Dear Prospective Applicant: Congratulations on taking the first step towards being considered for employment with the City of Winter Haven. Having presented you with the attached job application, this is an opportune time to share with you some details about the following. The City’s hiring process: o Applications are accepted through the advertised closing date. o When the job closes, all applications received are processed and screened to determine eligibility for interview. o If you are selected for interview, you will be contacted by telephone within 10 working days following the advertised closing date. o After all interviews are conducted, department staff will make a recommendation for hire that is subject to the City Manager’s approval. Once the recommendation is approved in writing, a thorough background screening is done and if satisfactory, the candidate is offered employment pending the results of a post offer of employment physical examination with a drug screen. City paid wages: o A fair wage is paid in exchange for working with the City. o Pay rates typically begin at the minimum for advertised positions. o Employees are paid bi-weekly, and direct deposit is available. o If funding in the budget is approved, pay adjustments are granted per the annual Step for Performance Pay Plan, at the employee’s annual performance evaluation each year.¹ Certain benefits mutually funded by the City and its full time employees: o Optional health insurance program participation - Full time employees may elect to participate in the City’s medical, dental, prescription and basic life insurance plan; the employee cost is only $48.69 per pay period. Eligible dependent medical, prescription and dental insurance coverage is also available; employees can pay an additional $128.58 per pay period to insure one dependent, or $154.29 per pay period to insure two dependents or $185.16 to insure an entire family. An optional insurance premium tax-deferred program is offered too.  o Mandatory pension program participation - All full-time City employees are required by ordinance to contribute to the fire or police pension plan or general employee 401(a) plan, whichever is applicable. The certified firefighter contribution is 10% of salary; the certified police officer contribution is 8.2% of salary and the general employee contribution is 3%of salary. Pre-tax contributions are payroll deducted bi-weekly and can only be disbursed upon retirement or other employment termination. Employees who terminate prior to being vested have the option of rolling their contributions over into another plan or receiving a refund of their contributions plus interest and minus taxes. The City of Winter Haven is an employer of choice that embraces and supports innovation, creativity, and diversity. Eager to build a workforce dedicated to serving this community and its citizens, the City seeks to hire well qualified professionals possessing the core values of pride, honesty, integrity, respect and a willingness to make a long-term commitment to accomplishing established goals and objectives. If you meet this criteria and are interested in further pursuing the potential for joining the City’s team, complete the employment application in detail. Be thorough and honest, because all information contained in this document is subject to being verified by the City. If something is omitted or found to be untrue, this could immediately disqualify you for employment consideration. Please submit your completed application to a Human Resources’ staff member on or before the advertised closing date. Sincerely, Shawn Dykes Human Resources Director ¹ Employees in certain union represented job classifications may experience a delay in receiving a pay adjustment because such adjustments are subject to collective bargaining.  An Equal Opportunity Employer Thank you for your interest in employment with the Winter Haven Fire Department (WHFD). This application must be either typed or printed in legible form. Non-legible applications will be returned. Applications must include a resume and be submitted to Human Resources. Incomplete applications may not be considered for employment. Complete the application as follows: 1. Answer all questions. If they do not apply to you, place an “N/A” in the blank space provided for your answer. 2. Provide names and complete mailing addresses, including zip code of former employers, dates of employment, and your job title. 3. List complete and correct mailing and physical addresses, including zip code of former residences. 4. List complete and correct mailing addresses, including zip code of all references. 