City of Florida City Police Department

404 West Palm Drive Florida City, FL 33034-0570 (305) 247-8223


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Employment Application & Background Information


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P O LICE



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Applicant's Name: _

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SS #: -------- Primary Contact #: _ _ Position Applying For: 0 Patrol Officer

0 Certified

0 Communications Officer 0 Police Records Technician 0 Secretary/Clerk

0 Non-Certified

0 Other: ------------

Application Date:------------------ ID Assigned : _


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WE ARE AN EQUAL OPPORTUNITY EMPLOYER


The City of Florida City Police Department is an equal opportun ity employer (EOE), and, in accordance with applicable Federal and State Jaws does not unlawfully discriminate on the basis of race, color, religion, national origin, disability, age, gender or other legally protected status or classification.


It is the policy of the City of Florida City Police Department to provide equal employment opportunity (EEO) for all applicants and employees. This EEO policy applies to all areas of employment including recruitment, hiring, training, promotion, compensation, benefits, transfer and other terms and

conditions of employment.


The minimum age for police officer applicants is 21 years of age. The minimum age for all other positions is 18 years of age. Under Florida Jaw, police officers and communications officers must be citizens of the United States.

D:\fcpd forms\personnel\police application 0404

This employment application is not an offer of employment, or a contract for employment. The completion of this application or any other instrument does not stand as an agreement, or promise to hire the applicant, and any statement to the contrary by any unauthorized employee is void. The Chief of Police is the ONLY person authorized to make an offer of employment. This application will be held on file in accordance with current Florida law. Applicants will be given consideration for open positions only.


Instructions for Completing this Application


( 1) Print or type. USE ONLY BLACK INK.


  1. Complete all questions.


  2. Any questions not pertaining to you individually, list as "NIA" for Not Applicable.


  3. If more writing space is needed throughout this application form, you may write your answers on paper and attach them to the application. Be sure to clearly identify the question number you are referring to.


  4. The Affidavit of Applicant and Authorization for Release of Personal and Criminal History Record Information on the following pages must be signed ON LY in the presence of a Notary Public.


(6) If specific portions of this application are not notarized, the application will not be processed.


  1. Attach copies* of the following:


    1. Birth Certificate (naturalized U.S. citizens must also attach copy of naturalization papers; persons legally permitted employment in the United States must also attach copies of such permits)


    2. High School Diploma or G.E.D. Certificate


    3. All post-secondary (college, vocational school, etc.) diplomas and transcript s


    4. Ifyou were in the military, documentation of m ilitary training/experience and a DD-21 4


    5. Peace Officer Certification Certificate and Diploma from police academy


    6. Police training certificates/training records


    7. Driver's License


    8. Marriage License (if applicabl)


      1. Proof of Vehicular Insurance (if applicable)


J. Social Security Card


* If some of these documents are not readily obtainable, you may omit attaching them, if you explain the reason they cannot be attached. Xerox copies of all documents are acceptable for application submission purposes, but original/certified copies are required if an offer of employment is made and accepted.

Affidavit of Applicant


As the Applicant, I state that I understand and/or certify the following:


I . That ifl do not wish to answer a question in the application process, I may do so; however my application will not be processed .


  1. Exclusive of the aforementioned statement, all information, which is recorded in the application process, will be used only for identification and/or in relation to consideration of qualification of the applicant for employment.


  2. That I have read and understand all questions and instructions in this application and that my answers during the application process are factual and complete to the best of my knowledge and belief.


  3. That truthfu l and complete responses in the application process are required.


  4. That discovery of intentional omissions or incorrect answers may be a basis for the termination of the application process, and may result in criminal prosecution for the offense of False Statements under Florida law section 837.06, a misdemeanor punishable by a maximum fine of $1,000 or imprisonment for not less than one (1) or more than five (5) years, or both; and/or for the offense of Perjury (False Swearing) under Florida code section 837.01 1, a felony punishable by a maximum fine of $1,000 or imprisonment for not less than one ( 1) or more than five (5) years, or both.


  5. That falsification during the application process by an individual hired may result in termination of employment with this Agency.


  6. That the City of Florida City Pol ice Department operates within the scope of a Standard

    Operation Procedures (SOP) Manual and that if an offer of employment is made and accepted, the applicant agrees to work in accordance with the policies and procedures of this manual.


