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APPLICATION FOR EMPLOYMENT
1059||Document1|B
(1)
11TH JUDICIAL CIRCUIT EQUAL EMPLOYMENT OPPORTUNITY/
MIAMI-DADE COUNTY, FLORIDA AFFIRMATIVE ACTION EMPLOYER
Position(s) applied for: (1) ________________________________ (2)
Please check: Full time Part time Summer Employment
Date available to start: ____________________________ Hours available to work:
***NOTICE TO APPLICANT***
PLEASE READ BEFORE COMPLETING APPLICATION: ALL SECTIONS OF THIS
APPLICATION MUST BE COMPLETED FULLY IN ORDER FOR THIS OFFICE TO CONSIDER
YOU FOR EMPLOYMENT OPPORTUNITIES.
SECTION A: Social Security #: XXX-XX-_________
PRINT YOUR LEGAL NAME AS IT APPEARS ON YOUR SOCIAL SECURITY CARD:
(FIRST) (MIDDLE) (LAST)
ADDRESS: , , ,
(STREET) (CITY) (STATE) (ZIP)
TELEPHONE: (H) ___________________ (W) ___________________________ (C) #
eMail Address:
SECTION B - EDUCATION:
High School or GED ________ Yes _________ No Name of School:
COLLEGE NAME
MAJOR
CREDIT
HOURS
EARNED
ACADEMIC DEGREE
EARNED
GRADUATED
YES or NO
Other Education
(Technical, etc.)
MAJOR
CREDIT
HOURS
EARNED
CERTIFICATE
YES or NO
GRADUATED
YES or NO
NAME OF LAW
SCHOOL
CREDIT
HOURS
EARNED
GRADUATED
YES or NO
SPECIAL HONORS AND EXTRACURRICULAR ACTIVITIES:
Education:
Community:
1059 - 5/22/00||Document1|B
(2)
Please ensure all employment information on this application is true and accurate, and that no attempt has been made to
conceal pertinent information. Any omissions, falsifications, mis-statements, or mis-representations may disqualify you for
employment consideration and if hired, could be grounds for termination at a later date.
SECTION C - EMPLOYMENT HISTORY (List most recent employment first and list only employment for the last 10 years):
1. Employer: Position Held:
Address: City: ST: Zip:
Supervisor: Telephone: Hours per week:
Dates of Employment: From (Month/Year): _______________________ To (Month/Year): ____________________
Salary (Choose One): Annual: ___________________ Monthly: __________________ Hourly:
Job Responsibilities:
Reason for leaving (If still employed, reason you want to leave):
2. Employer: Position Held:
Address: City: ST: Zip:
Supervisor: Telephone: Hours per week:
Dates of Employment: From (Month/Year): _______________________ To (Month/Year): ____________________
Salary (Choose One): Annual: ___________________ Monthly: __________________ Hourly:
Job Responsibilities:
Reason for leaving (If still employed, reason you want to leave):
1059||Document1|B
(3)
SECTION C - EMPLOYMENT HISTORY CONTINUED:
3. Employer: Position Held:
Address: City: ST: Zip:
Supervisor: Telephone: Hours per week:
Dates of Employment: From (Month/Year): _______________________ To (Month/Year): ____________________
Salary (Choose One): Annual: ___________________ Monthly: __________________ Hourly:
Job Responsibilities:
Reason for leaving (If still employed, reason you want to leave):
4. Employer: Position Held:
Address: City: ST: Zip:
Supervisor: Telephone: Hours per week:
Dates of Employment: From (Month/Year): _______________________ To (Month/Year): ____________________
Salary (Choose One): Annual: ___________________ Monthly: __________________ Hourly:
Job Responsibilities:
Reason for leaving (If still employed, reason you want to leave):
1059||Document1|B
(4)
SECTION D -MILITARY:
Branch: Dates of Service:
Grade/Rank on Discharge: Theaters of Service:
Decorations: Legal Duties (if any):
SELECTIVE SERVICE REGISTRATION: This applies to males between eighteen and twenty-six years of age who are either
United States citizens or aliens (including parolees and refugees and those who are lawfully admitted to the United States and for
asylum) residing in the United States; and are or were required to register under the Military Selective Service Act (50 U.S.C. App.
453). Nonimmigrant aliens admitted under Section 101 (a)(15) of the Immigration and Nationality Act (8 U.S.C. 1101), such as
those admitted on visitor or student visas, and lawfully remaining in the United States, are exempt from registration. If employed
with this office, you will be required to show proof of Selective Service registration, if applicable.
VETERAN'S PREFERENCE - Check the appropriate box if you are claiming veteran's preference.
