PINELLAS COUNTY SHERIFF'S POLICE ATHLETIC LEAGUE Inc. APPLICATION FOR EMPLOYMENT

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1 PLEASE TYPE OR PRINT LEGIBLY PINELLAS COUNTY SHERIFF'S POLICE ATHLETIC LEAGUE Inc. APPLICATION FOR EMPLOYMENT NAME LAST FIRST MIDDLE MAIDEN APT.COMPLEXNAME BLDG# APT# ADDRESS _ POSITION(S) APPLIED FOR (1) (2) CITY STATE ZIP (3) _ No more than three (3) positions HOME PHONE BUSINESS PHONE CELL PHONE _ DATE OF BIRTH SOCIAL SECURITY NUMBER _ DRIVER'S LICENSE NUMBER STATE APPLICANT QUESTIONNAIRE INSTRUCTIONS Read every question carefully. ANSWER EVERY QUESTION - LEAVE NO BLANK SPACES. A Candidate may be rejected "who has intentionally made a false statement or omitted a material fact, or practices, or attempted to practice, any deception or fraud in their application and their examination, or in securing their eligibility for appointment." 1. Give any other names you have used or been known by (include nickname) 2. Where were you born? _ Residence at Time of Birth City/Town County State Country Indicate Which A. Where Naturalized _ B. When Naturalized _ Certificate Number _ Th' IS section F or Off icial u se oruv Approved/Disapproved for Hire Date

2 4. IN CHRONOLOGICAL ORDER, list each place you have resided for the past 5 years: MUST CONTAIN FULL/COMPLETE ADDRESS WITH ZIP CODE Mo. Yr. To Mo. Yr. Address CitylTown State Zip Code ARRESTS, SUMMONSES, ETC. 5. Have you ever been charged, cited, arrested, or convicted, for violation of any laws (including moving traffic violations) by juvenile authorities, or any civilian law enforcement agency, (regardless of whether the record in your case has been "sealed," "expunged," "dropped", or otherwise stricken? (If YES, list each instance below) Date Violation Actual Charge Location City & State Court Disposition or Sentence Police Agency Concerned If space is insufficient. use continuation sheet on page Have you ever been fingerprinted? Yes or No _ VVhen? VVhere? Purpose? VVhen? VVhere? Purpose? EMPLOYMENT 6. List below, CHRONOLOGICALLY, most current first, each and every place in which you were employed for the past 7 years. OMIT NONE. Give CORRECT, FULL ADDRESSES. Give dates of idleness between each period of employment, in proper sequence. (Include all part-time employment) Mo. Yr. To Mo. Yr. Name & Present Address of Employer Position Supervisor! Telephone Reason for Leaving If space is insufflcient, use continuation sheet on page 5

3 MILITARY SERVICE 16. Have you ever served in a Military Organization of the United States? Yes or No 17. Give period or period of active military service. _ To To 18. Givebranchofservice 19. Were you ever court-martialed, tried on charges, the subject of a summary court, or received an Article 15? Yes or No Number of times _ 20. Type of discharge received? _ 21. Are you now or were you ever an Active or Inactive member of the Reserve Forces (any branch), or National Guard, of the United States or any foreign government? Yes or No State which, active or inactive _ Branch _ Unit _ Rank _ 22. List high schooliged and colleges you have attended EDUCATION Mo. Yr. Mo. Yr. School Complete Address Year Graduated, # of Credits 23. What college degrees, professional licenses or law enforcement certifications do you possess? PERSONAL REFERENCES 25. List three (3) personal references, local if possible. DO NOT use former employers or relatives as references. Name Complete Address & Zip Code Phone Number

4 The Police Athletic League is an Affirmative Action/Equal Employment Opportunity Employer and offers employment opportunities to all persons without regard to race, color, religion, age, sex, national origin or marital status. We recognize veteran's preference as provided by Florida Law and we are committed to a drug free workplace. The Police Athletic League does not discriminate against qualified individuals with a disability in regard to the applications process, in hiring, advancement or other terms, conditions, and privileges of employment. PLEASE READ CAREFULL Y APPLICANT'S CERTIFICATION AND AGREEMENT AGREEMENTS: PROBATION PERIOD - It is understood that I shall be considered as on a temporary basis during a probationary period of one (1) year from date of appointment and may be discharged or laid off before the expiration of that period without recourse. STATEMENT OF APPLICATION - I hereby authorize my former employers to furnish their records of any service, my reason for leaving their employ, together with all information they may have concerning me, whether on record or not. I also release them and their company from any liability for any damage whatsoever for issuing same. It is agreed that any misrepresentation or omission by me in this application will be sufficient cause for its cancellation or rejection or dismissal from service of the Police Athletic League if I am appointed. It is also agreed that I have answered all of the questions on this form completely. If not, this application may be rejected. I also understand that I must update the application immediately upon my change of address, change of employment, or any arrests or convictions. I hereby certify the facts set forth in the above employment application are true and complete to the best of my knowledge. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice. Upon termination of appointment I authorize the Pinellas County Sheriffs Office-Police Athletic League to hold my final paycheck until all issued property is returned. STATE OF FLORIDA ) COUNTY OF PINELLAS) CITY OF LARGO ) (Candidate sign here in present of Notary Public) AFFIDAVIT STATE OF FLORIDA COUNTY OF PINELLAS The foregoing instrument was acknowledged before me this day of _ by, who is personally known to me or who has produced as identification and who did (did not) take an oath. Signature Name N'-'-O=-:.,TA"-"-'R...:..Y...:..P-=U:,..:B:..:L""'IC=--- Title CONTINUATION SHEET Please refer to Number of question(s) continued.

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