5. Notarize pages of the application before submitting it to Human Resources. You are hereby informed that a thorough background investigation, including information regarding your character, general reputation, personal characteristics, and mode of living, drug test, and physical exam in accordance with NFPA 1582 will be part of the candidate selection process. This information is solely for the purpose of evaluating your qualifications and eligibility for employment with the WHFD. Any falsification of information on your application will automatically disqualify you from consideration for employment with the WHFD. The submission of this application carries the understanding that you are authorizing the WHFD to contact any and all available sources for the purpose of obtaining information regarding your qualifications. Expected duration of the selection process may take up to eight weeks. This application must include copies of the following: 1. Birth Certificate 2. High School Diploma or State Equivalency 3. Proof of Name Change (if applicable) 4. DD 214 Form - Military Service Discharge Documents (if applicable) 5. Driver License 6. College Transcripts (Submit a sealed copy of the transcripts with the application or provide the email address [email protected] for electronic transcripts sent directly from the educational institution.) 7. Social Security Card 8. Fire Standard Certificate F.S.633 9. Emergency Medical Technician (E.M.T.) 10. Paramedic Certificate (if applicable) 11. Valid CPR Card 12. Certificates: IS-100, IS-200, IS-700, IS-800 13. Emergency Vehicle Operator Course Certificate (EVOC) - 16 hours 14. National Testing Network’s Candidate Physical Ability Test (CPAT) – Within the last six (6) months of the job posting closing date 15. Completion of the National Testing Network’s FireTEAM Assessment 16. Resume POLYGRAPH EXAMINATION Prior to making a final recommendation for hire applicants being considered for employment/placement will be required to undergo a polygraph examination regarding personal background and other aspects of their character. Employment will be contingent upon the results of the polygraph examination as well as the availability of a position with the WHFD. The following is a list of subject areas from which polygraph questions will be drawn: Credit History; Work Record; Honesty; Use of Alcohol; Driving History; Arrests and Convictions; Drugs, Narcotics, and Marijuana; Gambling; Blackmail; Friends and Associates; and Loyalty to the United States. 1  An Equal Opportunity Employer Position(s) Applying For: _______________________ _______________________ ______________________ How did you learn of this employment opportunity? _____ Newspaper _____ Radio _____ City Website _____ City Employee _____ Other: _ Applicant Name: ______________________________________________________________________________ (Last) (First) (Middle Name) Social Security Number*:________________________________________________________________________ *In accord with Resolution R-08-06, this information is collected and solely used by the City of Winter Haven for identity verification and service, security background checks. Address: ____________________________________________________________________________________ (Number) (Street) (City) (State) (Zip) Primary Secondary Phone: ( ) ________________ Phone: ( ) _________________Email: ______________________________ No Yes Give Details Do you have a valid Florida driver License Class: ____________________________ license? License Number: ____________________________ Expiration Date: ____________________________ Have you had one or more chargeable motor vehicle crashes or code violations If yes, complete the chart below. Attach a separate sheet of (i.e. speeding ticket, seat belt violation, paper for additional incidents. etc.) within the past three years? Date of Nature of Incident Violation/Charge City/County/State Action Taken 1. 2. 3. No Yes Give Details Are you at least 18 years of age for employment? Are you legally authorized to work in the U.S.? 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 U.S. Branch:___________________________________________ Armed Forces? Entry Date: ____________ Discharge Date: _____________ Discharge Type: ___________________________________ _________________________________________________ Note: Explain a dishonorable discharge, so the underlying circumstances can be weighed individually and an improper disqualification may be avoided. Are you claiming veteran’s employment If yes, file documentation with application. preference? 2  An Equal Opportunity Employer No Yes Give Details Are you now using or have you ever used illegal controlled substances or illegal drugs? If so, explain. Have you ever been employed by the When: _________________________________________ City of Winter Haven? Where: _________________________________________ Have you ever been dismissed from a When: _________________________________________ job for inefficiency, delinquency, Describe circumstances: ___________________________ misconduct or any other reason? _______________________________________________ Have you ever been formally or When: _________________________________________ informally accused of unlawful Describe circumstances: ___________________________ harassment or discrimination? _______________________________________________ _______________________________________________ Are you now under charges for any Describe charges: _________________________________ offense against the law? ______________________________________________ Have you EVER at any time had Describe circumstances: ____________________________ adjudication withheld, plead guilty, no ______________________________________________ contest or been convicted of ANY Note: A conviction is not necessarily a disqualifying factor; offense against the law? truthfully give all facts so a decision can be made. Have you ever been a defendant in a Explain: _______________________________________ civil action for an intentional tort? ______________________________________________ EDUCATION Years to Degree/Diploma Level of School Name Course Complete or Received Education Street Address of Study Number of No Yes Type City / State / Zip Credits G.E.D. Home School High School Trade School College/ University List other education or special courses taken; include total hours and the training provider/sponsor name. