TOWN OF HILLIARD APPLICATION FOR APPONTMENT 15859 W CR 108 Hilliard, FL 32046 Phone: 904-845-3555  [email protected] Application for Appointment We are an equal opportunity employer dedicated to non-discrimination in employment on the basis of race, color, age, religion, sex, national origin, disability, marital status, or veteran status. Date: Are you 18 years or older Yes No Name: Phone: Current Address: Street City State Zip Code Mailing Address: Street City State Zip Code Referred by: Are you related to a Town Employee? Yes No If yes, provide their name and department: Appointment Desired Desired Position: Start Date: Desired Salary: Have you ever applied before? Yes No If yes, for what position and when? Are there any days / hours you will not work? If yes, explain: Education Information High School: Name State Degree Grade Average College: Name State Degree Grade Average Trade, Business or Correspondence School: Name State Degree Grade Average Other (Including Graduate School): Name State Degree Grade Average Updated 1/2026 1  TOWN OF HILLIARD APPLICATION FOR APPONTMENT 15859 W CR 108 Hilliard, FL 32046 Phone: 904-845-3555  [email protected] Legal Information Have you ever been convicted of, pled guilty, no contest, or noto contendere to a crime? Yes No If yes, explain: Have you ever been charged with a crime and either been placed on a court ordered probation, have a adjudication withheld, or entered a pre-trial intervention program? Yes No If yes, explain: Have you ever been a defendant in a civil action for intential tort? Yes No If yes, explain: Previous Employment Information – List below sequentially all employers in the last ten (10) years beginning with the current or most recent employer. (Use additional pages if necessary). From: Date Business Name Position Salary Reason for Leaving To: Date Business Name Position Salary Reason for Leaving From: Date Business Name Position Salary Reason for Leaving To: Date Business Name Position Salary Reason for Leaving From: Date Business Name Position Salary Reason for Leaving To: Date Business Name Position Salary Reason for Leaving From: Date Business Name Position Salary Reason for Leaving To: Date Business Name Position Salary Reason for Leaving From: Date Business Name Position Salary Reason for Leaving To: Date Business Name Position Salary Reason for Leaving Updated 1/2026 2  TOWN OF HILLIARD APPLICATION FOR APPONTMENT 15859 W CR 108 Hilliard, FL 32046 Phone: 904-845-3555  [email protected] Did you work for any of these employers under a di erent name? Yes No If yes, which employer(s) and under what name? Please explain any gaps in employment history: Have you ever received any written reprimands or disciplinary suspensions during any previous employment? Yes No If yes, explain: Have you ever been discharged or asked to resign? Yes No If yes, explain: Driving Record Do you have a valid driver’s license? Yes No What class of license do you possess? Have you had a suspension or probation of your license in the last five (5) years? Yes No List below all tra ic violations (except parking) on your record for the last five (5) years and all motor vehicle accidents in which you were involved (use additional page if necessary). Date Location Description Result Date Location Description Result Date Location Description Result Updated 1/2026 3  TOWN OF HILLIARD APPLICATION FOR APPONTMENT 15859 W CR 108 Hilliard, FL 32046 Phone: 904-845-3555  [email protected] References – Give the names of three (3) persons not related to you, whom you have known at least one year. Name Number Address Acquainted Name Number Address Acquainted Name Number Address Acquainted Military Record Were you in the Armed Forces? Yes No If yes, what branch? Did you receive any training in the U.S. Armed Forces that is relevant to this o ice? Yes No If yes, explain? Please provide a copy of your DD-214 upon submission of this application Veteran’s Preference Do you claim veteran’s preference? Yes No (Chapter 295, Florida Statues, excludes non-disables, retired military persons from veteran’s preference points) A. Based on active duty during wartime or Vietnam era? Yes B. As a veteran with a compensable service-connected disability? Yes C. As the unmarried spouse of a veteran who was killed in action or who died of a service-connected disability? Yes D. As the spouse of a veteran who cannot quality for employment because of a total and permanent service-connected disability, Yes or the spouse of a person missing in action, or forcibility detained by a foreign power? E. Have you ever used a veteran’s preference at any time? Yes You must submit current documentation of your veteran’s preference status. Please attach a copy of this verification to the application. Updated 1/2026 4