application for employment - titusville, florida

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City of Titusville

Human Resources

P.O. Box 2806

Titusville, FL 32781-2806

(321) 567-3731 – Job Line

www.titusville.com

If you require accommodations in order to complete this application, please contact Human Resources.

Check the type of work you are interested in: Full-Time Part-Time Temporary

Position Applying For: ____________________________________________

HOW DO WE CONTACT YOU?

Last Name First Name Middle Initial

Mailing Address

City County State Zip

( ) ( )

Home Phone Alternate Phone Email Address

ARE YOU UNDER 18 YEARS OF AGE? YES NO

TYPE OF LICENSE: Driver’s Chauffeur’s CDL – Class: _____________ State: _________

Drivers License Number_______________________________________ Exp date:__________

Is your license currently suspended or revoked? Yes No If yes, Why?____________________________________

Has your license ever been suspended or revoked? Yes No

If your qualifications for employment are based on the rating of your knowledge, abilities, and skills for the position(s) you

apply for; and, if you qualify, your name is placed on an application register. Applications remain active for six (6) months.

Your availability is your responsibility. Notify us if you change your name, address, or phone number. Your name will be

removed from the register if you cannot be contacted for an interview three times or if you are interviewed three times,

without a job offer. Applications may also be rejected for the following reasons: (1) Failure to complete application;

(2) Failure to provide required documents when requested; (3) Not fully meeting all job requirements; (4) Failure to obtain

a passing score on any required tests. Applicants failing the drug/alcohol screen are ineligible for consideration of

employment of one year. A new application must be submitted to regain active status.

Have you filed an application with the City of Titusville within the last six (6) months? Yes No

Have you ever worked for the City of Titusville? Yes No If yes, date(s)________ Position Title: ___________

Check status: Citizen of the United States

Legal Alien (Alien Number ______________________)(Proof of U.S. Citizenship or Immigration status will be required upon employment.)

If Yes, what year? _______ In what state? _________ Why? __________________________________________________

CITY OF TITUSVILLE

APPLICATION FOR

EMPLOYMENT

“An Equal Opportunity/Veterans’

Preference Employer” Applications are Public Record

A Drug Free Workplace

Today’s Date: __________________

___________________

FOR OFFICE USE ONLY

Dept.:____________ Rate:_________ Position: ______________ Date:_____ Requisition#:____________

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Application for Employment 8/2018

http://www.titusville.com/

PLACEDATE SENTENCE OR FINE

connection with any offense (

Yes

contendre to, or been convicted of a felony or firstdegree misdemeanor, received a suspended sentence, or forfeited bail in

OFFENSE

No. Show all convictions; including driving while intoxicated convictions.

civilian or military court? except minor traffic violations) in any

Have you ever been charged with, indicted on charges of, pled guilty to, pled nolo LAW VIOLATION RECORD: LAW VIOLATION RECORD:

PLACEDATE SENTENCE OR FINE

connection with any offense (

Yes

contendre to, or been convicted of a felony or firstdegree misdemeanor, received a suspended sentence, or forfeited bail in

OFFENSE

No. Show all convictions; including driving while intoxicated convictions.

civilian or military court? except minor traffic violations) in any

Have you ever been charged with, indicted on charges of, pled guilty to, pled nolo

EDUCATION: What is the highest grade you completed in school?

NAME AND LOCATION OF HIGH SCHOOL AND/OR COLLEGEAREA OF STUDY

#HRSCOMPLETED

SEMESTER QUARTERDEGREE

To be completed by FIRE DEPARTMENT applicants ONLY.

LY.

1. Are you a certified Police Officer in the State of Florida? Yes No. If yes, submit a copy of the Standards

Certificate and Police Testing Certification.

1. Do you possess a valid Certificate from the Florida State Fire Marshal Bureau of Fire Standards and Training? Yes No

2. Do you possess a valid Emergency Medical Technician Certification from the Florida Department of Health and

Rehabilitative Services? Yes No. If yes, submit copies of Standards and EMT Certification.

To be completed by POLICE DEPARTMENT applicants ON

SPECIAL SKILLS, APTITUDES AND OTHER QUALIFICATIONS:

Typing Speed ____________ WPM Office machines you operate efficiently: Computer

Other:_________________________

What type of Computer/Software do you have experience operating:____________________________________________

LIST ANY MACHINERY OR HEAVY EQUIPMENT THAT YOU HAVE OPERATED:

________________________________________________________

___________________________________________

___________________________________________________________________________________________________

Can you read schematics?

Yes

No

Can you read blueprints?

Yes

No

2 Application for Employment 8/2018

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LICENSURE, REGISTRATION, SPECIAL CERTIFICATIONS: Water License, Notary Public, Journeyman, etc.

