certain investigators in the Department of Children and Families [SEE §119.07(3)(k)1,F.S.].
DP-E-16 Rev. 11/95
✂
VETERANS’ PREFERENCE CLAIM (Please see instructions on page 3) YOUR NAME
✂
EEO SURVEY
Note: Employer remove this section
prior to the selection process.
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 TO 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.
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
IF ELIGIBLE, WHICH VETERANS’ PREFERENCE CATEGORY ARE YOU CLAIMING?
(Please indicate number from Veterans’ Preference Information section on page 3)
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? 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.
Note: Employer remove this section
upon completion of the selection process.
