Employment Application

Position (s) Applied For:
Location (s) Desired:
Date of Availability
MM slash DD slash YYYY
Availability:
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Personal Information
Name:
First Last
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number:
Email Address:
Best time to reach you:

: Hours

Minutes

AM/PM
May we contact you at work?
- Yes
- No
Have you ever been employed at FDDC before?
- Yes
- No
If yes, please provide dates of employment:
What is your desired salary range?
Will you relocate if the job requires it?
- Yes
- No
Will you travel if the job requires it?
- Yes
- No
Will you work overtime if required?
- Yes
- No
Background Information
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?
- Yes
- No
Answering "YES" to this question does not constitute an automatic bar to employment. Factors such as date of the offence, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account
If Yes, please provide date(s) and details:
Work Authorization:
Are you 18 years of age or older?
- Yes
- No
In compliance with the Immigration and Control Reform Act of 1986, this Company hires only citizens of the United States and lawfully authorized alien workers. If a conditional offer of employment is made, you will be required to provide identification and proof of citizenship or authorization to work in the U.S.
Are you legally authorized to work in the United States?
- Yes
- No
This Organization is an Equal Opportunity Employer / Drug Free Workplace
Employment History:
NOTE: ALL INFORMATION TO BE FILLED IN COMPLETELY. "SEE RESUME" IS NOT ACCEPTABLE
Employer Name:
Employer Phone Number:
Employer Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Job Title:
Final Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
FROM:
MM slash DD slash YYYY

DATES OF EMPLOYMENT
TO:
MM slash DD slash YYYY
Hourly Rate / Salary:
STARTING
Hourly Rate / Salary:
FINAL
Summarize the Type of Work Performance and Job Responsibilities:
May We Contact for Reference?
- Yes
- No
Employer Name:
Employer Phone Number:
Employer Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Job Title:
Final Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
FROM:
MM slash DD slash YYYY

DATES OF EMPLOYMENT
TO:
MM slash DD slash YYYY
Hourly Rate / Salary:
STARTING
Hourly Rate / Salary:
FINAL
Summarize the Type of Work Performance and Job Responsibilities:
May We Contact for Reference?
- Yes
- No
Employer Name:
Employer Phone Number:
Employer Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Job Title:
Final Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
FROM:
MM slash DD slash YYYY

DATES OF EMPLOYMENT
TO:
MM slash DD slash YYYY
Hourly Rate / Salary:
STARTING
Hourly Rate / Salary:
FINAL
Summarize the Type of Work Performance and Job Responsibilities:
May We Contact for Reference?
- Yes
- No
Employer:
Employer Phone Number:
Employer Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Job Title:
Final Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
FROM:
MM slash DD slash YYYY

DATES OF EMPLOYMENT
TO:
MM slash DD slash YYYY
Hourly Rate / Salary
STARTING
Hourly Rate / Salary
FINAL
Summarize the Type of Work Performance and Job Responsibilities:
May We Contact for Reference?
- Yes
- No
COMMENTS:
INCLUDING EXPLANATION OF ANY GAPS IN EMPLOYMENT
Education Background
List last three (3) schools attended, starting with most recent.
1.
School Location (City & State) Years Completed Diploma, Degree or Certificate Course of Study / Major
Did you Graduate?
- Yes
- No
2.
School Location (City & State) Years Completed Diploma, Degree or Certificate Course of Study / Major
Did you Graduate?
- Yes
- No
3.
School Location (City & State) Years Completed Diploma, Degree or Certificate Course of Study / Major
Did you Graduate?
- Yes
- No
Licensure & Certifications
Please list any licenses, registrations, and certifications that are applicable to the position for which you are applying. Examples may include any technical or professional certifications.
Licensure & Certifications
License, Registration, Certification Number Date Received Exp. Date State Licensing Agency

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References
List name and telephone number of three business/work references who are NOT related to you. If not applicable, list three school or personal references who are NOT related to you
Name:
First Last
Phone:
Number of Years Known:
Relationship:
Name:
First Last
Phone:
Number of Years Known:
Relationship:
Name:
First Last
Phone:
Number of Years Known:
Relationship:
Computer Skills
Please rate your computer skills from 0-10; 0=No Experience & 10=Expert
Word:
PowerPoint:
Excel:
Outlook:
SharePoint:
Other Software Skills:
Hardware Skills:
Additional Information
LIST ANY PROFESSIONAL, TRADE, BUSINESS, OR CIVIC ASSOCIATIONS AND ANY OFFICES HELD
Please list all organizations here:
Organization Offices Held

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List Any Additional Qualifications or Information You Would Like FDDC to Consider:
Applicant Statements:
Applicant Certifies:
I Agree
I certify that the information furnished in this application and any supporting documents are true and complete to the best of my knowledge and belief. I understand that any misrepresentation or omission of material fact on this or any other record submitted pertinent to employment with this employer will constitute grounds for immediate dismissal.
Employer's Policies
I Agree
This employer is an equal opportunity employer and does not discriminate in recruiting, hiring, compensation, promotion or other employment terms based upon race, color, religion, creed, national origin, citizenship, gender, age disability, or veteran status. The information requested in this application will be used in a nondiscriminatory manner and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.
Employer Drug-Free Policy
I Agree
In accordance with the alcohol and drug abuse policies, prospective employees may be asked to submit to a drug screen analysis for substance abuse. Current employees may be asked to submit to a drug screen or alcohol blood test at any time during employment with this employer. The results of such analysis may be grounds for disqualifying an offer of employment or terminating employment with this employer.
Application Verification
I Agree
I expressly authorize, without reservation, the employer, its representative, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.
Level 2 Background Screening
I Agree
All prospective employees shall be fingerprinted in accordance with the Volunteer & Employee Criminal History System (VECHS) agreement with the Florida Department of Law Enforcement Criminal Justice Information Services Division User Services Bureau.

A prospective employee has the right to challenge the accuracy and completeness of any information contained in the report and to obtain a determination as to the validity of such challenge before a final determination is made.

The use of criminal history records and information obtained from processed fingerprint submissions is restricted and such information should be used only to determine the suitability for employment and/or access to children, elderly, or disabled.

A copy of the screening results is available upon request.
I-9 Documentation
I Agree
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard
This Employer is an Equal Opportunity Employer/Drug Free Workplace
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENTS
Resume*
Max. file size: 128 MB.
Signature*
Date*
MM slash DD slash YYYY

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