License, Registration or

Certification

Number Date Received Expiration Date State licensing

Agency

RELATIVES EMPLOYED BY THE CITY OF TITUSVILLE: Do you have any relatives by blood or marriage

including elected officials, working for the City of Titusville? Yes No If yes, complete the following:

FULL NAME OF RELATIVE (S) DEPARTMENT RELATIONSHIP

REFERENCES: List three (3) references who are not relatives:

NAME COMPLETE ADDRESS PHONE OCCUPATION YEARS

KNOWN

Occasionally the format of an employment application makes it difficult for an individual to adequately

summarize one’s background. Use the space below to provide any additional information necessary to describe

your full qualifications for the position(s) applied for.

Human Resources Use: (Please Initial/Date)

1. Are you currently employed? Yes No. If yes, may we contact your current employer? Yes No.

2. Have you ever been discharged or asked to resign from any position? Yes No. If yes, give details below: _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________


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3. List below all jobs for the last ten (10) years; include prior experience, if relevant. List paid and volunteer experience; include exact

dates of military service. List specific duties, skills and equipment operated and supervisory experience.

USE ADDITIONAL SHEETS OF PAPER AS NECESSARY. A RESUME MAY BE USED TO SUPPLEMENT BUT NOT SUBSTITUTE

APPLICATION INFORMATION

CURRENT OR LAST EMPLOYER: From: (mo.) (yr.)

Address: To: (mo.) (yr.)

Job Title: # of Employees Supervised: Full-time Part-time

Duties: Starting salary: $

Ending salary: $

Department:

Supervisor:

Reason for leaving: Phone Number:

CURRENT OR LAST EMPLOYER: From: (mo.) (yr.) Address: To: (mo.) (yr.)



Ending salary: $

Department:

Supervisor:





Ending salary: $

Department:

Supervisor:





Ending salary: $

Department:

Supervisor:


APPLICANT CERTIFICATION – READ CAREFULLY BEFORE SIGNING: : I understand that applications submitted for City employment are public records. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith. I understand that any incorrect, incomplete, exaggerated or false

information furnished by me will subject me to disqualification or to discharge at any time. If employed by the City of Titusville, I agree

to comply with all its orders, rules and regulations. I hereby authorize my former employers, schools and character references to give any

information regarding my employment and to furnish any other information they may have concerning me. I understand that final

approval of employment may depend upon satisfactory completion of a criminal background check, consumer credit check report, driver’s

license verification, and a post-offer employment physical examination, including a drug/alcohol screen per F.S. 112.0455. Post offer

examinations for positions in the Police and Fire Departments may include: an electrocardiogram, a visual acuity examination,

psychological examination by a City appointed psychologist, physical agility test, polygraph examination and fingerprinting.

Date: __________________ Signature of Applicant: ________________________________________________________________


VETERANS’ PREFERENCE ELIGIBILITY FORM City of Titusville - Human Resources 555 South Washington Ave, Titusville, FL 32781

(321) 567-3728

Florida Statutes Section 295.057 provides for Veterans’ Preference for eligible veterans and family members in employment appointment, retention, reinstatement, reemployment, and promotion. Please note that preference will not be awarded retroactively.

SUBMISSION: If you seek Veterans’ Preference, please complete both pages of this form. Select the appropriate check box on page 2 and provide all required documentation from the Department of Defense (SS) and/or the Department of Veterans’ Affairs (DVA). The information must be received by the posted close date for the position.

IMPORTANT NOTICES:

In accordance with Florida law, preference in appointment, employment and promotion shall be given first to those persons included in categories 1 and 2 and second to those persons included under categories 3, 4, 5, 6 and 7 (as shown on the next page). Preference in appointment and employment requires that a preferred applicant be given special consideration in each step of the employment selection process but does not require the employment of a preferred applicant over a non-preferred applicant who is more qualified for the position.

If a qualified applicant claiming Veterans’ Preference for a vacant position is not selected, he/she may file a complaint with the Florida Department of Veterans’ Affairs. A complaint must be filed within 21 days of the applicant receiving notice of the hiring decision made by the employing agency or as otherwise provided in Rule 55A-7.016, Florida Administrative Code.

Submission of this form and accompanied documentation does not constitute automatic eligibility for Veterans’ Preference. Eligibility for Veterans’ Preference is subject to verification of information and documentation provided.

