OFFICE USE ONLY City of Flagler Beach INSTRUCTIONS: APPROVED  Human Resources Division Please print or type all information. The DISAPPROVED  application must be filled out accurately and REASONS: completely. Answer all questions. Do not _______________________ leave an item blank. If an item does not _______________________ apply, write N/A (not applicable). Incomplete _______________________ applications will not be considered. All _______________________ statements made on the application are BY: subject to verification. Exaggerated, false, or misleading statements may be cause for Received: ___________ rejection of the application and/or termination 105 South 2nd Street, of employment. Eligibility for hire may be Post Office Box 70 based on a rating of this application; Flagler Beach, Florida 32136 therefore, completeness and accuracy is of Phone (386) 517-2000 Fax (386) 517-2008 the utmost importance. Position Applied for: __________________________________________________________________ Last Name: _______________________________ First: ___________________________ Middle Initial: ___________________ Street Address: __________________________________________________________________________________________ City: ______________________________________________ State: _______________ Zip Code: _____________________ Home Phone: ____________________ Work/Message Phone: ______________________ E-Mail: ________________________ Please Check Appropriate Response 1. Have you ever worked for the City of Flagler Beach? 6. Have you ever been found guilty of, had adjudication  Yes  No withheld, or pled no contest to any violation of law? If yes, please give date(s) of employment. ____________  Yes  No 2. Are you a U.S. citizen?  Yes  No If yes, please give details below: If no, are you authorized by Immigration and Naturalization to Date: ___________________________________________ work in the U.S.?  Yes  No Agency: _________________________________________ Alien #A: _______________________________________ Admission #: ____________________________________ Offense/Charge: __________________________________ 3. Will you work night shift?  Yes  No  Felony  Misdemeanor  Other Will you work weekends?  Yes  No Explanation / outcome: _____________________________ 4. Have you ever been fired, forced to resign, or resigned in lieu ________________________________________________ of termination?  Yes  No If yes, please explain below: Note: A conviction does not automatically mean you cannot be employed by the City of Flagler Beach. The nature of the Employer's Name: ____________________ Date: _______ offense, how long ago it occurred, etc., are given Reason: ________________________________________ consideration. _______________________________________________ Attach additional sheets as needed. 5. Are you related to a City employee or is any member of your family employed by the City of Flagler Beach? 7. Were you in the U. S. Armed Forces?  Yes  No  Yes  No If yes, please give the person's Did you receive an honorable discharge?  Yes  No Name:__________________________________________ Are you claiming veteran's preference?  Yes  No Relationship: ____________________________________ If yes, a copy of your DD 214 must accompany this application. Department: _____________________________________ Revised 04/06/2018 8. DRIVER’S LICENSE INFORMATION Do you have a valid Driver's License?  Yes  No Has your license ever been revoked?  Yes  No CDL Class: ________________________________________ If yes, please provide dates and explain: Endorsements: _____________________________________ _________________________________________________ _____________________________________________ Has your license ever been suspended?  Yes  No 9. PLEASE LIST ALL TRAFFIC CITATIONS RECEIVED WITHIN THE LAST SEVEN (7) YEARS (driving under the influence, driving while intoxicated, etc., should be listed under number 6 on page 1). Date: _____________________________________________ Date: _____________________________________________ Agency: ___________________________________________ Agency: ___________________________________________ Offense/Charge: ____________________________________ Offense/Charge: ____________________________________ Points: ____________________________________________ Points: ____________________________________________ Outcome: __________________________________________ Outcome: _________________________________________ Date: _____________________________________________ Date: _____________________________________________ Agency: ___________________________________________ Agency: ___________________________________________ Offense/Charge: ____________________________________ Offense/Charge: ____________________________________ Points: ____________________________________________ Points: ____________________________________________ Outcome: __________________________________________ Outcome: ___________________________________ If you have more than four citations within the last seven years, please attach a separate sheet in the same format. 10. EDUCATION AND SPECIAL TRAINING Do you have a High School Diploma?  Yes  No GED?  Yes  No If not, highest grade completed: _________________ Name and location of last High School attended: ___________________________________________________________________ Name City State List Special Training (Business, Trade, Vocational, Armed Forces Schools, etc.) Below: Name and Total Hours Hours Course/Subject Taken Certificates Received Location Completed Required for certification List Colleges and Universities Attended Below: Name and Credit Hours Did you Major/Minor Degree Type of Degree Received Location Received graduate? Field of Program Sem. Qtr. Yes No of Study Revised 04/06/2018 INSTRUCTIONS: Beginning with your present or most recent job, describe your paid work experience for the past ten (10) years and list a minimum of three (3) employers. List each promotion or transfer as a separate job even if they were with the same employer. Include Military, part time, and self- employment. List all gaps in work history in spaces provided. If you have more than four (4) separate periods of employment, sign and attach sheets in the same format as below. Resumes will not be accepted as official applications. (Job 1) Present or most recent Employer Employer: ____________________________________________________ From To Total Time Address: _____________________________________________________ Mo. Yr. Mo. Yr. Yrs. Mo. Telephone Number: ____________________________________________ Your Job Title: _________________________________________________ Hours per Week Supervisor’s Name and Title: _____________________________________ Starting Salary $ ___________ per_________ Reason for Leaving Position: _____________________________________ Last Salary $ ___________ per_________ May we contact your present employer?  