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 3  An Equal Opportunity Employer Answer only 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 you answer “YES” please explain: List honors, awards, scholarships, etc: Extracurricular activities: Foreign language spoken: Foreign language read: Foreign language written: Are you Issued in/by Date Expiration Certification/License Type certified or Which State Issued Date licensed? (Mo./Yr.) (Mo./Yr.) No Yes Building Inspector Code Enforcement – Level I, II or III Emergency Medical Technician (EMT) Firefighter Minimum Standards Lifeguard Paramedic Police Officer Minimum Standards Wastewater Treatment Operator A, B or C Water Treatment Operator A, B or C Water Safety Instructor (WSI) Other: 4  An Equal Opportunity Employer EMPLOYMENT HISTORY Begin with present employer and list all jobs held since you started working. This section must be completed even with a resume attached to the application. 1. Company Name:______________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: __________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 2. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 3. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 4. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 5  An Equal Opportunity Employer 5. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 6. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 7. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ 8. Company Name: _____________________________ Employed: From: ____________ To: _____________ Street: ____________________________________ Pay Rate: Start: ____________ End: _____________ City/State/Zip: ______________________________ Job Title: ____________________________________ Telephone Number: _________________________ Duties: ____________________________________ Supervisor Name: __________________________ _____________________________________________ Reason for leaving: _________________________ ______________________________________________ __________________________________________ (Attach additional sheet if necessary.) Note: Employers listed above will be contacted, unless you indicate otherwise. Please specify which employer, if any, you prefer not be contacted and state the reason why. Do not contact: Employer Number(s) ________ Reason: _______________________________________ 6  An Equal Opportunity Employer The information you provide from this point forward will not be presented to the pre-screening panel that determines which applications continue on in the hiring process. Only the previous pages will be viewed by the panel. If the panel agrees your application merits further consideration, then the information provided on the remaining pages will be used to conduct a background investigation. PERSONAL DATA Applicant Name: Maiden Name (if applicable): Date of Birth: Place of Birth: City / County / State Are you eligible to work in the United States? Yes No Have you ever had your name legally changed? Yes No If you answered “YES” to the above question, provide: a. Your previous name(s): b. Date and Location of Change: c. Reason for Change: Have you ever been known by any other name? Yes No If “YES”, list all, including nicknames and street names: List all social networking addresses: List below in chronological order all previous places of residence since elementary school. Begin with your present address and work backward. Attach a separate sheet of paper for additional residences if necessary. From/To (Month/Year) Address City State Zip 7  An Equal Opportunity Employer CAREER INTEREST Names of relatives or friends employed by the WHFD: Have you ever worked for or applied to the WHFD before? Yes No If “YES” explain: Have you ever applied to or been employed by any other fire department? Yes No If “YES” state name of department and dates of employment or application: If you were not hired, state reason(s) for non-selection: Are you now on any employment eligibility list? Yes No If “Yes” state where and for what position? Have you ever been dismissed, disciplined, or asked to resign employment because of misconduct or unsatisfactory service? Yes No If “Yes” list those employers who either (1) Dismissed you; (2) Disciplined you; or (3) Requested that you resign or be terminated: Employer’s Name Date Supervisor Involved May we contact previous employers? Yes No If “No” please state your reasons: 8  An Equal Opportunity Employer May we contact your present employer in the final post