The following positions are exempt from Veterans' Preference provisions:

Positions filled by officers elected by popular vote or persons appointed to fill vacancies in suck offices and personal secretaryof each such officer

Members of boards and commissions Persons employed on a temporary basis without benefits Heads of departments Positions which require licensure such as a physician Positions which require that the employee be a member of The Florida Bar

PERSON APPLYING FOR PREFERENCE

VETERAN INFORMATION (to be provided by the person applying for preference)

Veteran’s Name (Last, First, Middle - exactly as it appears on service records)

Branch of Service Type of Discharge/Character of Service

Veteran’s periods of service

Date of Entry: Date of Discharge:

Dates of Active Duty

From: To:

Dates of Training

From:

To:

Does the veteran have a service connected disability? Yes No

If yes, is the service connected disability compensable? Yes No

What is the percentage of disability? %

Documentation you will be submitting for consideration for Veterans’ Preference:

WARTIME ERAS: For the purpose of determining Veterans' Preference, wartime era is limited to service during the following time

periods:

September 1, 2010 through present (Operation New Dawn) June 27, 1950 to January 31, 1955 (Korea Conflict)

March 19, 2003 through present (Operation Iraqi Freedom) December 7, 1941 to December 31, 1946 (WWII)

October 7, 2001 through present (Operation Enduring Freedom) April 6, 1917 to July 1, 1921, if one day of service was

August 2, 1990 through January 2, 1992 (Persian Gulf War) between April 5, 1917 and November 12, 1918 (WWI)

February 28, 1961 to May 7, 1975 (Vietnam Era) April 6, 1917 to April 1, 1920, if served in Russia (WWI) April 6, 1917 to November 11, 1918 (WWI)


PERSON APPLYING FOR PREFERENCE

Name (Last, First, Middle)

TYPE OF VETERANS’ PREFERENCE CLAIMED

Check the box below to indicate the type of preference you are claiming and answer all questions associated with that box. Submit this form and the listed documentation with the employment application to be received by the posted close date for the position.

CATEGORY/DOCUMENTATION REQUIRED

(1) A disabled veteran who has served on active duty in any branch of the U.S. Armed Forces, has received an honorable discharge, and hasestablished the present existence of a service-connected disability that is compensable under public laws administered by the U.S. Departmentof Veterans Affairs; or who is receiving compensation, disability retirement benefits, or pension by reason of public laws administered by theU.S. Department of Veterans Affairs and U.S. Department of Defense.

Required documents: A Department of Defense document, commonly known as form DD-214 (Member 4 Copy recommended) or militarydischarge papers, or equivalent certification from the DVA listing military status, dates of service and discharge type and a document from theDepartment of Defense, the DVA, or the Department certifying that the veteran has a service-connected disability.

(2) The spouse of a person who has a total disability, permanent in nature, resulting from a service-connected disability and who, because of thisdisability, cannot qualify for employment; and the spouse of a person missing in action, captured in line of duty by a hostile force, or forciblydetained or interned in line of duty by a foreign government or power.

Are you presently married to the veteran? Yes No If No, have you remarried? Do not count marriages that were annulled. Yes No

Required documents:

Spouses of disabled veterans: A Department of Defense document, commonly known as form DD-214 (Member 4 Copy recommended) or military discharge papers, or equivalent certification from the DVA, listing the spouse’s military status, dates of service and discharge type and a certification from the Department of Defense or the VA that the veteran is totally and permanently disabled or an identification card issued by the Department; and evidence of marriage to the veteran and a *statement that the spouse is still married to the veteran at the time of the application for employment; and submit proof that the disabled veteran cannot qualify for employment because of the service-connected disability.

Spouses of persons on active duty: A Department of Defense document or the DVA certifying that the person on active duty is listed as missing in action, captured in line of duty, or forcibly detained or interned in line of duty by a foreign government or power; and evidence of marriage and a statement that the spouse is married to the person on active duty at the time of application for employment.*

* Signing this form will serve as statement that you are still married to the veteran at the time of this application.

(3) A wartime veteran as defined in s. 1.01(14), who has served at least one day during a wartime period. Active duty for training may not beallowed for eligibility under this paragraph.

Required documents: A Department of Defense document, commonly known as form DD-214 (Member 4 Copy recommended) or

military discharge papers, or equivalent certification from the DVA, listing military status, dates of service and discharge type.

(4) The unremarried widow or widower of a veteran who died of a service-connected disability.

Were you married to the veteran when he or she died? Yes No Have you remarried since the veteran’s death? Do not count marriages that were annulled. Yes No

Required documents: A Department of Defense document or the DVA certifying the service-connected death of the veteran, and evidence

of marriage and a statement that the spouse is not remarried.*

*Signing this form will serve as statement that you (the spouse) has not remarried at the time of this application.

(5) The mother, father, legal guardian, or unremarried widow or widower of a member of the U.S. Armed Forces who died in the line of dutyunder combat-related conditions, as verified by the U.S. Department of Defense.