1. A veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement, or pension
under public laws administered by the U.S. Veterans Administration and the Department of Defense, or
2. The spouse of a veteran who cannot qualify for employment because of a total and permanent disability, or the spouse of a
veteran missing in action, captured, or forcibly detained by a foreign power, or
3. A veteran of any war who has served on active duty for 181 consecutive days or more, or who has served 180 consecutive
days or more since January 31, 1955, and who was honorably discharged from the Armed Forces of the United States of
America if any part of such active duty was performed during a wartime era, excluding active duty for training, or
4. The unremarried widow or widower of a veteran who died of a service-connected disability.
Branch of Service Date of Entry Date of Discharge
Have you claimed and been employed using veteran’s preference since October 1, 1987? Yes No
If yes,
Name of Employer
NOTE: Under Florida law, preference in appointment shall be given by the state first to those persons included in 1 and 2 above,
and second to those persons included in 3 and 4 above. If an applicant claiming veteran's preference for a vacant position is not
selected for the vacant position, he/she may file a complaint with the Division of Veterans Affairs, P.0. Box 1437, St. Petersburg,
Florida 33731. A complaint must be filed within 21 days of the applicant receiving notice of the hiring decision made by the
employing agency or at any time if no notice is given.
In order to be considered for Veteran’s Preference, a copy of your DD214 must be submitted with your Employment Application.
1059||Document1|B
(5)
SECTION E - MISCELLANEOUS:
1. Have you ever been arrested or cited for any crime or offense? Florida Statutes 112.011(2)(a) and 943.058 authorize the
asking of this question. Please refer to attached ADDENDUM I on page 9 to respond.
2. Have you ever been ordered to pay child support? Yes No
a. If yes, in what County or State? ____________________________________
b. Have you ever been delinquent in your child support payments? Yes No
3. Do you have any objections to being fingerprinted and having your background investigated? Yes No
If yes, why?
4. Have you ever been disciplined or discharged for fighting, assaults, or related behavior? Yes No
If yes, please explain
5. Do you have any objections to your present employer being contacted? Yes No
If yes, please explain: _______________________________________________________________________________
6. Do you feel you are qualified to work under pressure? Yes No
7. Have you ever applied for employment at this Office? Yes No
If yes, under what name:
Month and year you applied:
8. Who referred you?
(Name of person, school, or agency)
SECTION F - SPECIAL SKILLS: (Answer where applicable)
Language proficiency:
Particular investigative training or experience:
Particular legal writing training or experience:
Clerical skills: Typing speed __________ W.P.M.; Dictating and/or other office equipment you can operate:
List any additional job-related skills:
1059||Document1|B
(6)
SECTION G - REFERENCES:
Friends or relatives employed by this office:
1.
(Name) (Department) (Relationship)
2.
(Name) (Department) (Relationship)
Character references - list three persons who have known you for five or more years - do not include relatives or former employers:
1.
(Name) (Complete Address) (Telephone)
2.
(Name) (Complete Address) (Telephone)
3.
(Name) (Complete Address) (Telephone)
SECTION H - CERTIFICATION: ** READ BEFORE SIGNING **
I hereby certify that all statements made on this form are true and correct, and that no attempt has been made to conceal pertinent
information. I am aware that any omissions, falsifications, misstatements, or misrepresentations may disqualify me for
employment consideration and, if I am hired, may be grounds for termination at a later date. I authorize my former employers,
schools, personal references and institutions of credit to provide any information that they may have regarding me, whether or not
it is on their records. I hereby release them and their company from liability for divulging same. I further understand that if
employed, a background investigation will be made and should such investigation reveal any misrepresentation, I will be subject to
immediate dismissal; and I agree to hold the State Attorney’s Office and persons named herein blameless in that event.
As a condition of employment, I agree that I will hold in strict confidence and will not disclose any information which I receive in
the course of my employment relating in any manner to the proceedings of the State Attorney’s Office or any other affiliated agency.
Date: Signature:
EMPLOYMENT ELIGIBILITY
We appreciate your interest in considering employment with the State Attorney’s Office. The Immigration Reform and Control Act
of 1986 requires that we hire only United States citizens or aliens lawfully authorized to work in the United States. Therefore, we
wish to inform you again that before beginning employment, you must provide proof of citizenship or other authorized
documentation to work in the United States. You may present one document from List A OR one document from List B and one
document from List C.
LIST A LIST B LIST C
UNITED STATES PASSPORT DRIVER LICENSE ORIGINAL SOCIAL SECURITY CARD
CERTIFICATE OF U.S. CITIZENSHIP OR PICTURE I.D. CERTIFIED BIRTH CERTIFICATE
CERTIFICATE OF NATURALIZATION U.S. MILITARY CARD UNEXPIRED INS EMPLOYMENT
UNEXPIRED FOREIGN PASSPORT AUTHORIZATION
ALIEN REGISTRATION CARD WITH PHOTO
STATE ATTORNEY KATHERINE FERNANDEZ RUNDLE
ELEVENTH JUDICIAL CIRCUIT OF FLORIDA STATE ATTORNEY
E.R. GRAHAM BUILDING
1350 N.W. 12TH AVENUE TELEPHONE (305) 547-0100
MIAMI, FLORIDA 33136-2111
1059 - 5/22/00||Document1|B
(7)
RELEASE FORM
I authorize my former employers, schools, personal references and institutions of credit to provide any information that
they may have regarding me, whether or not it is on their records. I hereby release them and their company from liability for
divulging same.
