OfficeoftheStateAttorneyEMPLOYMENTAPPLICATION

EqualOpportunityEmployer/AffirmativeActionEmployer

TheOfficeoftheStateAttorneydoesnottolerateviolenceinthe

FOROFFICIALUSEONLY
//

Agency AuthorizedDateClassCodeStatus

POSITIONAPPLIEDFOR

Title:

workplace.

WheretoFindVacancyInformation:

PositionNumber:

DateAvailable:

OntheInternet:

OneStopCareerCenters-yourlocaltelephonedirectoryorvisit

employflorida.net

StateAgencyPersonnelOffices

CountiesofInterest:

MinimumAcceptableSalary:

GENERALINSTRUCTIONS

HOWDOWECONTACTYOU

Completethisapplicationinitsentirely.

Typeorprintinink.

Specify the position forwhich you are applying. (Note: Aseparate applicationmustbesubmittedforeachvacancy.Photocopiesareacceptable.)

Yourapplication mustbereceivedbytheofficeannouncing thevacancybytheclosingdate.

SignyournameintheCertification Section(page4). Allinformation yousubmitissubjecttoverification.

Name(Last,First,MI)

SocialSecurityNumberPeopleFirstEmployeeIDNumber(ifany)YourMailingAddress

CityCountyStateZipCode

HomePhoneBusinessPhoneCellPhone

EDUCATION

EmailAddress

HIGHSCHOOL
NAME/LOCATIONOFSCHOOL / YOURNAME,IFDIFFERENTWHILEATTENDINGSCHOOL:
RECEIVED:DiplomaOther(specify)None
GRADUATIONYEAR:
COLLEGE,UNIVERSITYORPROFESSIONAL SCHOOL: (TRANSCRIPTS MAYBEREQUIRED)
NAMEOFSCHOOL / LOCATION / DATESOF
ATTENDANCE(MONTH/YEAR) / CREDITHOURSEARNED / MAJOR/MINORCOURSEOFSTUDY / TYPEOFDEGREEEARNED
FROM / TO / QTR / SEM

YOURNAME,IFDIFFERENTWHILEATTENDINGSCHOOL:

JOB-RELATED TRAININGORCOURSEWORK:(VOCATIONAL,TRADE,GOVERNMENTAL,BUSINESS,ARMEDFORCES,ETC.)
NAMEOFSCHOOL / LOCATION / DATESOFATTENDANCE(MONTH/YEAR) / CREDITHOURSEARNED / COURSEOFSTUDY / TRAININGCOMPLETED?
YES / NO
FROM / TO / CLASS / CLOCK

YOURNAME,IFDIFFERENTWHILEATTENDINGSCHOOL:

LICENSURE,REGISTRATION,CERTIFICATION EXAMPLES:DriverLicense,TeacherCertification,RN,LPN,PE,CPA,etc.

LICENSE,REGISTRATION ORCERTIFICATION: / Number / ExpirationDate / StateLicensing

PERIODSOFEMPLOYMENT

Describeyourworkexperienceindetail,beginningwithyourcurrentormostrecentjob.Includemilitaryservice(indicaterank)andvolunteerwork,ifapplicable. Indicatenumberofemployeessupervised.Useaseparateblocktodescribeeachpositionorgapinemployment. Ifneeded,attachadditionalsheets,usingthesameformatastheapplication. Allotherinformationinthissectionmustbecompleted. Resumesmaybeattachedtoprovideadditionalinformation.