offer stages of processing? Yes No If “No” please state your reasons: DRUG USE Have you ever used an illegal drug? Yes No If “YES” please explain by listing when, what type of drug and the circumstances that led to the use. Have you ever used a prescription drug prescribed for someone else? Yes No If “YES” please explain by listing when, what type of drug and the circumstances that led to the use. MILITARY RECORD If you have never served in the Armed Forces of the United States, please sign the below statement: I, have never served in any branch of the United States Armed Forces. (Print Name) 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: ________ 9  An Equal Opportunity Employer Branch of Service: Highest Rank: Service #: Duty Dates: From: ________ To: ________ From: ________ To: ________ Are you now or have you ever been a member of the Reserve Unit or the National Guard? Yes _____No If Yes, state the branch of service, name and location of your unit and whether you attend drills, meetings, or camps: Military specialization and duties 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 details: Date: Place: Nature of Offense: Action Taken: FOREIGN MILITARY RECORD Have you ever served in the Armed Forces of any foreign nation? Yes No If “Yes” indicate the nation Date of entry Date of Separation Highest rank held Type of Separation 10  An Equal Opportunity Employer 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: Have you ever been bonded? Yes No If employed by the WHFD, do you anticipate any income other than your salary? Yes No If “Yes” list the source: CRIMINAL AND JUVENILE RECORD Have you ever been arrested, charged or received a notice or summons to appear for any criminal violations? Yes No If “Yes” explain below. Have you ever been convicted of a felony or misdemeanor? Yes No If “Yes” explain below. To your knowledge, has any member of your family ever been arrested for any reason other than traffic violations? Yes No If “Yes” explain below. If you answered yes to any of the questions above, list all such matters, 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. Include all matters taking place while you were classified as a juvenile under the law of any state. Applicant Place & Dept Charge Court & Place Date of Charge Disposition 11  An Equal Opportunity Employer Relative’s Name / Relationship Place & Dept Charge Court & Place Date of Charge Disposition Have you ever been reported as a missing person? Yes No If “YES” please explain: Have you or your spouse ever been a plaintiff or defendant in a civil and/or criminal court action? Yes No If “YES” please explain: 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 “YES” please explain: 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: 12  An Equal Opportunity Employer 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 other races? Yes No If “Yes” please explain: Have you belonged or associated with any local or national groups which advocate the overthrow of the government of the United States? Yes No If “Yes” please explain: Tattoos / Markings Do you have any tattoos or other markings? Yes No If yes, please explain and attach photos of them: 13  An Equal Opportunity Employer Do any of your tattoos or other markings indicate past or current gang membership, affiliation, or activity? Yes No If “Yes” please explain: Do you have any tattoos or other markings that represent hatred against other races or cultures? Yes No If “Yes” please explain: Do you have any tattoos or other markings which indicate participation in any type of criminal activity? Yes No If “Yes” please explain: 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” indicate the (1) Date, (2) Location, (3) Charge(s), (4) Injuries, and (5) Final Disposition of any police charges or civil liability: 14  An Equal Opportunity Employer Have you ever been refused a driver license by any state? Yes No If “Yes”, state the reason(s) for the refusal: Have you “ever” received a traffic citation other than parking? Yes No If “Yes”, list the (1) City, County, and State, (2) Name(s) of Agency issuing the citation(s), (3) Date, (4) Charges, and (5) Final Disposition. Do you have any unpaid or outstanding summonses against you for any parking violations? Yes No If “Yes”, list how many and where? Have you ever been declined an automobile insurance policy or had a policy cancelled? Yes No If “YES” please explain: 15  An Equal Opportunity Employer 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 WHFD? Yes No __________________________________ Applicant’s Signature If “No”, state your reason(s) 16  An Equal Opportunity Employer PERSONAL REFERENCES Fill in the names of persons who have seen you frequently during the past year. List persons who are not related to you or who are not former employers. All persons that you list may be asked to appraise your character, ability, experience, personality, and other qualities. Name: Street Address: City: State: Zip Code: Home Phone: Alternate Phone: Years Known: Email Address: Name: Street Address: City: State: Zip Code: Home Phone: Alternate Phone: Years Known: Email Address: Name: Street Address: City: State: Zip Code: Home Phone: Alternate Phone: Years Known: Email Address: Name: Street Address: City: State: Zip Code: Home Phone: Alternate Phone: Years Known: Email Address: Note: Please make sure to list complete address information including zip code. 17  An Equal Opportunity Employer Essay Question Please write several paragraphs in the space below (not more than one page) telling us why you should be considered for the position you have applied for. Only handwritten answers will be accepted, no typed answers. 