  7. That all information provided will be verified by written request, interview, testing, psychological test, physical agility testing, med ical exam, drug screening, polygraph exam or computer verification of drivers/criminal history and drivers license status; that the present and all former employers will be contacted for infonnation to determine qualification s for employment with this Agency.


  8. That ifl am offered employment with the City of Florida City Police Depmtment, and ifl accept such employment, that I will be initially employed as a probationary employee for a period of twelve calendar months from date of hire. I understand that ifl am not available to work during the probationary period due to illness, injury, or other reason, my probationary period may be extended beyond 12 months from date of hire. I understand that my work performance will be evaluated, and if such work performance is not in keeping with agency standards, I will be provided written notification of my failure to achieve agency work performance standards. I also understand that I will be provided with training to assist me in reaching those standard s of work performance. However, I understand completely and fully that if I fail to meet departmental standard s, I can be terminated from employment.


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l 0. That my work performance will be evaluated during my probationary period; and if I have not obtained Agency standards of work performance, that my employment with the City of Florida City Police Department will be terminated. I understand that upon such tennination all such

salary and other compensations will also be tenninated. I further understand that upon termination that I must return aII property issued to me by the City of Florida City Police Department, or make suitable restitution for the same. I understand that I do not have a right to appeal

termination unless such tennination is illegal.


1 1 . That in the event I achieve Agency work performance standards at the end of my probationary period that I will be classified as a regular employee. I also understand that as a regular employee, should my work performance fall below Agency standards, that I might be terminated .


  1. After successful completion of my probation period , that I may be terminated for any good and sufficient cause; to include, but not limited to criminal activity or violation of Department policies and procedures. I understand that I have appeal rights as provided in the City of Florida City Police Department's Standard Operating Proced ures manual. However, 1 completely and

    fully understand that as a probationary employee, 1may be terminated at any time and for any or no reason, and have no rights of appeal, unless such termination is illegal.


  2. That should I not successfully complete my probationary period for any reason or resigned from my employment within one year of employment date, I agree to pay the City of Florida City, within 30 days of employment termination , a minimum of $500.00 and a maximum of $1,000.00 (based on job assignment and uniform/equipment requirements) as liquidated damages in recognition for all expenses incurred by the City of Florida City as part of the hiring and employment process.


  3. That I fully understand once I become a regular employee (Dispatcher, Officer-Full time, Part time, or Reserve) if for any reason I leave within six (6) months of receivi ng my yearly clothing allowance (two pants and two shirts) I agree to pay the City of Florida City, by way of payroll deduction, the entire cost of said uniforms.


  4. That I fully and completely relieve the City of Florida City and all its employees from any responsibility from the incursion of any debts or expenses from any law enforcement training from my present employer, and any and all former employers.


  5. That I understand that: (a) federal law 18 U.S.C. 922 prohibits persons who have been convicted of a domestic violence related crime from access to, possession, shipment, or transportation of firearms or ammunition; and (b) that most jobs at the Florida City Police Department may involve contact with firearms or ammun ition and thus are covered under this federal law; and (c) that all applicants and employees are required to submit to a review of their criminal history record prior to employment and as a condition of continued employment, and (d) that I give my consent for such criminal history record checks to be made now and at any point during any such employment.


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  1. That I understand and acknowledge that if any information presented in this application changes between the time I submit the application and any conditional offer of employment is made, that I must advise the Florida City Police Department of those changes in writing.


  2. That I will receive a Security Identification Card while the City of Florida City employs me. In the event I lose/misplace this card, I will be responsible to reimburse the city $10.00 per occasion.


SIGN THIS ONLY IN THE PRESENCE OF THE NOTARY PUBLIC AND UNDER OATH


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Applicant's Signature Date


Before me personally appeared the above said person who says that he/she executed the above Affidavit Of Applicant of his/her own free will and accord, with full knowledge of the purpose therefore.


