Fill - Free fillable Groveland Fire Dep Application Final Rev1 (City of Groveland) PDF form

Page 1 of 25

APPLICATION

Thank you for your interest in employment with the Groveland Fire Department. This application must be either typed

or printed legibly. Non-legible applications will NOT be accepted. Applications MUST be submitted in person to

the Groveland Fire Department unless otherwise instructed.

COMPLETE THE APPLICATION AS FOLLOWS:

1. Answer ALL questions.

 Note: if a question does not apply to you, place an “N/A” in the blank space provided for your answer.

2. Provide names of former employers along with their complete mailing addresses (including zip code), a good

contact phone number, your dates of employment, your rate of pay, your job title and specific duties.

3. List complete and correct physical and mailing addresses (including zip code) of your former residences.

This application MUST include certified copies of the following:

1. Proof of Name Change (if applicable)

This application MUST also include copies of the following:

1. Driver License

2. Social Security Card

3. High School Diploma or GED

4. DD 214 Form - Military Service Discharge Documents (if applicable)

5. Current valid State of Florida Minimum Fire Standards Certificate of Compliance

6. Current valid State of Florida EMT or Paramedic Certification

7. Current American Heart Association BLS Health Provider (EMT)

8. Current American Heart Association ACLS Health Provider (Paramedic)

9. Copy of approved 16 hour emergency vehicle operations course certification (EVOC/CEVO)=

Note: Any falsification of information on your application will automatically disqualify you from consideration for

employment with Groveland Fire Department.

ACKNOWLEDGMENT:

You are hereby informed that a thorough background investigation, including information regarding your character,

general reputation, personal characteristics, and mode of living will be part of the application process. This information

is solely for the purpose of evaluating your qualifications and eligibility for employment with The Groveland Fire

Department.

The submission of this application carries the understanding that you are authorizing The Groveland Fire Department to

contact any and all available sources for the purpose of obtaining information regarding

your qualifications.

EXAMINATIONS:

Prior to making a final recommendation for hire, applicants being considered for employment / placement will be

required to undergo a thorough background investigation in addition to the following selection process examinations:

1. Oral Board Interview

2. Written Examination

3. Physical Assessment Test P.A.T.

4. Physical / Drug Screen

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Rev 10/19

Page 2 of 25

Position:

:Applying

For:

Applicant Name:

(Last)

(First)

(Middle)

Street Address:

City:

State:

Zip:

Phone #:

Alternate Phone #:

Social Security #:

Email:

Social Media Addresses:

Do you have a valid Florida driver license?

☐ Yes / ☐ No

License Class:

Driver License #:

Expiration Date:

Are you at least 18 years of age for civilian employment or 19 years of age for employment?

☐ Yes / ☐ No

Are you legally authorized to work in the United States?

☐ Yes / ☐ No

(Note: Employment is subject to verification of minimum legal age and the provision of documentation to confirm U.S. work authorization).

Have you ever served in the US Armed Forces?

☐ Yes / ☐ No

If yes, complete following information:

Branch:

Entry Date:

Discharge Date:

Discharge Type:

(Note: Explain a dishonorable discharge, so the underlying circumstances can be weighed individually to avoid an improper disqualification.)

Are you claiming Veteran’s employment preference?

☐ Yes / ☐ No

If yes, file documentation with application.

Are you now using or have you ever used illegal controlled substances or illegal drugs?

☐ Yes / ☐ No

If yes, explain:

Have you ever been employed by the City of Groveland?

☐ Yes / ☐ No

If yes, when?

Have you ever been dismissed from a job for inefficiency, delinquency, misconduct, or other reason?

☐ Yes / ☐ No

If yes, when? Describe circumstances:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Rev 10/19

Page 3 of 25

Have you ever been formally or informally accused of unlawful harassment or discrimination?

☐ Yes / ☐ No

If yes, when?

Describe circumstances:

Are you currently under invesitgation for any offense against the law?

