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Employment-Application-PDF Town of Bay Harbor Islands

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Town of Bay Harbor Islands
9665 Bay Harbor Terrace
Bay Harbor Islands, FL 33154
www.bayharborislands.org
EMPLOYMENT APPLICATION
An Equal Opportunity Employer and a Drug Free Workplace
The Town of Bay Harbor Islands does not tolerate violence in the workplace.
We consider applications for all positions without regard to race, color, religion, creed,
gender, national origin, age, disability, marital, or veteran status, sexual orientation,
or any other legally protected status.
INSTRUCTIONS: Please print or type all information. The application must be filled out accurately and completely.
Answer all questions. Do not leave an item blank. If an item does not apply, write N/A. If you need additional space to
answer a question fully, you may use full sheets of paper that are the same size as this page. On each additional page,
be sure to include your name and the position title applying for. You may also attach copies of documents or certificates
which support your application. All materials submitted become the property of the Town and will not be returned. All
statements made on the application are subject to verification. Exaggerated, false, or misleading statements may be
cause for rejection of the application and/or termination of employment.
NOTICE OF COLLECTION OF SOCIAL SECURITY NUMBER
In accordance with F.S. 119.071(5)(a)2, your social security number is requested for the purpose of payroll eligibility
verification, processing employment benefits, applicant and employee background checks, and income reporting, and will
be used solely for these purposes.
POSITION APPLYING FOR: DATE:
If referred by a current Town employee, indicate his/her name here:
REFERRED BY:
How did you learn about the position for which you are applying?
Advertisement Friend Walk-In Town’s Website Employment Agency Relative Other
CURRENT PERSONAL DATA
LAST NAME: FIRST NAME:
ADDRESS:
SOCIAL SECURITY NUMBER:
CELL PHONE:
HOME PHONE: BUSINESS PHONE:
EMPLOYMENT AVAILABILITY
ARE YOU PRESENTLY EMPLOYED? YES NO
IF SO, MAY WE CONTACT YOUR EMPLOYER? YES NO
EMPLOYMENT WITH THE TOWN OF BAY HARBOR ISLANDS MAY REQUIRE WORKING WEEKENDS, SHIFTS AND
HOLIDAYS. ARE YOU ABLE TO WORK: (Check all that apply)
FULL-TIME PART-TIME SHIFT WORK EVENINGS WEEKENDS HOLIDAYS TEMPORARY
EARLIEST YOU WOULD BE ABLE TO START:
SALARY DESIRED:
Page 1 of 8
Page 2 of 8
ARE YOU OVER 18 YEARS OF AGE? YES NO
ARE YOU RELATED TO ANYONE PRESENTLY EMPLOYED BY THE TOWN? YES NO
IF YES, GIVE NAME AND RELATIONSHIP:
HAVE YOU EVER BEEN EMPLOYED BY THE TOWN OF BAY HARBOR ISLANDS? YES NO
IF YES, PLEASE LIST DATES EMPLOYED, POSITION, AND REASON FOR LEAVING:
RELIABILITY/CAPABILITY
WOULD YOU BE WILLING AND ABLE TO PERFORM ALL OF THE TASKS REQUIRED BY THE JOB FOR WHICH YOU ARE
APPLYING? YES NO
IF NOT, EXPLAIN WHICH TASKS, PLEASE BE SPECIFIC
HAVE YOU FILED ANY TYPE OF FRAUDULENT CLAIM AGAINST ANY OF YOUR PRESENT OR PAST EMPLOYERS?
YES NO
IF YES, EXPLAIN
WILL YOU BE ABLE TO ABIDE BY THE SAFETY RULES? YES NO
HAVE YOU EVER BEEN DISCIPLINED FOR VIOLATING SAFETY RULES OR REGULATIONS? YES NO
HOW MANY DAYS OF WORK (OR SCHOOL) HAVE YOU MISSED IN THE LAST TWO YEARS?