1NAMEOFPRESENTORLASTEMPLOYER:

ADDRESS: PHONE: TITLE: SUPERVISOR'SNAME: FROM: / / TO: / / HOURSPERWEEK:

ANNUALSALARY: STARTING/ENDINGMAYWECONTACTYOUREMPLOYER?YES NO

()

YOURNAMEIFDIFFERENTDURINGEMPLOYMENT

DUTIESANDRESPONSIBILITIES:

REASON(S)FORLEAVING:

2NAMEOFPRESENTORLASTEMPLOYER:

ADDRESS: PHONE: TITLE: SUPERVISOR'SNAME: FROM: / / TO: / / HOURSPERWEEK:

ANNUALSALARY:

()

YOURNAMEIFDIFFERENTDURINGEMPLOYMENT

STARTING/ENDING

MAYWECONTACTYOUREMPLOYER?YESNO

DUTIESANDRESPONSIBILITIES:

REASON(S)FORLEAVING:

3NAMEOFPRESENTORLASTEMPLOYER:

ADDRESS: PHONE: TITLE: SUPERVISOR'SNAME: FROM: / / TO: / / HOURSPERWEEK:

ANNUALSALARY: STARTING/ENDINGMAYWECONTACTYOUREMPLOYER?YES NO

()

YOURNAMEIFDIFFERENTDURINGEMPLOYMENT

DUTIESANDRESPONSIBILITIES:

REASON(S)FORLEAVING:

4NAMEOFPRESENTORLASTEMPLOYER:

ADDRESS: PHONE: TITLE: SUPERVISOR'SNAME: FROM: / / TO: / / HOURSPERWEEK:

ANNUALSALARY: STARTING/ENDINGMAYWECONTACTYOUREMPLOYER?YES NO

()

YOURNAMEIFDIFFERENTDURINGEMPLOYMENT

DUTIESANDRESPONSIBILITIES:

REASON(S)FORLEAVING:

5NAMEOFPRESENTORLASTEMPLOYER:

ADDRESS: PHONE: TITLE: SUPERVISOR'SNAME: FROM: / / TO: / / HOURSPERWEEK:

ANNUALSALARY: STARTING/ENDINGMAYWECONTACTYOUREMPLOYER?YES NO

()

YOURNAMEIFDIFFERENTDURINGEMPLOYMENT

DUTIESANDRESPONSIBILITIES:

REASON(S)FORLEAVING:

6NAMEOFPRESENTORLASTEMPLOYER:

ADDRESS: PHONE: TITLE: SUPERVISOR'SNAME: FROM: / / TO: / / HOURSPERWEEK:

()

ANNUALSALARY: STARTING/ENDINGMAYWECONTACTYOUREMPLOYER?YES NO

YOURNAMEIFDIFFERENTDURINGEMPLOYMENT

DUTIESANDRESPONSIBILITIES:

REASON(S)FORLEAVING:

Ifneeded,attachadditionalsheets,usingthesameformatasontheapplication. Resumesmaybeattachedtoprovideadditionalinformation.

KNOWLEDGE/SKILLS/ABILITIES(KSAs)

ListKSAsyoupossessandbelieverelevanttothepositionyouseek,suchasoperatingheavyequipment,computerskills,fluencyin

language(s),etc.

EXEMPTIONFROMPUBLICRECORDSDISCLOSURE

AREYOUACURRENTORFORMERLAWENFORCEMENTOFFICER,OTHEREMPLOYEE**ORTHESPOUSE

ORCHILDOFONE,WHOISEXEMPTFROMPUBLICRECORDSDISCLOSUREUNDER §119.07,F.S.? YES NO

**Othercoveredjobsinclude:correctionalandcorrectionalprobationofficers,firefighters,certainjudges,assistancestateattorneys,stateattorneys,assistantandstatewideprosecutors,personneloftheDepartmentofRevenueorlocalgovernmentswhoseresponsibilitiesincluderevenuecollectionandenforcementorchildsupportenforcement,andcertaininvestigatorsintheDepartmentofChildrenandFamilies[see§119.07,F.S.].

BACKGROUNDINFORMATION

HAVEYOUEVERBEENCONVICTEDOFAFELONYORAMISDEMEANOR?YESNO

If"YES",whatcharge(s)? Whereconvicted?DateofConviction

HAVEYOUEVERPLEDNOLOCONTENDEREORPLEDGUILTYTOACRIMEWHICHISAFELONYORAMISDEMEANOR?YESNO

If"YES",whatcharge(s)? Whereconvicted?DateofConviction

HAVEYOUEVERHADTHEADJUDICATIONOFGUILTWITHHELDTOACRIMEWHICHISAFELONYORAMISDEMEANOR?YESNO

If"YES",whatcharge(s)?DateofConvictionWhereconvicted?