☐ Yes / ☐

If yes, describe charges:

Have you EVER at any time had adjudication withheld, plead guilty, no contest or been convicted of ANY offense

against the law?

☐ Yes / ☐ No

If yes, describe circumstances:

(Note: a conviction is not necessarily a disqualifying factor. Truthfully give all facts so a decision can be made.)

Have you ever been a defendant in a civil action for an intentional tort?

☐ Yes / ☐ No

If yes, explain:

EDUCATION

Level of

School Name

Course of

Years to

Degree / Diploma

Education

Street Address

Study

Complete

Received?

City / State / Zip

# of Credits

Yes / No

Type

G.E.D.

☐ Yes / ☐ No

High School

☐ Yes / ☐ No

Trade School

☐ Yes / ☐ No

College /

University

☐ Yes / ☐ No

List other education or special courses taken (include total hours and the training provider / sponsor name.

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 4 of 25

Answer if applicable:

Is G.E.D. sanctioned by a State Board of Education?

☐ Yes / ☐ No

While in school were you ever suspended, expelled, or otherwise disciplined?

☐ Yes / ☐ No

If yes, please explain:

List honors, awards, scholarships, etc.:

Extracurricular activities:

Foreign language spoken:

Foreign language read:

Foreign language written:

Certification / License Type

Are You

Issued In / By

Date

Expiration

Certified or

Which State

Issued

Date

Licensed?

(Mo / Yr)

American Heart Healthcare Provider BLS

☐ Yes / ☐ No

American Heart Healthcare Provider ACLS

☐ Yes / ☐ No

State of Florida EMT Certification

☐ Yes / ☐ No

State of Florida Paramedic Certification

☐ Yes / ☐ No

Florida Firefighter Compliance Certification

☐ Yes / ☐ No

Other:

☐ Yes / ☐ No

Other:

☐ Yes / ☐ No

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Other:

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EMPLOYMENT HISTORY

(Begin with present employer and list all jobs held since you started working)

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 6 of 25

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Company Name:

Employed From:

To:

Street:

Duties:

City:

State / Zip Code:

Telephone #:

Reason for Leaving:

Supervisor Name:

Pay Rate Start:

End:

Job Title:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 7 of 25

PERSONAL DATA

Applicant Name:

Maiden Name (if applicable):

Have you ever had your name legally changed?

☐ Yes / ☐ No

If you answered “Yes” to the above question, what was:

1. Your previous name(s):

2. Date and location of change:

3. Reason for change:

Have you ever been known by any other name?

☐ Yes / ☐ No

If you answered “Yes”, list all names (include nicknames and street names):

Date of Birth:

Place of Birth:

Are you eligible to work in the United States?

☐ Yes / ☐ No

List all social networking addresses:

PLACES OF RESIDENCE

(Note: List in chronological order all previous places of residence since elementary school. Begin with your

present address and work backwards. If necessary, attach a separate sheet of paper for additional residences.)

From / To

Street Address

City

State

Zip

(Month / Year)

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

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CAREER INTEREST

Names of relatives and friends employed by GFD:

Have you ever worked for or applied to GFD before?

☐ Yes / ☐ No

If yes, explain:

Have you ever applied to any other Fire Department?

☐ Yes / ☐ No

If yes, complete the following chart:

Date Applied

Agency Name

Reason for Non-Selection

Are you currently on any employment eligibility list?

☐ Yes / ☐ No

If yes, state agency name(s):

Have you had any Fire/EMT/Paramedic training by any local, state or federal agency?

☐ Yes / ☐ No

If yes, complete the following chart:

Date

Location

Training Received

Certificate Title

(If Applicable)

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

Page 9 of 25

Have you ever been dismissed, disciplined, and/or asked to resign employment due to misconduct or unsatisfactory

service and/or job performance?

☐ Yes / ☐ No

If “Yes”, complete below chart:

Date

Employer Name

Description of Circumstances

DRUG USE

Have you ever used an illegal drug?