WOULD YOU BE WILLING AND ABLE TO REPORT TO WORK ON TIME EVERY DAY ON A REGULAR AND CONSISTENT
BASIS? YES NO
IF NO, PLEASE EXPLAIN
CITIZENSHIP INFORMATION
The Town of Bay Harbor Islands hires only U.S. Citizens and lawfully authorized alien workers. If a conditional offer of employment is made, you will be
required to provide identification and proof of citizenship or authorization to work in the U.S.
ARE YOU A U.S. CITIZEN OR ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.? YES NO
CAN YOU, UPON EMPLOYMENT, SUBMIT DOCUMENTATION VERIFYING YOUR RIGHT TO WORK AND YOUR IDENTITY?
YES NO
EDUCATION
SELECT HIGHEST GRADE COMPLETED: GRADE/HIGH SCHOOL COLLEGE/UNIVERSITY GRADUATE SCHOOL
9 10 11 12 1 2 3 4 1 2 3 4
SCHOOL NAME/ADDRESS
ATTENDANCE DATES DEGREE
GRADE SCHOOL
HIGH SCHOOL
COLLEGE/UNIVERSITY
GRADUATE SCHOOL
OTHER/GED
Page 3 of 8
EMPLOYMENT HISTORY
(THIS SECTION MUST BE COMPLETED EVEN IF ATTACHING A RESUME)
INSTRUCTIONS
: BEGINNING WITH YOUR PRESENT OR MOST RECENT EMPLOYER, LIST ALL FULL AND PART-TIME EMPLOYMENT FOR THE LAST TEN YEARS AND
ACCOUNT FOR ALL PERIODS OF UNEMPLOYMENT WHICH EXCEED THREE MONTHS
. USE ADDITIONAL SHEETS IF NECESSARY. IF YOU HAVE BEEN EMPLOYED UNDER
OTHER NAMES
, LIST WITH APPLICABLE EMPLOYER. INCLUDE ANY JOB-RELATED VOLUNTEER ACTIVITIES AND SELF-EMPLOYMENT.
PRESENT/MOST RECENT EMPLOYER NAME:
STREET ADDRESS:
CITY, STATE, ZIP: TELEPHONE NUMBER:
JOB TITLE:
SUPERVISOR’S NAME:
HIRE DATE:
SEPARATION (END) DATE:
JOB DUTIES & RESPONSIBILITIES:
STARTING SALARY:
ENDING SALARY:
REASON FOR LEAVING (Be specific, this area must be completed):
EMPLOYER NAME:
STREET ADDRESS:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
JOB TITLE: SUPERVISOR’S NAME:
HIRE DATE:
SEPARATION (END) DATE:
JOB DUTIES & RESPONSIBILITIES:
STARTING SALARY:
ENDING SALARY:
REASON FOR LEAVING (Be specific, this area must be completed):
EMPLOYER NAME:
STREET ADDRESS:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
JOB TITLE:
SUPERVISOR’S NAME:
HIRE DATE: SEPARATION (END) DATE:
JOB DUTIES & RESPONSIBILITIES:
STARTING SALARY:
ENDING SALARY:
REASON FOR LEAVING (Be specific, this area must be completed):
Page 4 of 8
SUPPLEMENTAL EMPLOYMENT INFORMATION
IF YOU WORKED IN ANY OF YOUR PREVIOUS POSITIONS UNDER ANOTHER NAME, PLEASE GIVE THAT NAME(S)
BELOW: (FOR REFERENCE CHECKING PURPOSES)
NAME
COMPANY
NAME COMPANY
HAVE YOU EVER BEEN FIRED OR ASKED TO RESIGN FROM A JOB? YES NO
IF YES, PLEASE EXPLAIN:
HAVE YOU EVER BEEN DISCIPLINED, OR RECEIVED A VERBAL OR WRITTEN WARNING FOR ABSENTEEISMS OR
TARDINESS? YES NO
IF YES, PLEASE EXPLAIN