NOTE: A"YES"answertothesequestionswillnotautomaticallybaryoufromemployment. Thenature,job-relatedness,severityanddateoftheoffenseinrelationtothe

positionforwhichyourareapplyingareconsidered.[see§119.071,F.S.]

CITIZENSHIP

TheStateofFloridahiresonlyU.S.citizenandlawfullyauthorizedalienworkers.Ifaconditionalofferofemploymentismade,youwillberequiredtoprovide identificationandproofofcitizenshiporauthorizationtoworkintheU.S.

AREYOUAU.S.CITIZENORAREYOULEGALLYAUTHORIZEDTOWORKINTHEU.S.?YESNO

RELATIVES

TOYOURKNOWLEDGE,DOYOUHAVEANYRELATIVESWORKINGINTHISAGENCY?YESNO

SELECTIVESERVICESYSTEMREGISTRATION

Allmalesbetweentheagesof18and26mustberegisteredwiththeSelectiveServiceSystemorexempt.

IFYOUAREAMALEBETWEENTHEAGESOF18AND26,DOYOUHAVEPROOFOFREGISTRATIONWITHTHESELECTIVE

SERVICESYSTEMOREXEMPTIONFROMSUCHREGISTRATION?YESNO

CERTIFICATION

Iamawarethatanyomissions,falsifications,misstatements,ormisrepresentationsabovemaydisqualifymeforemploymentconsiderationand,ifIamhired,maybegroundsforterminationatalaterdate. IunderstandthatanyinformationIgivemaybeinvestigatedasallowedbylaw. Iconsenttothereleaseofinformationaboutmyabilityemploymenthistory,andfitnessforemploymentbyemployers,schools,lawenforcementagencies,andotherindividualsandorganizationstoinvestigators,personnelstaff,andotherauthorizedemployeesofFloridastategovernmentforemploymentpurposes. ThisconsentshallcontinuetobeeffectiveduringmyemploymentifIamhired. Iunderstandthatapplicationssubmittedforstateemploymentarepublicrecords. Icertifythattothebestofmyknowledgeandbeliefallofthestatementscontainedhereinandonanyattachmentsaretrue,correct,complete,andmadeingoodfaith.

SIGNATURE: DATE

EmployerMJSTremovethissectionuponcompletionoftheselectionprocess

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YOURNAME:

POSITIONTITLEFORWHICHYOUAREAPPLYING: POSITIONNUMBER:

VETERAN'SPREFERENCEINFORMATION

(CareerServicepositionsonly)Forthepurposesofappointments,retention,reinstatementandreemployment,Veterans'Preferenceensuresthatveteransandeligiblespousesofveteransaregivenconsiderationateachstepoftheselectionprocess. However,preferencedoesnotguaranteethataveteranortheeligiblespouseofaveteranwillbethecandidateselectedtofilltheposition. CompletionoftheVeterans'PreferencesectionismadeonavoluntarybasisandkeptconfidentialinaccordancewiththeAmericanswithDisabilitiesAct.ListedbelowarethefourVeterans'Preferencecategories.

1. Aveteranwithaservice-connecteddisabilitywhoiseligiblefororreceivingcompensation,disabilityretirement,orpensionunderpubliclawsadministeredbytheU.S.DepartmentofVeterans'AffairsandtheDepartmentofDefense,or

2. Thespouseofaveteranwhocannotqualifyforemploymentbecauseofatotalandpermanentdisability,orthespouseofaveteranmissinginaction,captured,orforciblydetainedbyaforeignpower,or

3. Aveteranofanywarwhohasservedonactivedutyforonedayormoreduringawartimeperiod,excludingactivedutyfortraining,andwhowasdischargedunderhonorableconditionsfromtheArmedForcesoftheUnitedStatesofAmerica,or

4.Theunremarriedwidoworwidowerofaveteranwhodiedofaservice-connecteddisability.