☐ Yes / ☐ No

If “Yes”, complete the below chart:

Date(s) Type of Drug Used Circumstances Leading to Usage

Have you ever used a prescription drug prescribed for someone else?

☐ Yes / ☐ No

If “Yes”, complete the below chart:

Date(s) Type of Prescription Medication Circumstances Leading to Usage

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 10 of 25

SOCIAL HISTORY

List all clubs, societies, civic and/or organizations to which you are or have been a member:

Name of Organization

Street Address

Active

Date of

Phone #

City / State / Zip

Membership

☐ Yes / ☐ No

FAMILY BACKGROUND

List alphabetically by last name all members of your immediate family and if applicable your spouse’s immediate

family to include father, father-in-law, step-father, mother, mother-in-law, step-mother, brother, brother-in-law,

step-brother, sister, sister-in-law, step-sister, guardians, and foster parents. Please include deceased relatives.

Relationship

Name (Last, First, Middle)

Address

Occupation

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 11 of 25

MILITARY RECORD

If you have NEVER served in the Armed Forces of the United States, please SIGN the below statement:

, have never served in any branch of the United States Armed Forces.

Signature of Applicant

If you HAVE served in the Armed Forces of the United States, please complete the following:

Branch of Service:

Highest Rank:

Service #:

Duty Dates:

From:

To:

From:

To:

Branch of Service:

Highest Rank:

Service #:

Duty Dates:

From:

To:

From:

To:

Military specialization and duties:

Are you now or have you ever been a member of the Reserve Unit of the National Guard?

☐ Yes / ☐ No

If “Yes”, state the branch of service, name and location of your unit and whether you attended drills, meetings, or

camps:

Have you ever been tried on charges, or were you the subject of a summary court, court martial, deck court,

captain’s mast, company punishment, or any other type of disciplinary action while a member of the armed forces?

☐ Yes / ☐ No

If “Yes”, please provide the following details:

Date:

Place:

Nature of Offense:

Action Taken:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 12 of 25

FOREIGN MILITARY RECORDS

Have you ever served in the Armed Forces of any foreign nation?

☐ Yes / ☐ No

If “Yes”, indicate Nation:

Highest Rank Held:

Duty Dates:

From:

To:

Type of Separation:

RESIDENCE

Own / Buying:

Renting:

Leasing:

Living w/ Relatives / Friends:

Other:

If “Other”, please explain:

FINANCIAL HISTORY

Have you ever been a party to a financially related court action?

☐ Yes / ☐ No

If “Yes”, please explain:

If you are responsible for making child support payments, has legal action ever been taken against you for either

failing to make payments or delaying payments?

☐ Yes / ☐ No

If “Yes”, please explain:

☐ Yes / ☐ No

Have you ever been bonded?

☐ Yes / ☐ No

If employed by Groveland Fire Department, do you anticipate any income

other than your salary? If “Yes, list sources of income:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 13 of 25

CRIMINAL AND JUVENILE RECORD

Have you ever been arrested, charged or received a notice or summons to appear for any criminal violation?

☐ Yes / ☐ No

Have you ever been convicted of a felony and/or misdemeanor?

☐ Yes / ☐ No

Have you ever been detained by any law enforcement officer for investigative purposes OR have you ever been the

subject of OR a suspect in any criminal investigation?

☐ Yes / ☐ No

If you answered “Yes” to the above questions, please complete the following chart even if you were not formally

charged, did not appear in court, pled not guilty or nolo contendere, had adjudication withheld or deferred, were

found not guilty, or had the matter settled by payment of a fine or forfeiture of collateral. Note: include all matters

taking place while you were classified as a juvenile under the law of any state.

Date

Charge

Agency

Court

Disposition

To your knowledge, has any member of your family ever been arrested for any reason other than a traffic violation?

☐ Yes / ☐ No

If “Yes”, complete below chart:

Relatives Name

Relationship

Date

Charge

Disposition

Have you ever been reported as a missing person?