LIST ANY LICENSES, CERTIFICATES, OR ADDITIONAL SKILLS, INCLUDING KNOWLEDGE OF SOFTWARE PROGRAMS YOU
HAVE THAT MAY BE HELPFUL IN DOING THIS JOB:
DESCRIBE ANY SPECIAL EQUIPMENT OR MACHINERY YOU CAN OPERATE THAT MAY BE HELPFUL IN DOING THIS JOB:
LIST ANY PROFESSIONAL, TECHNICAL, OR TRADE ASSOCIATION IN WHICH YOU ARE A MEMBER:
INDICATE ANY FOREIGN LANGUAGES YOU CAN SPEAK, READ AND/OR WRITE:
FLUENT GOOD FAIR
SPEAK
READ
WRITE
BACKGROUND INFORMATION
HAVE YOU EVER BEEN ARRESTED, INDICTED, CONVICTED, OR PLED NO CONTEST TO ANY VIOLATION OF THE LAW,
ORDINANCE, OR CRIMINAL TRAFFIC VIOLATION? YES NO
IF YES, PROVIDE DETAILS BELOW, INCLUDING FINES, ARRESTS, CONVICTIONS, PROBATION, JAIL OR PRISON
SENTENCES (INCLUDING THOSE WHILE IN THE MILITARY):
A “YES” answer to this question will not necessarily bar you from employment. The nature, severity, and date of the
offense in relation to the position for which you are applying are considered.
DATE OFFENSE CHARGE NAME/LOCATION OF COURT DISPOSITION/SENTENCE
Page 5 of 8
HAVE YOU EVER BEEN REFUSED A SURETY BOND? YES NO
IF YES, WHEN?
HAVE YOU EVER BEEN NAMED IN A CHARGE OF DISCRIMINATION OR A DEFENDANT IN A LAWSUIT? YES NO
IF YES, PLEASE GIVE DATE, EMPLOYER AND BRIEF STATEMENT OF WHAT THE COMPLAINTS WERE ON A SEPARATE
SHEET OF PAPER. (NOTE: THIS WILL NOT AUTOMATICALLY EXCLUDE YOU FROM CONSIDERATION)
NOTE: A CRIMINAL BACKGROUND CHECK AND DRIVING RECORD CHECK WILL BE CONDUCTED IF YOU ARE CONSIDERED FOR EMPLOYMENT.
INFORMATION CONCERNING ARRESTS AND CONVICTIONS MAY NOT NECESSARILY DISQUALIFY AN APPLICANT. HOWEVER, ANY APPLICANT WHO
FALSIFIES THE APPLICATION BY FAILING TO PROVIDE REQUIRED INFORMATION ON ARRESTS AND CONVICTIONS WILL, IF EMPLOYED, BE SUBJECT
TO DISMISSAL, OR, IF NOT EMPLOYED, BE SUBJECT TO DISQUALIFICATION.
DRIVER LICENSE
DO YOU POSSESS A CURRENT, VALID DRIVER LICENSE? YES NO
IF NO, STATE REASON:
DRIVER LICENSE NUMBER:
STATE:
DRIVER LICENSE TYPE: OPERATOR CDL A B C D E
CDL ENDORSEMENTS:
HAVE YOUR DRIVING PRIVILEGES EVER BEEN SUSPENDED OR REVOKED? YES NO
IF YES, EXPLAIN:
REFERENCES
LIST THREE (3) PERSONAL OR PROFESSIONAL REFERENCES (NO RELATIVES OR EMPLOYERS)
NAME OCCUPATION TELEPHONE YEARS KNOWN
MILITARY SERVICE
HAVE YOU EVER SERVED IN THE U.S. MILITARY? YES NO
IF YES, BRANCH:
DATES OF ACTIVE DUTY (FROM/TO):
RANK:
OCCUPATIONAL SPECIALTY:
TYPE OF DISCHARGE:
VETERANS’ PREFERENCE
ARE YOU CLAIMING VETERANS’ PREFERENCE PURSUANT TO F.S. 295.07? YES NO
IF YES, PLEASE DESIGNATE THE BASIS FOR YOUR PREFERENCE ON A FORM OBTAINED FROM THE TOWN OF BAY
HARBOR ISLANDS AND ATTACH COPIES OF SUPPORTING DOCUMENTATION (DD214). THIS FORM MUST BE
SUBMITTED WITH THE APPLICATION.