Relationship to service member: Mother Father Legal Guardian Unremarried widow/widower

Required documents: A Department of Defense document certifying the service-connected death of the veteran under combat-relatedconditions. In addition, the legal guardian shall provide proper court documents establishing the legal authority of Guardianship.

(6) A veteran as defined in s. 1.01(14). Active duty for training may not be allowed for eligibility under this paragraph.

Required documents: A Department of Defense document, commonly known as form DD-214 (Member 4 Copy recommended) or

military discharge papers, or equivalent certification from the DVA, listing military status, dates of service and discharge type.

(7) A current member of any reserve component of the United States Armed Forces or the Florida National Guard.

Required documents: A letter from Commanding Officer stating the dates of military service to establish service member is currently active.

Certification

I acknowledge that I have read and understood the rights expressed in this notice. I certify that all information provided is true, complete and correct to the best of my knowledge and belief, and is made in good faith.

Name: Date


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CITY OF TITUSVILLE, FLORIDA THIS FORM MUST BE SUBMITTED WITH EMPLOYMENT APPLICATION

TO: POLICE DEPARTMENT APPLICANTS &FIREFIGHTER/EMT APPLICANTS

SUBJECT: (A) STATEMENT ATTESTING YOU ARE A NON-SMOKER AND A NON-USER OF TOBACCO OR TOBACCO PRODUCTS FOR AT LEAST ONE YEAR IMMEDIATELY PRECEDING APPLICATION, AS EVIDENCED BY YOUR SWORN AFFIDAVIT BELOW.

(B) CONSENT FORM FOR POST-OFFER OF EMPLOYMENT DRUGAND ALCOHOL SCREENING.

(A) I , acknowledge that tobacco use of anykind (e.g., smoking, chewing, dipping, etc.) is prohibited for me whether I am on or off duty, forso long as I am an employee of the City of Titusville. Furthermore, I attest that I have been anon-user of tobacco products for at least one year immediately preceding this application foremployment with the City of Titusville.

I agree that I will not use tobacco on or off duty for so long as I am an employee of the City of Titusville. I further agree that if I do use tobacco while so employed, whether the use is on or off duty, I may be subject to disciplinary action up to and including termination of employment.

________ ____ WITNESS SIGNATURE APPLICANT SIGNATURE DATE

(B) I understand that as a part of the post-offer of employment process, the City of Titusville willconduct a background investigation to determine my suitability to fill the position for which I haveapplied. In keeping with its efforts to identify the most qualified individuals for public safetypositions, I do hereby voluntarily consent to be the sampling of subsequent testing of my bodyfluids (urine and/or blood) for the purpose of a drug and alcohol screen to determine fitness forduty.

I understand that refusal to undergo the testing will be grounds for rejection of my application for employment. I also understand that a positive test will result in the removal of my application for employment from consideration for a period of one year, at which time I may submit another application.

I further understand that the results of the testing may be utilized in conjunction with any other information developed during the post-offer of employment process to determine my eligibility for the position for which I have applied, and the City will have complete discretion in determining if I am offered a position.

SIGNATURE OF APPLICANT DATE

8/2018 Application for Employment 8/2018

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VOLUNTARY - CONFIDENTIAL

EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

The following information is voluntary and will be used in our Affirmative Action Program reporting. This

information is confidential. It is kept separately from your application and is not used to evaluate your

qualifications. Thank you for your cooperation.

Name: _________________________________________ Date: _____________________ Female Male

CHECK THE RACE/ETHNIC GROUP WITH WHICH YOU IDENTIFY:

CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:

Vietnam Era Veteran Disabled Veteran Status Disabled Individual

Position(s) Applied For: _______________________________________________________________________

____________________________________________________________________________________________

For Affirmative Action Officer’s Use Only – Placement Information

Dept./Div. #: ______________________ Position: ________________ Date of Placement: _________________

Cut Here -------------------------------------------------------------------------------------------------------------------------------

Name __________________________________________________________________________________________

Thank you for submitting your application to the City of Titusville. We would like to know how you heard about the

open position. Please complete this form by checking the appropriate referral source.

____ EFSC – Titusville

____ Brevard Rehabilitation

____ NAACP

____ UCF

____ Walk-in

____ Other ________________

___ The City’s Telephone Job line

___ City Employee Referral, Name ________________

___ Trade Magazine

___ Orlando Sentinel

___ Florida Today

___ Florida Dept. of Labor – Titusville

___ EFSC – Cocoa

___ Website _______________________

8/18 Application for Employment 8/2018

Black AsianWhite Hispanic or Latino Native Hawaiian or other Pacific American Indian/Alaskan Native Two or more races

application for employment - titusville, florida

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