☐ Yes / ☐ No

If “Yes”, please explain:

Have you (or your spouse if applicable) ever been the plaintiff or defendant in a civil and/or criminal court case?

☐ Yes / ☐ No

If “Yes”, please explain below:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 14 of 25

GANGS / GROUPS

Have you ever belonged to or been associated with any criminal youth gang such as the Bloods, Crips, Latin Kings,

Folk Nation, People Nation, etc. either locally or in another state?

☐ Yes / ☐ No

If “Yes”, please explain:

Have you ever belonged to or been associated with any criminal motorcycle gang such as the Hell’s Angels,

Pagans, Outlaws, etc. either locally or in another state?

☐ Yes / ☐ No

If “Yes”, please explain:

Have you ever been the member of any local or national group that advocates hatred against another race?

☐ Yes / ☐ No

If “Yes”, please explain:

Have you belonged to or associated with any local or national group which advocates the overthrow of the

government of the United States?

☐ Yes / ☐ No

If “Yes”, please explain:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 15 of 25

TATTOOS / MARKINGS

Do you have any tattoos or other markings?

☐ Yes / ☐ No

(Note: if “No”, continue to next page.)

Do you have any tattoos or other markings which indicate past or current gang memberships, affiliation or activity?

☐ Yes / ☐ No

Do you have any tattoos or other markings that represent hatred against other races or cultures?

☐ Yes / ☐ No

Do you have any tattoos or other markings which indicate participation in any type of criminal activity?

☐ Yes / ☐ No

If you have neck or arm tattoos, are they visible when wearing a collared or short sleeve shirt?

☐ Yes / ☐ No

If you answered “Yes” to any of the above questions, please describe and ATTACH PHOTOS of each one:

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

Page 16 of 25

MOTOR VEHICLE OPERATING RECORD

Can you operate a motor vehicle?

☐ Yes / ☐ No

Has your driver license ever been suspended or revoked?

☐ Yes / ☐ No

If “Yes”, please complete the below chart:

Date

Location

Charges

Final Disposition

Have you ever been refused a driver license by any state?

☐ Yes / ☐ No

If “Yes”, please explain:

Have you ever received a traffic citation other than parking?

☐ Yes / ☐ No

Date

Agency

State

Charge

Final Disposition

Do you have any unpaid or outstanding summonses against you for any parking violation?

☐ Yes / ☐ No

If “Yes”, please explain:

Have you ever been declined an automobile insurance policy or hand a policy cancelled?

☐ Yes / ☐ No

If “Yes”, please explain:

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

Page 17 of 25

REFERENCES

Fill in the names of persons NOT RELATED TO YOU and NOT FORMER EMPLOYERS who have known you

for at least five (5) years. All persons listed may be contacted and asked to appraise your character, ability,

experience, personality, and other qualities. Make certain their contact information is current and accurate.

Name:

Street Address:

State:

Zip:

City:

State:

Zip:

Phone:

Email:

Years Known:

Name:

Street Address:

City:

State:

Zip:

Phone:

Email:

Years Known:

Name:

Street Address:

City:

State:

Zip:

Phone:

Email:

Years Known:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

click to sign

signature

click to edit

Page 18 of 25

LOYALTY

Have you ever, by word of mouth or in writing, advocated, advised, or taught the doctrine that the Government of

the United States of America, or any political subdivision thereof, should be overthrown by force, violence, or any

unlawful means?

☐ Yes / ☐ No

POLYGRAPH EXAMINATION

Are you willing to take a polygraph examination to verify all information supplied in this application and all

other information supplied by you to the Groveland Fire Department?

☐ Yes / ☐ No

Applicant’s Signature

If “No”, state your reason:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 19 of 25

ESSAY QUESTION

Why should we consider you for the position to which you have applied? Please keep answer to one page.