Sworn to and subscribed before me, this day of ----------

20----


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Notary Public's Signature

Place Commi ssion information and Seal:

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City of Florida City Pol ice Department 404 West Palm Drive

Florida City, FL 33034-0570 Compliance Office - (305) 247-8223

Authorization for Release of Personal Information and Criminal History Record Information


I,---------------------------·' do hereby authorize the

(print your name)

review and full disclosure of all records concerning myself to any duly authorized agent(s) of the City of Florida City Florida Police Department, whether the said records are of a public, private, or confidential nature.


The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; financial or credit institutions ; including records of commercial or retail credit agencies (including credit reports and/or ratings); and other financial statements wherever filed; medical and psychiatric treatment and/or consultation; including hospitals, clinics, private practitioner s, and the United States Veterans Administration ; employment and pre-employment records, including internal investigations, reports, background reports, polygraph exam results, performanc e appraisal, efficiency or fit-for-duty reports, complaints, or grievances

filed by or against me; and the records, recollections of attorneys' at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have or have had an interest; and any other document or article of information deemed pertinent for the purposes of assessing my suitability for employment.


I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly-in whole or in part, upon this release authorization will be considered in determining my suitability as a candidate for employment or other service by the City of Florida City Police Department. I also

certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this; and hereby specifically release them from any liability which may be incurred as a result of furnishing such information .


I hereby authorize the Florida City Pol ice Department to receive any criminal history record information and driver's history information pertaining to me, which may be in the files of any criminal justice agency, to include Florida,

and National Crime lnfonnation Center files. This authorization shall remain in effect from now through any period of employment or other service to the City of Florida City and I understand that such on-going consent is a condition of employment or other service to the City of Florida City.


A photocopy of this release form will be as valid as an original thereof, even though the said photocopy does not contain any original writing of my signature.

Applicant's Printed Name: Other Names J have been known by :---------------------------

Race: Sex: Date of Birth: -------SSN: -------------

Address:


SIGN THIS ONLY IN THE PRESENCE OF THE NOTARY PUBLIC AND UNDER OATH


Applicant's Signature: Sworn to me and subscribed in my presence, this day of __ __, 20


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Notary Public's Signature

Place Commission information and Seal:

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Section A :Job Task


A-1 Each position has a job description. You must read the job description to comply with the application process.


Are you capable of performing the duties and tasks in thejob description for the position for which you have applied? Yes No


Interview, psychological testing, medical examination, physical agility testing, and/or other forms of testing to determine your ability to perform the tasks directly related to the position for which you have applied will verify this.


These tests will be perfom1ed in accordance with cun-ent departmental requirements for all candidates being considered for employment.


    1. Position s of Patrol Officer and Communications Officer require employees to work shifts. Shift work includes working a 24-hour a day clock, weekend s, and holidays. Clerical positions may require clerks to work courts, which are held in the evening hours. Do you object to working shifts, hol idays, weekends, or non-daytime hours? No Yes


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    2. Ifemployed by this Agency, do you agree to work rotating shift assignments based on the needs of the Agency? Yes _ No _


    3. Do you object to adherence to following policies, procedures and directives of your supervisors?

Yes _ No Ifyes, explain:


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Section B : Personal Information


B-1 Name: (Print)


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FIRST MIDDLE LAST


Other Names You Have Used or Have Been Known By:


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B-2 Sex: _ Race: _ Date of Birth : Blood Type: _ _ Eye Color: _ Hair Color: _ Height: _ Weight: __

B-3 Social Security Number:--------------------------


    1. Home Address: Number Street Apt No.


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      City State ZIP


    2. Phone Numbers (with Area Codes):


      Pager Other _ _ __

      Home ---------------Business -------------


    3. Are you a citizen of the United States, or legally authorized to work in the United States? Yes _ No _(* Police Officers and Communications Operator MUST be a U.S. citizen,

      pursuant to OCGA 35-8-8.)


      B-6a Marital Status: _Single Manied Divorced Widow Other


      If married :


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      B-6b Spouse Name:


      _ Date of Birth:---------

      Spouse address:-----------------------------


      List dependents:


      Name: ___ __ __ Date of Birth: --------

      Name:---------------- Date of Birth: --------

      Name: ---------------- Date of Birth : --------

      Name: _ _ _

      Date of Birth: --------

      Name: ---------------- Date of Birth:--------


    4. Are you being paid, urged, or coerced by any person or organization to work for thi s Agency?

Yes No


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B-8 How did you find out about this position?