Yes  No Specific Duties: ____________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Number of Employees supervised (if applicable): BETWEEN THESE JOBS (if applicable):  UNEMPLOYED  IN SCHOOL FROM (mo/yr): TO (mo/yr): (Job 2) Present or most recent Employer Employer: ____________________________________________________ From To Total Time Address: _____________________________________________________ Mo. Yr. Mo. Yr. Yrs. Mo. Telephone Number: ____________________________________________ Your Job Title: _________________________________________________ Hours per Week Supervisor’s Name and Title: _____________________________________ Starting Salary $ ___________ per_________ Reason for Leaving Position: _____________________________________ Last Salary $ ___________ per_________ May we contact your present employer?  Yes  No Specific Duties: ____________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Number of Employees supervised (if applicable): BETWEEN THESE JOBS (if applicable):  UNEMPLOYED  IN SCHOOL FROM (mo/yr): TO (mo/yr): (Job 3) Present or most recent Employer Employer: ____________________________________________________ From To Total Time Address: _____________________________________________________ Mo. Yr. Mo. Yr. Yrs. Mo. Telephone Number: ____________________________________________ Your Job Title: _________________________________________________ Hours per Week Supervisor’s Name and Title: _____________________________________ Starting Salary $ ___________ per_________ Reason for Leaving Position: _____________________________________ Last Salary $ ___________ per_________ May we contact your present employer?  Yes  No Specific Duties: ____________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Number of Employees supervised (if applicable): BETWEEN THESE JOBS (if applicable):  UNEMPLOYED  IN SCHOOL FROM (mo/yr): TO (mo/yr): (Job 4) Present or most recent Employer Employer: ____________________________________________________ From To Total Time Address: _____________________________________________________ Mo. Yr. Mo. Yr. Yrs. Mo. Telephone Number: ____________________________________________ Your Job Title: _________________________________________________ Hours per Week Supervisor’s Name and Title: _____________________________________ Starting Salary $ ___________ per_________ Reason for Leaving Position: _____________________________________ Last Salary $ ___________ per_________ May we contact your present employer?  Yes  No Specific Duties: ____________________________________________________________________________________________ ________________________________________________________________________________________________________ Number of Employees supervised (if applicable): Revised 04/06/2018 Did You:  Answer all questions completely?  Cover a full 10-year employment history?  Explain all gaps in employment?  Sign and date the application? Please read this statement carefully before signing below: The City of Flagler Beach is an Equal Opportunity Employer. I hereby certify that each response on this application and all other information I have furnished in applying for employment with the City of Flagler Beach is true and correct. I understand that any incorrect, incomplete, or false statement or information I have furnished may subject me to disqualification or to immediate discharge at any time. I understand that neither the completion of this application nor any part of my consideration for employment establishes any obligation for the City of Flagler Beach to hire me. If I am hired, I understand that either the City of Flagler Beach or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. SIGN YOUR NAME HERE DATE NOTES:  If you require special testing accommodations due to a disability, please notify the staff BEFORE the test date. Revised 04/06/2018  City of Flagler Beach EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION SURVEY TO ALL APPLICANTS: The following information is being gathered by the City of Flagler Beach for research, affirmative action, and federal EEO reporting requirements. If you choose not to answer any of the items, you will not be subject to adverse treatment; however, we urge you to do so and assure you that this information will not be used to evaluate your application, and will be kept confidential. JOB/POSITION APPLIED FOR: ______________________________________ NAME OF APPLICANT: ______________________________________ DATE OF BIRTH (Month/Day/Year): ______________________________________ SEX  Male  Female Ethnicity or ancestry Categories (Check One) Applicant’s ethnicity or ancestry refers to an individual’s nationality, lineage or the country in which the individual or individual’s parents or ancestors were born before their arrival in the United States  African American (not of Hispanic origin): All persons having origins in any of the racial groups of Africa.  Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.  Hispanic: All persons of Spanish or Portuguese culture with origins in Spain, Portugal, Mexico, South America, Central America or the Caribbean, regardless of race.  Native American: All persons having origins in any of the Indian tribes of North America prior to 1835.  White (not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.  Asian American: persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Island, including the Hawaiian Islands prior to 1778.  Not Known/Other HOW DID YOU LEARN OF THIS POSITION?  Ad in newspaper  Ad in trade journal  City bulletin board/walk-in  Friend/City Employee  Internet  Agency Referral Revised 04/06/2018