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

Page 20 of 25

READ THIS APPLICATION AND YOUR ANSWERS CAREFULLY BEFORE SIGNING BELOW

I, , affirm that all statements made by me on this application are true,

complete and correct to the best of my knowledge and belief. I understand and agree that if I make any misstatements

or omissions of fact, I am subject to disqualification or dismissal and to such other penalties prescribed by law,

personnel policy or regulations. I am aware that statements made by me in this application are subject to later

investigation. I am further aware that should any investigation disclose any misrepresentation, falsification, omission,

or concealment of material fact, my application may be rejected. If already appointed, I may be dismissed. I voluntarily

give The Groveland Fire Department, or its duly authorized representative, the right to make a thorough investigation

of my past employment and activities. I agree to cooperate in such investigation and I further release from all liability

and responsibility any and all persons, companies or corporations supplying such information.

Please sign below in the presence of a Notary.

Applicant’s Signature:

Date:

State of Florida

County of

Sworn to before me this

day of

, 20

Signature of Notary

(Notary Seal)

DO NOT WRITE IN THIS SECTION

(For Human Resources – Office Use Only)

An Equal Opportunity Employer

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 21 of 25

An Equal Opportunity Employer

FCRA NOTICE AND CONSENT

CITY OF GROVELAND

PLEASE READ THIS NOTICE AND CONSENT FORM CAREFULLY

This notice and consent form is provided to you in compliance with the Fair Credit Reporting Act (“FCRA”). The

FCRA is a federal law governing the provision of certain data to employers by third-party provides called “consumer

reporting agencies.”

In connection with your application and/or employment, and provided that you give written consent below, The

Groveland Fire Department may obtain a consumer report containing information about you. A consumer report is

defined as a written, oral, or other communication of any information by a consumer reporting agency bearing on your

creditworthiness, credit standing, credit capacity, character, general reputation, general personal characteristics, or

mode of living (including criminal history and background), which will be used or will be expected to be used or

collected whole or in part for the purpose of serving as a factor in establishing your eligibility for employment. Please

be informed and understand that you may obtain a copy of any such report, and that you may dispute the accuracy or

completeness of the information report to the City of Groveland Fire Department by writing or calling the consumer

reporting agency directly.

I hereby agree and consent that the City of Groveland conduct security consumer report(s) on me, and using

the consumer report(s) in whole or in part in arriving at a decision regarding my employment.

Applicant’s Signature:

Date:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 22 of 25

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of

consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and

specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history

records). Here is a summary of your major rights under the FCRA. For more information, including information about

additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade

Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or

another type of consumer report to deny your application for credit, insurance, or employment – or to take another

adverse action against you – must tell you, and must give you the name, address, and phone number of the agency

that provided the information.

• You have the right to know what is in your file. You may request and obtain all the information about you in the

files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper

identification, which may include your Social Security number. In many cases, the disclosure will be free. You

are entitled to a free file disclosure if:

o a person has taken adverse action against you because of information in your credit report;

o you are the victim of identity theft and place a fraud alert in your file;

o your file contains inaccurate information as a result of fraud;

o you are on public assistance or

o you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each

nationwide credit bureau and from nationwide specialty consumer reporting agencies. See

www.ftc.gov/credit for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness

based on information from credit bureaus. You may request a credit score from consumer reporting agencies that

create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some

mortgage transactions, you will receive credit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is

incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your

dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information.

Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days.

However, a consumer reporting agency may continue to report information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting

agency may not report negative information that is more than seven years old, or bankruptcies that are more than

10 years old.

• Access to your file is limited. A consumer reporting agency may provide information about you only to people

with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other

business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give

out information about you to your employer, or potential employer, without your written consent given to the

employer. Written consent generally is not required in the trucking industry. For more information, go to

www.ftc.gov/credit.

(continued on next page)

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

Page 23 of 25

• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.

Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if

you choose to remove your name and address from the lists these offers are based on. You may opt-out with the

nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer

reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in

state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For more information, visit

www.ftc.gov/credit.