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B-9 Are you a fugitive from justice? Yes _ No _ Ifyes, where?


B- I 0 Are you now, or have you ever been, a member of any foreign or domestic organization, association, movement , group or combination of persons which has adopted or shows a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States, or which seeks to alter the fonn of government of the United States by uncon stitutional means? Yes No Ifyes, explain:


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B-12 List the city and state you were born in, and each city and state in which you resided, were employed, attended school, or were stationed in the military service.


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Section C : Work History


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C-1 List all job s you have held in the last ten ( I 0) years. Start with your present or most recent job first. If you need more space, you may attach additional sheets. Include Military Service in proper time sequences and temporary or part-time jobs no matter how little time was involved. This infonnation will be verified by background investigation. Ifyou do not authorize contact to your present employer, your application will not be processed. You MUST provide complete addresses of employers.


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Name of Employer:--------------------------------


Street Address:--------------------------------


City, State & ZIP:-----------------------------


Your Title :------------------------------------

Specific Job Duties: _ _

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Name & Title of Supervisor:

_ _ __

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Number of people you supervised: _

_Salary: $_

per

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Reason for Leaving: -------------------------------


From ---------To ---------Business Phone:-------------

Name of Employer :------------------------------


Street Address:----------------------------------

City, State & ZIP:-----------------------------


Your Title:------------------------------------

Specific Job Duties:____ _ ___ __ ___


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Name & Title of Supervisor: Number of people you supervi sed: _ _ Salary: $_ _ _ per

Reason for Leaving: -------------------------------

If you need space to list additional employers, you may make copies of this page.


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Name of Employer: -------------------------------­


Street Address: ---------------------------------

City, State & ZIP:-----------------------------

Your Title: _ _

____ _

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Specific Job Duties: _ ____ ___


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Name & Title of Supervisor:----------------------------

Number of people you supervised: ____ Salary: $__ per


Reason for Leaving:

____ ___

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Name of Employer: -------------------------------­

Street Address :---------------------------------

City, State & ZIP:-----------------------------­

Your Title:


Specific Job Duties: _

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__ _ _

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Name & Title of Supervisor:_


_


_


__


Number of people you supervised:


_Salary: $_


_


_ per


Reason for Leaving :


___


_


___


____


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Name of Employer: --------------------------------


Street Address: --------------------------------


City, State & ZIP: ------------------------------

Your Title:


Specific Job Duties:__ _

_ __

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Name & Title of Supervisor: Number of people you supervised:


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_Salary: $


_ per

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_ __

Reason for Leaving:-------------------------------


C-2 Have you ever been asked to resign or have been terminated from ajob in the last ten ( I 0) years?

Yes _ No _ lf yes, explain:


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Section D: Military Service


For all of the following questions, military service includes active duty, reserve duty and National Guard service.


    1. List periods of all military service:


      Rank Held Assignment Branch


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    2. Were you ever court-martialed , tried on charges, or were you the subject of a summary court, deck court, captain's mast or company punishment , or any other disciplinary action while in military service? Yes No lf yes, explain:


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    3. Did you ever commit any criminal act while in the military service?

      Yes _ No _ If yes, explain :


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    4. Military Training/Experience: List relevant military training and experience below :


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Section E :Education/Training


E-1 High School Graduate or G.E.D.? Yes No


Name of High School: _

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City & State:----------------------------

IfG.E.D., issuing authority :

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* You must attach copy of H.S. Diploma or G.E.D.

___ _


    1. Indicate below the schools you have attended, location (city and state), your degree and/or major area, and the number and type (quarter hours, semester hours, clock hours) of credits earned.


      CollegeNocational Schools


      Name of School: ---------------------------

      City & State:----------------------------

      Maior Area: ---------------Degree?: ------------

      N umber & Type of Credits Earned: _ _ _ _


      Name of School:---------------------------

      City & State:----------------------------


      Major Area:

      _ Degree?:------------

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      Number & Type of Credits Earned:----------------------

      Name of School: ---------------------------

      City & State: -----------------------------

      Major Area: _ Degree?: _ _ Number & Type of Credits Earned: __ _ _ ___


      Name of School: ---------------------------

      City & State: -----------------------------

      Major Area: _ ___ Degree?: __


      Number & Type of Credits Earned :----------------------

    2. List any specific or technical skills and abilities, including speaking foreign languages :


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    3. Typing Skills?: Yes

      No __ Words per minute:_

      __ __

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    4. Computer Skills?: Yes No

      If yes, then list programs and computer hardware you are

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      familiar with .Indicate your level of experience and knowledge.