Page 6 of 8
CERTIFICATION
This must be signed. Please read carefully.
I certify that there are no misrepresentations, omissions, or falsifications in the statements and answers on this
application and that all the foregoing entries made by me are true, complete and correct to the best of my knowledge
and belief.
I hereby authorize the Town of Bay Harbor Islands to verify all information contained herein and I release all past
employers and all references from any and all liability for the release of information to the Town of Bay Harbor Islands.
I understand that all job offers from the Town of Bay Harbor Islands are conditioned on successful completion of a health
questionnaire, polygraph, and medical examination by a Town appointed physician/facility and psychological evaluation to
determine my ability to perform any job offered. The examination shall include an alcohol/drug screen for which I give
consent and agree to give a specimen of my blood and/or urine to any medical facility designated by the Town of Bay
Harbor Islands for this purpose.
I also understand that in accordance with Florida Statutes, employment with the Town of Bay Harbor Islands is “at-will”
and as such, may be terminated without cause and without notice by either party at any time.
I understand that the Town of Bay Harbor Islands will not tolerate unlawful discrimination or unlawful harassment and
that employees have an affirmative duty to report such incidents and that such conduct is grounds for termination of
employment.
I hereby swear or affirm that there are no misrepresentations or omissions in or falsifications of the above statements
and answers to questions. I understand, should the investigation disclose such misrepresentations, falsifications or
omissions, my application will be rejected and I will be disqualified from present processing or, if after my acceptance for
employment, subsequent investigation should disclose misrepresentations, falsifications or omissions, regardless of when
this information becomes known to the Town of Bay Harbor Islands, it will be just cause for immediate dismissal from
employment with the Town of Bay Harbor Islands. This consent shall continue to be effective during my employment if I
am hired.
SIGNATURE DATE
HAVE YOU READ ALL INSTRUCTIONS ON THE APPLICATION AND ANSWERED ALL QUESTIONS? If so, Please Initial Here:
FOR HUMAN RESOURCES DEPARTMENT USE ONLY
Arrange Interview: YES NO
Date:
Interviewer(s):
Remarks:
Employed: YES NO
Date of Employment:
Department:
Job Title:
Hourly/Salary Rate:
Approved:
Town Manager Date Department Head Date
CLAIM FOR VETERANS’ PREFERENCE
(TO BE USED BY VETERANS & RELATIVES OF VETERANS)
Attach a copy of your discharge papers (DD214) and submit with Application.
INSTRUCTIONS: Complete ONLY if you are claiming Veterans’ Preference. All applicants claiming Veterans’ Preference must complete
this form and include all supporting documentation which are to be submitted with your application.
F.S. 1.01(14) defines the term Veteran as one who has served in the active military and who is discharged under honorable conditions only, or who later
received an upgraded discharge under honorable conditions notwithstanding any action by the Department of Veteran’s Affairs on individuals discharged
or released with other than honorable discharges. To receive benefits as a wartime veteran, a veteran must have served for one day or more during one
of the following: World War II, Korean Conflict, Vietnam Era, Persian Gulf War, Operation Enduring Freedom, Operation Iraqi Freedom (documentation
of such service must be provided at the time of application).
