Fill - Free fillable VOLUNTEERSINPUBLICSERVICE(VIPS)APPLICATION HILLSBOROUGH COUNTY CODE ENFORCEMENT (Hillsborough County) PDF form

HILLSBOROUGH COUNTY CODE ENFORCEMENT

VOLUNTEERSINPUBLICSERVICE(VIPS)APPLICATION



OnbehalfofHillsboroughCounty,thankyouforyourinterestinvolunteeringwithCodeEnforcement.Werecognizethatyourtimeis

valuableandappreciateyourspiritofcommunity.Inordertobeconsideredasa volunteer,certaininformationmustbeprovidedin

ordertoensurethatonlyqualifiedmembersofthe

communityareretainedforservice.

PLEASEREADANDFOLLOW THEINSTRUCTIONSCONTAINEDINTHISPACKET.THEAPPLICATIONMUSTBEFILLEDOUTCOMPLETELY

AND ACCURATELY. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. MUCH OF THIS APPLICATION CAN BE COMPLETED

ELECTRONICALLY;HOWEVER,ASSIGNATURESAREREQUIRED,APRINTEDAPPLICATIONMUSTBESUBMITTEDTO

THEDEPARTMENT

FORCONSIDERATION.



FullName:EmailAddress:



OtherName(s)Used:SocialSecurityNumber:



Driver’sLicense#:StateDLIssuedBy:DateofBirth:



HomeAddress:



City:State:ZIPCode:



HomePhone:CellPhone:



University/SchoolDegreeIssuedBy:DateDegreeReceived:



EmergencyContactName:



EmergencyContactPhoneNumber:

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Ifselected,inwhatgeographicalareawillyoubevolunteering?



AsaHillsboroughCountyvolunteer,youwillbeaffordedthefollowingminimumbenefits:



 Liability Insurance: Hillsborough County is self‐insured and volunteers will be covered to the same extent as regular

employees when performing their assigned duties. It is imperative that any accidents be reported to the VIPS Program

Managerimmediately.

 WORKERS’ COMPENSATION: Volunteers injured while performing their assigned duties will

be covered by workers’

compensationtothesameextentasregularemployees.ItisimperativethatanyaccidentorinjurybereportedtotheVIPS

ProgramManagerimmediately.



WhentheCountyutilizesvolunteers,itassumescertainrisks;therefore,somepersonalquestionsmustbeasked.Whenworkingfor

HillsboroughCounty,volunteers,asbylaw,arenodifferentthanaregularemployee.AllinformationrequestedbytheCountywillbe

usedsolelyforpurposesofqualificationfortheVIPSprogram.



Have you ever been convicted of, pled nolo contender (no contest), or pled guilty to a criminal offense?



(Non‐criminal driving

infractionsorsimilarcivilinfractionsneednotbedisclosed.)

YESNO

IfYES,pleaseprovidethefollowinginformation:



Date Location(County,State) Charge Disposition

  



PERSONALHISTORY

TheundersignedrequestspermissiontoparticipateintheHillsboroughCountyCodeEnforcementVIPSProgramSnipeSignInitiative

(SnipeSignVolunteerProgram)asavolunteerengagedintheremovalanddisposalofillegalsnipesignsfromtheCounty’sRightOf

Way.



In consideration ofgranting such permission, theUndersigned herebyAGREESNOT TO SUE Hillsborough County,the Hillsborough

CountyCodeEnforcementDepartment,theBoardofCountyCommissionersof HillsboroughCounty,and/oranyotherdepartment,

division,officeemployeeoragentoftheCounty(hereafter,the“County”),eitherindividuallyorinanofficialcapacity,

foranyandall

liabilities, claims, actions damages costs or expenses which the undersigned may have against the County in connection with

participationintheSnipeSignVolunteerProgram,includingtraveltoorfromallactivities.TheUndersignedacknowledgesandagrees

that this release and waiver includes any claimor

actionbased on thenegligence, action, or inaction of the County or otherwise,

exceptforbenefitswhichmaybeappropriatepursuanttoChapter440,FloridaStatutes.



The Undersigned hereby holds harmless and indemnify the County from and against any and all claims, liabilities, loss, damages,

attorneys’ fees or expenses of whatever kind which the Undersigned may sustain or be required to pay, even if allowing the

Undersignedtoparticipateinsaidactivityislaterfoundtobe

negligent.



THEUNDERSIGNEDHEREBYASSUMESFULLRESPONSIBILITYFORRISKOFBODILYINJURYORPROPERTYDAMAGE.



I,theundersigned,havereadthisReleaseandIndemnityAgreementandunderstandandagreetoallofitsterms.



________________________________________________________________________________

SignatureofApplicantPrintNameDate

By signing the release below, I hereby authorize Hillsborough County to contact any and all corporations, former employers,

educationalinstitutions,lawenforcementagencies,city/county,stateandfederalcourts,andmilitarybranchestoreleaseinformation

about my backgroundincluding but not limited to, information aboutemployment, education,driving record, criminalrecordand



generalpublicrecordshistorytoHillsboroughCounty.



Incompliancewithsection119.071(5)FLStatutes(PublicRecordsLaw)bythis document,HillsboroughCountyherebydisclosestoyou

thatyour SocialSecurity numberis requestedfor the purpose of applicantand employeebackgroundand criminal historychecks,

identityverification,verificationofpastemployment,newhireandunemploymentreporting,processingemployment

benefitsand

drugscreening,incomereporting,Workers’Compreporting,payrollprocessingandreportingwillbeusedsolelyforthosepurposes.



I understand that volunteering for Hillsborough County is subject to satisfactory completion of a background check/investigation,

includingverificationofinformationIsuppliedinmyapplication.



I release from all liability all persons, companies and schools supplying such information. I release Hillsborough County from and

indemnifyHillsboroughCountyagainstanyliabilitywhatsoeverinconnectionwithsuchbackgroundinvestigationandtheuseofthe

resultstherein.IalsounderstandthatIwillbegivenacopyofthe

backgroundcheck/investigationreportshouldanyadverseaction

ornon‐selectionbeconsideredduetotheresultsofthereport.



HILLSBOROUGHCOUNTYISADRUGFREEWORKPLACE.BACKGROUNDCHECKSMUSTBECOMPLETEDPRIORTOAUTHORIZATION

TOVOLUNTEERUNDERTHISORANYOTHERCOUNTYPROGRAM.



Forsafetyreasons,IunderstandthatapplicationsmaybeprocessedthroughtheHillsboroughCountySheriff’sDepartmentorother

law enforcement agencies. I also understand that additional information and/or a personal interview may be required prior to

approval.



Iherebycertifythattheinformationcontainedhereinistrueandaccuratetothebestofmyknowledge.Ifurtherunderstandthatany

falsificationand/oromissionswillresultinthepermanentdisqualificationfromthisvolunteerservice.



________________________________________________________________________________



SignatureofApplicantPrintNameDate

DateApplicantInterviewed:StaffMemberCompletingInterview:BackgroundCheckApproved:YN



AuthorizedDuties,Restrictions&Comments:__________________________________________________________________________



____________________________________________________________________________________________________________

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VIPSRELEASEANDINDEMNITYAGREEMENT

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VOLUNTEERSINPUBLICSERVICE(VIPS)APPLICATION HILLSBOROUGH COUNTY CODE ENFORCEMENT (Hillsborough County)

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