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    5. Have you ever been expelled or suspended from any school, or were you ever disciplined by any school officia l? Yes _ No _ Ifyes, explain:


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Section F : Police Officer Status & Training


F-1 Have you ever attended a basic mandate school for police officers? Yes _ No _ Ifyes, then :


Where Attended: ---------------------------

Dates Attended: ------------------Graduate?: -------

Certification/Registration Number: State: __ _


F-2

Are you a Florida Certified Police Officer? Yes No


Florida Certification N umber:------------------------ F-3 What is your current status with F.D.L.E.?

Florida: -------------------------------

0ther states? ------------------------------

F-4 Attach a copy of your F.D.L.E. Profile to this application.


List below police related training you have received which is NOT on the F.D.L.E. Profile: Course/Subject Matter Location


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Section G: Criminal Activity


It is important that you answer each of the followi ng questions factually and truthfully. Applicant acknowledges that this will be verified with an extensive background investigation includ ing Florida/National Crime Information Center and local checks.


    1. Have you ever committed any criminal offense(s)? Yes __ No _ Ifyes, explain:


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    2. Have you ever been arrested for any criminal offense(s)? Yes _ No _ If yes, explain :


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G-3 Have you ever been convicted of any criminal offense(s)? Yes _ No _ Ifyes, explain:


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G-4 Have you ever posted bond for a criminal offense? Yes _ No _


Ifyes, for what purpose? _ __ ___ _


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G-5 Have you ever been placed on probation or parole? Yes _ No _ Ifyes, explain:


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G-6 Do you have any illegal gambling debts? Yes _ No _ If yes, explain:


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    1. Have you ever stolen money to gamble? Yes _ No _ If yes, explain:


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    2. Did you ever work for an illegal gambler or someone you knew to be involved in criminal gambling activity? Yes _ No Ifyes, explain:


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G-9


Have you ever been fingerprinted? Yes _ No _


If yes, give details below:

Agency Fingerprinted By

Purpose


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G-10 Please l ist the name of all agencies you have applied and application statu s? (If more space needed, list infonnation a separate sheet)

Agency Status


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Section H: Traffic History


H-1 Do you have a driver's license? Yes No If yes, then give the following details: Name on License: License Number : License State:

Expiration Date:

List any restriction s: H-2 Have you ever possessed an operator's license issued by any state other than Florida?

Yes No If yes, then :


State: Expiration Date: Name on License: License Number: H-8 List below all traffic citations you have been issued. This will be verified by computer check.

Location (State & City): Approximate Date: Nature of Violation: Penalty/Disposition:


Location (State & City): Approximate Date: Nature of Violation: Penalty/Disposition :


Location (State & City): Approximate Date: Nature of Violation: Penalty/Disposition:

Section I: Alcohol/Drug Use


This section deals with alcohol and drug use and abuse. Answer each question truthfully.


    1. Have you ever been terminated because of alcohol consumption or illegal drug abuse?

      Yes No


    2. Have you ever been disciplined by an employer because of your alcohol consumpt ion habits or illegal drug abuse? Yes _ No_


    1. In the past, have you ever called in sick on a job because of drunkenness or because of illegal drug abuse? Yes _ No _


    2. During the last ten ( 10) years, approximately how many times have you used alcohol during working hours? (This would include during lunch or coffee breaks, as well as while actually working.) Circle the approximate number:


0 5 10 15 20 25 50 75 100 200 300 400


1-5 In your lifetime, approximately how many times have you used mari juana or other illegal drugs?


Marijuana

5

15 25

50

75

100

200

300+

Other Illegal Drugs

5

15 25

50

75

100

200

300+


List any illegal drugs (including marijuana) you have ever taken, and the last time you used it:


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    1. Have you ever been an-ested becau se of illegal alcohol consumption or illegal drugs? (including DUI) Yes _ No _ If yes, explain. Include when, where, and disposition of case:


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    2. Have you ever sold, or possessed with intent to distribute, any illegal drugs (including marijuana)?