• Enforcement and other rights. States may enforce the FCRA, and many states have their own consumer reporting

laws. In some cases, you may have more rights under state law. For more information, contact your state or local

consumer protection agency or your state Attorney General.

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

Page 24 of 25

The information requested below is used for EEO (Equal Employment Opportunity) purposes only and NOT

to evaluate your application for employment with The Groveland Police Department. Completion of this form

by you is strictly voluntary. You are NOT legally required to supply this information; however, your

Assistance in doing so is appreciated. Thank you.

Date:

Position Applied For:

Gender:

☐ Male / ☐ Female

Age Group:

☐ 16 - 22

☐ 23 - 39

☐ 40 - 70

☐ Over 70

Race / Ethnic Origin:

☐ White, Non-Hispanic or Latino

☐ Black or Black and White, Non-Hispanic or Latino

☐ Hispanic or Latino

☐ Asian or Asian and White, Non-Hispanic or Latino

☐ American Indian / Alaskan Native, Non-Hispanic or Latino

☐ Native Hawaiian – Other Pacific Islander, Non-Hispanic or Latino

☐ 2+ Races, Non-Hispanic or Latino

Disabled:

☐ Yes / ☐ No

If “Yes”, describe disability:

Military Status:

☐ Non-Veteran

☐ Veteran

☐ Disabled Veteran

Actively Served During Which (Check Applicable):

☐ WWII / Korea

☐ Persian Gulf

☐ Iraq / Afghanistan

☐ Operation Enduring Freedom

☐ Other:

How did you hear about the position to which you are applying?

☐ News Chief

☐ The Ledger

☐ Other Newspaper

☐ Magazine / Publication

☐ Word of Mouth

☐ Walk-In / General Job Search

☐ Search Firm or Employment Agency

☐ Civic / Professional Organization

☐ Internet / City Website

☐ City of Groveland Employee

☐ College or University

☐ Other:

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

click to sign

signature

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I, _________________________________________, having made an application for a

position with the Groveland Fire Department, do hereby solemnly swear or affirm that I

am, and have been, a nonuser of cigarettes and other tobacco products for at least one

year immediately preceding the date of my application. (Pursuant to Florida State

Statues 633.34 (6))

I understand that it is a condition of my employment that I do not use cigarettes and

other tobacco products on or off the job during the term of my employment with the

City. I further understand that my failure to comply with this requirement may result in

my dismissal.

_____________________________________

Signature

The above oath was subscribed and sworn to before me this _________ day of

_________________, 20_____.

_________________________________

NOTARY PUBLIC, STATE OF FLORIDA

Page 25 of 25

Groveland Fire Department

156 S. Lake Ave

Groveland, Florida 34736

TOBACCO POLICY

(such as maiden name)

: *

By my signature below, I have authorized the City Of Groveland, Florida to conduct a criminal history check and

verification of other personal information. This is to serve as an authorization to release information to the City,

as requested by the City, in order to verify my qualifications and fitness for employment with the City. The release

of information that I hereby authorize includes: FDLE State Criminal History and/or local police background check;

employment record, including performance evaluations and disciplinary actions; school record; records affecting

character or reputation; divorce record (if applicable); arrest records; criminal records; records from any law

enforcement agency; driver's license details and history; driving history; recorded polygraph examination history

or application status; any and all information of a confidential, privileged, non-confidential, and non-privileged

nature; and photocopies of same, if available. I further hereby release the record holder, his or her

organization/agency, and other related entities from any liability or damage which may result from furnishing to the

City the requested information.

I also acknowledge receipt of the notice regarding my Social Security number provided below.*

The foregoing instrument was acknowledged before me by __________________________________________

who has produced ________________________________ as identification and who did not take an oath, and

who appeared before me at the time of notarization.

WITNESS, my hand and official seal, this __________ day of ___________________________, 20_________.

Groveland

Groveland Fire

Department

156 S. Lake Ave

Groveland, Florida 34736

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Groveland Fire Dep Application Final Rev1 (City of Groveland)

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