Are you a resident of the State of Florida? (Veterans’ Preference is only available to Florida Residents) YES NO
I. APPLICANT INFORMATION
Your Name: Date:
Last First Middle Initial
Your Social Security Number: Position Applying For:
Veteran’s Name (If you are not the veteran):
Veteran’s Social Security Number (If you are not the veteran):
If Active Service, Branch of Service:
Date of Entry: Date of Discharge:
II. VETERANS’ STATUS CLAIMED
Please check the following appropriate statement as it applies to you. Please check ONLY one. I claim Veterans’ Preference based upon
the following:
_____ *As a veteran with a compensable service-connected disability who is eligible for or receiving compensation, disability
retirement or pension under public laws administered by the U.S. Veteran’s Administration and the Department of
Defense.
_____ *As the spouse of a veteran who cannot qualify for employment because of total and permanent service-connected
disability, or the spouse of a veteran missing in action, captured or forcibly detained by a foreign power.
_____ 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.
_____ *As the unremarried spouse of a veteran who was killed in action, or died of a service-connected disability.
_____ A veteran who has served in a campaign or expedition for which a qualifying campaign badge or expeditionary medal
has been authorized (including any armed forces expeditionary medal or the global war on terrorism medal).
*A statement of disability certification from the Department of Veteran’s Affairs must be submitted at time of application.
Have you been employed through Veterans’ Preference since October 1, 1987? YES NO
If yes, please provide the name and telephone of the employer:
I hereby certify that the information provided above is true and correct. I understand that falsification of the information is a criminal violation and may
subject me to prosecution and possible incarceration and/or fine and will result in dismissal if employed. I have received notice of the appropriate
procedures to follow in order to initiate an investigation into any non-compliance with the Veterans’ Preference laws.
Signature Date
NOTE: Any eligible applicant who believes he/she was not afforded employment preference in accordance with F.S. 295.08 may file a complaint with the
Division of Veterans’ Affairs within 21 days from the date of notice of hiring decision.
Page 7 of 8
EQUAL OPPORTUNITY EMPLOYER DATA
(THIS SURVEY IS VOLUNTARY)
THE TOWN OF BAY HARBOR ISLANDS IS AN EQUAL OPPORTUNITY EMPLOYER, AND IS COMMITTED TO RECRUIT,
EMPLOY AND PROMOTE PERSONNEL WITHOUT REGARD TO RACE, COLOR, GENDER, AGE, RELIGION, MARITAL
STATUS, DISABILITY, NATIONAL ORIGIN OR VETERAN’S STATUS IN COMPLIANCE WITH ALL FEDERAL, STATE, AND
LOCAL LEGISLATION AND REGULATIONS PERTAINING TO NON-DISCRIMINATION. THE TOWN OF BAY HARBOR
ISLANDS COLLECTS DEMOGRAPHIC DATA TO COMPLY WITH FEDERAL AND STATE GUIDELINES. TO ASSIST US IN OUR
CONTINUING EFFORT TO DO SO, THIS DATA IS COMPILED ON AN ON-GOING BASIS. HOWEVER, YOUR COOPERATION
IN COMPLETING THE FOLLOWING IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY
EMPLOYMENT DECISION. THIS FORM IS REMOVED FROM THE APPLICATION UPON SUBMITTAL TO THE TOWN OF BAY
HARBOR ISLANDS AND IS KEPT IN A SEPARATE CONFIDENTIAL FILE.
DATE OF APPLICATION:
NAME:
MAILING ADDRESS:
TELEPHONE:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
POSITION APPLIED FOR:
RACE
: SEX: VETERAN:
WHITE (NON-HISPANIC) MALE YES
BLACK FEMALE NO
HISPANIC
ASIAN/PACIFIC ISLANDER
AMERICAN INDIAN/ALASKAN NATIVE DISABLED
:
YES
NO
REFERRAL RESOURCES
:
Advertisement (Specify Source)
Employment Agency
Town Employee (Please indicate name of referring employee on front page of application)
Friend
Relative
Town’s Website
Walk-In
Other (Please Specify)
Page 8 of 8
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Completed 11 July 2020

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