Yes _ No _ If yes, explain :


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I-9 Have you ever reported to work under the influence of alcohol or illegal drugs (including marijuana)? Yes __ No __ Ifyes, explain:


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Section J: Personal References


    1. List five (5) personal references that have known you for at least 5 years and can provide infonnation relating to your employability . These personal references cannot duplicate business references.


      1. Name:


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        Work Phone Relationship to Applicant:


      2. Name:


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        Work Phone ( ) ---------------------

        Relationship to Applicant:


      3. Name: Home Address:--------------------------


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        Home Phone: ( ) ----------------------


        Work Phone ) ---------------------

        Relationship to Applicant:

      4. Name : Home Address:-------------------------


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        Home Phone: ( ) ----------------------

        Work Phone Relationship to Applicant:


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      5. Name: Home Address: -------------------------

Home Phone: (


Work Phone ( ) ----------------------

Relationship to Applicant:

Section K: Applicant's Narrative Statement


K-1 In your own words, and in your own handwriting, please describe why you want to become an employee for the City of Florida City Police Department, and your long-term career goals:


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City of Florida City Police Pension Fund Enrollment Form


Date: _ __


TO THE BOARD OF TRUSTEES OF

THE CITY OF FLORIDA CITY POLICE PENSION FUND:


I, the undersigned , submit the following information for the purpose of participating in the City of Florida City Police Pension Fund as established by the City Ordinance.



Department:-------------- Name: _

Effective Date of Employment: _ Social Security #: __ _

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Marital Status: _

Sex: Male _

Female _

Address: --------------


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Date of Birth: _

City/State/Zip:------------- Place of Birth:_ _

Designation of beneficiary : I, the undersigned, do hereby designate:


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Name: _ _ Name:----------------

Name: _

Relationship: __ _ DOB:____ Relationship: DOB: _

Relationship : DOB: _


As the Revocable Beneficiary to whom I request the Board of Trustees of the City of Florida City Police Pension Fund to pay, in the event of my death before retirement on pension, the total amount of contributions previou sly made by me, and accrued benefits due to me as stipulated in the Ordinance.


AS THE REVOCABLE CONTINGENT BENEFICIARY , I FURTHER DESIGNATE:


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Name:---------------- Relationship:

_ DOB: _


I authorize the P/R Division of the City to deduct two percent (7 %) of my gross earn ing, excepting off-duty pay, for distribution to my pension fund.


I HEREBY CERTIFY AND WARRANT THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT:


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Signature of Employee Sworn to and subscribed before me this , day of __ , 20------"


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Notary Public in and for the State of Florida

Notary Seal:


CERTIFICATION OF BOARD OF TRUSTEES


We hereby certify that the above is an employee of the city of Florida City and is entitled to all pension benefits established by the City Ordinance.


ATTEST:


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SECRETARY CHAIRMAN

Reimbursement to the Florida City Police Department


Pursuant to Florida Statue Section 943.16, an applicant who attends approved police officer training at the expense of the Florida City Police Department must remain in the employment or appointment as a police officer with the Florida City Police Department until a ninimum of two years has elapsed from the date of appointment as a police officer. If the employment or appointment is terminated on his/her own initiative, he or she shall reimburse the Florida City Police Department for the cost of his/her participati on according to the schedule outlined in the statute. In addition to reimbursement for the full cost of tuition and other course expense, a trainee terminating employment shall reimburse the employee agency for the trainee's wages and benefits paid by the employing agency during the academy training period . The Florida City Police Department may institute a civil action to collect such costs if not reimbursed.


I, , hereby acknowledge receipt of this document and that I understand and (Print name of applicant)

Agree to my obligation as detailed above.


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Applicant's signature


STATE OF FLORIDA, COUNTY OF The foregoing instrument was acknowledged before me this

_ _ ___ (date) by _

_ __

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Who is personally known to me or who has produced (type of identification) as identification and who did (did not) take an oath.


-------------------- Notary' s signature


__ _

_ _ Notary's name

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_ __ Notary 's title or rank

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--------------------Serial number, if any