SECTION I. (To be completed by Applicant.)
PRINT FULL NAME SS #
SIGNATURE
Applicant - Please do not write below this line.
SECTION II. (To be completed by Human Resources)
The above named individual has provided us with the following information concerning past employment with your
organization: .
Please verify the information provided to us by the applicant by completing Section III.
DATES OF EMPLOYMENT: From To
POSITION HELD:
SALARY:
SECTION III. (To be completed by past employer.)
DATES OF EMPLOYMENT: From To
POSITION HELD:
SALARY:
REASON FOR TERMINATION:
PLEASE CHECK THE APPROPRIATE COLUMN INDICATING YOUR RATING OF THE APPLICANT
Above
Excellent Average Average Unsatisfactory
Quantity of Work _____ _____ _____ _____
Quality of Work _____ _____ _____ _____
Ability to Accept Supervision _____ _____ _____ _____
Relationship with Coworkers _____ _____ _____ _____
Attendance Record _____ _____ _____ _____
Would you reemploy? If not, why?
Do you recommend applicant?
Additional Remarks:
DATE: SIGNATURE:
Reference # Sent: TITLE:
1059 - 5/22/00||Document1|B
(8)
ADDENDUM I
SECTION I: DESCRIPTION
Florida Statutes 112.011(2)(a) , 943.0585 and 943.059(4) authorizes us to ask questions regarding any criminal
violations you may have had, even if the record was expunged and/or sealed. Therefore, you must include the crime
or offense even if the record was expunged and/or sealed.
1) Have you ever been Arrested, Received a Notice to Appear, Cited, Charged or Convicted of any criminal
violation? Yes No If yes, what was the date of the offense?
What were the charges and circumstances?
2) Have you ever pled Nolo Contendere or Pled Guilty to a Crime? Yes No
If yes, what was the date of the offense?
What were the charges and circumstances?
3) Have you ever had the adjudication of guilt withheld for a crime? Yes No
If yes, what was the date of the offense?
If yes, what were the charges and circumstances?
Additional Comments:
SECTION II: CERTIFICATION
*** READ BEFORE SIGNING ***
I hereby certify that all statements made on this Addendum are true and correct, and that no attempt has been made
to conceal pertinent information. I further understand that a background investigation will be made as part of the pre-
screening process and should such investigation reveal any misrepresentation, I will be subject to immediate
dismissal; and I agree to hold the State Attorney’s Office and persons named herein blameless in that event.
Date: Signature:
(9)
APPLICANT DATA RECORD
SECTION A
Until such time as you are hired by this office, the information you provide us in this section will be kept in a confidential file,
separate from your employment application, and will be used for the sole purpose of conducting a criminal background
investigation.
Full Legal Name (as it appears on your Social Security Card):
Other Names Used (Include Maiden Name):
Date: Position Applied For:
Length of Residence in Miami-Dade/Broward/Monroe County:
Present Address:
(Complete Street Address) (Apt. No.)
(City) (State) (Zip Code) (How long?)
Please list any other states and/or countries in which you have resided (include dates):
State From To
State From To
Country _______________________________________ From ______________________ To
Country _______________________________________ From ______________________ To
Social Security Number ________________________ Place of Birth______________________ Date of Birth:
Male _______________ Female _______________ Height _______________ Weight _______________ Age
Driver License Number: State:
Husband’s or Wife’s Full Name:
Husband’s or Wife’s Employer:
Full Name of Father: __________________________________ Full Name of Mother:
Mother’s Maiden Name:
SECTION B
Applicants are treated during interviews without regard to any characteristic protected by federal, State or local law. The State
Attorney’s Office is an Equal Employment Opportunity/Affirmative Action Employer. With the sole purpose to assist us in
complying with our Equal Employment Opportunity reporting obligations, please fill out the following section. Your responses
are voluntary.
A. Check if applicable: Hispanic or Latino
B. Check one:
White (Non-Hispanic or Latino) Black or African American Asian
American Indian or Alaska Native Pacific Islander or Native Hawaiian
Two or more of the 5 races in this section (B)
C. Check if Applicable: Disabled Veteran Physically or Mentally Disabled
Signature: Date:
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***NOTICE TO APPLICANT*** PLEASE READ BEFORE COMPLETING APPLICATION:

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Completed 24 January 2022

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