18  An Equal Opportunity Employer READ THIS APPLICATION AND YOUR ANSWERS CAREFULLY BEFORE SIGNING BELOW I, (print name)____________________________________ 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 and my name removed from the eligibility lists. If already appointed, I may be dismissed. I voluntarily give the City of Winter Haven Human Resources’ Office, 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 Signature: ______________________________________ Date: ________________________ State of Florida City/County of Sworn to before me this day of , 20 Signature of Notary DO NOT WRITE BELOW THIS LINE (For Human Resources’ Office Use Only) ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 19  An Equal Opportunity Employer FCRA NOTICE AND CONSENT CITY OF WINTER HAVEN 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 providers called “consumer reporting agencies.” In connection with your application and/or employment, and provided that you give your written consent below, the City 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 by writing or calling the consumer reporting agency directly. I hereby agree and consent to the City of Winter Haven 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 Date  An Equal Opportunity Employer 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.  An Equal Opportunity Employer  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.  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.  An Equal Opportunity Employer The information requested below is used for EEO purposes only and NOT to evaluate your application for employment with the City of Winter Haven. 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. 16 – 22 Age 23 – 39 Group 40 – 70 Over 70 White, Non-Hispanic or Latino Black or Black and White, Non-Hispanic or Latino Race Hispanic or Latino Ethnic Asian or Asian and White, Non-Hispanic or Latino Origin American Indian/Alaskan Native, Non-Hispanic or Latino Native Hawaiian-Other Pacific Islander, Non-Hispanic or Latino Balance 2+ Races, Non-Hispanic or Latino No Disabled Description of Disability Yes Non-Veteran Actively Served During (Circle Applicable) Military Status Veteran WWII/Korea, Persian Gulf, Vietnam, Iraq/Afghanistan; Operation Enduring Disabled Veteran Freedom, Other How did you learn of the position you are applying for? Walk-in, General Job Search Winter Haven News Chief Search Firm or Employment Agency The Lakeland Ledger Civic/Professional Organization Other Newspaper Internet/City Web Site Magazine/Publication City of Winter Haven Employee Word of Mouth College or University: Other:  AUTHORITY FOR RELEASE OF INFORMATION (BACKGROUND INVESTIGATION WAIVER) FIREFIGHTER APPLICANT APPLICANT NAME: ____________________________________________________________ PRINT FULL NAME: __________________________________________________________ OTHER NAMES USED / MAIDEN NAME(S): _____________________________________ DATE OF BIRTH: ____________________________________________________________ ADDRESS: __________________________________________________________________ LAST 4 DIGITS OF SOC. SEC. #: ______________________________ EMPLOYING AGENCY REQUESTING BACKGROUND INFORMATION: Winter Haven Public Safety Department To: Concerned Person or Authorized Representative of Any Organization, Institution or Repository of Records Having made application for employment at Winter Haven Fire Department, I hereby authorize any employee or authorized representative bearing this release, or copy thereof, to obtain any information in your files pertaining to my criminal history, or civil and criminal court records, or employment history. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for the official use of the requesting agency. Consent is granted for the agency to furnish such information, as is described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as the custodian of such records, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. A photocopy of this form will be as effective as the original. Applicant Signature________________________________________ __________________ Date AFFIDAVIT STATE OF _______________________________ COUNTY OF ___________________________________ Before me personally appeared __________________________________ who says that he/she executed the above instrument of his/her own free will and accord, with full knowledge of the purpose therefore. Sworn and subscribed in my presence this ___________ day of ___________________, 20_____. My Commission expires on _______________________, 20_____. Personally Known: ______-or- Produced Identification: ______ Notary Public: ___________________________________ Type of Identification Produced: _______________________________