ADD214orcomparabledocumentwhichservesasacertificateofreleaseordischargeclaimmustbefurnishedatthetimeofapplication. Inaddition,applicantsclaimingcategories1,2,or4abovemustfurnishsupportingdocumentationinaccordancewiththeprovisionsofRule55A-7.013,F.A.C. Wartimeperiodsaredefinedin.1.01(14),F.S.Veterans'Preferenceshallexpireafteraneligiblepersonhasbeenemployedbyanystateoragencyofapoliticalsubdivisionofthatstate. UnderFloridalaw,preferenceinappointmentshallbegivenbythestatetothosepersonsincategories1and2andthenthoseincategories3and4. Veterans'Preferencedoesnotapplytoretired-for-longevitymilitarypersonnelwhenacompetitiveexaminationisused. However,retiredmilitarypersonnelwithacompensabledisabilityareeligible,regardlessofwhetheracompetitiveexaminationisused.

IfanapplicantclaimingVeterans'Preferenceforavacantpositionisnotselected,he/shemayfileacomplaintwiththeFloridaDepartmentofVeterans'

Affairs,11351UlmertonRoad,Largo,Florida33778.Acomplaintmustbefiledwithin21daysoftheapplicantreceivingnoticeofthehiringdecisionmadebytheemployingagencyorwithin3monthsofthedatetheapplicationisfiledwiththeemployerifnonoticeisgiven.

VETERANS'PREFERENCECLAIM

IFELIGIBLE,WHICHVETERANS'PREFERENCECATEGORYAREYOUCLAIMING?(PleaseindicatenumberfromVeterans'PreferenceInformationsectionabove.)

NOTE: Ifyou are claiming Veterans' Preference you must meet the criteria and substantiate your claim byfurnishing aDD 214(CertificateofReleaseorDischargeformActiveDuty)andanyotherrequiredsupportingdocumentationwithyourapplication.

EmployerMJSTremovethissectionpriortotheselectionprocess.Thisinformationmustberetainedbytheagencypersonneloffice.

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EEOSURVEY

Althoughthefollowinginformationisnotmandatory,itisrequestedtoaidtheStateofFloridainitscommitmenttoEqualEmploymentOpportunityandAffirmativeAction. ApplicantswhobelievetheyhavebeendiscriminatedagainstmayfileacomplaintwiththeFloridaCommissiononHumanRelations,2009ApalacheeParkway,Tallahassee,Florida32301.

a. SEX MALE FEMALE

b. DATEOFBIRTH:

c.RACE(CheckOneOnly):

HISPANICorLATINO-ApersonofCuban,Mexican,PuertoRican,SouthorCentralAmerican,orotherSpanishcultureororigin,regardlessofrace.

WHITE(notHispanicorLatino) -ApersonhavingoriginsinanyoftheoriginalpeoplesofEurope,theMiddleEastorNorthAfrica.BLACKorAFRICANAMERICAN -ApersonhavingoriginsinanyoftheblackracialgroupsofAfrica.

PACIFICISLANDER(notHispanicorLatino)-ApersonhavingoriginsinanyofthepeoplesofHawaii,Guam,Samoa,orotherPacificIslands.

ASIAN(notHispanicorLatino) -ApersonhavingoriginsinanyoftheoriginalpeoplesoftheFarEast,SoutheastAsia,ortheIndianSubcontinent,including,forexample,Cambodia,China,India,Japan,Korea,Malaysia,Pakistan,thePhilippineIslands,Thailand,andVietnam.

AMERICANINDIANORALASKANNATIVE(notHispanicorLatino)-ApersonhavingoriginsinanyoftheoriginalpeoplesofNorthandSouth

America(includingCentralAmerica),andwhomaintaintribalaffiliationorcommunityattachment.

OTHER(notHispanicorLatino) -Allpersonswhoidentifywithnoneof,ormorethanoneoftheabovecategories(Specify):