PERSONAL INFORMATION EMPLOYMENT APPLICATION LEE COUNTY GOVERNMENT P.O. Bx 398 ATT: Human Resurces Frt Myers, Flrida 33902 (239) 533-2245 http://www.lee-cunty.cm JOB NUMBER: JOB TITLE: EXAM ID#: Received: Fr Official Use Only: QUAL: DNQ: Experience Training Other: NAME:(Last, First, Middle) ADDRESS:(Street, City, State, Zip Cde) HOME PHONE: ALTERNATE PHONE: EMAIL ADDRESS: DRIVER'S LICENSE: Yes N PREFERENCES PREFERRED SALARY: DRIVER'S LICENSE: State: LEGAL RIGHT TO WORK IN THE UNITED STATES? Yes N ARE YOU WILLING TO RELOCATE? Yes N Maybe WHAT TYPE OF JOB ARE YOU LOOKING FOR? TYPES OF WORK YOU WILL ACCEPT: SHIFTS YOU WILL ACCEPT: OBJECTIVE: EDUCATION SCHOOL NAME: LOCATION:(City, State) WORK EXPERIENCE DID YOU GRADUATE? Yes N DEGREE RECEIVED: Frm: T: ADDRESS:(Street, City, State, Zip Cde) Yes N
Frm: T: ADDRESS:(Street, City, State, Zip Cde) Yes N Frm: T: ADDRESS:(Street, City, State, Zip Cde) Yes N CERTIFICATES AND LICENSES SKILLS OFFICE SKILLS: Typing: Data Entry: OTHER SKILLS: LANGUAGE(S): Speak Read Write ADDITIONAL INFORMATION REFERENCES REFERENCE TYPE: NAME: POSITION: ADDRESS:(Street, City, State, Zip Cde) EMAIL ADDRESS: PHONE NUMBER: REFERENCE TYPE: NAME: POSITION:
ADDRESS:(Street, City, State, Zip Cde) EMAIL ADDRESS: PHONE NUMBER: Agency-Wide Questins 1. Are yu legally eligible fr emplyment in the United States? Yes 2. Have yu ever wrked in any psitin fr the Lee Cunty Bard f Cunty Cmmissiners? N 3. If yu answered "yes" t questin #2 abve, please list psitin, department, start date and end date. 4. Were yu a participant in the Lee Cunty Bard f Cunty Cmmissiners 2008 Vluntary Separatin Incentive Prgram (emplyee buy-ut)? N 5. D yu have any relatives wrking fr Lee Cunty Bard f Cunty Cmmissiners? 6. N If yu answered "yes" t questin #5 abve, please list name(s) and department(s) 7. Have yu ever been knwn r emplyed under any ther names? N 8. If yu answered "yes" t questin #7 abve, please list previus name(s). Enter "N/A", if nt applicable. n/a 9. D yu claim veteran's preference? N 10. If yu are claiming Veterans Preference, an electrnic cpy f the DD-214, alng with supprting dcuments (if required), must be attached t this applicatin at the time f submissin fr veterans preference cnsideratin. Failure t prvide these dcument(s) will dismiss my request fr Veteran's preference. Infrmatin regarding the dcuments needed fr each Veterans Preference qualifying categry can be fund n ur jbs pprtunity page under the Veterans, Internships and Jb Classificatins sectin. Nt Applicable If yu claim veteran's preference, please chse categry and prvide the supprt dcuments at time f applicatin. Fr eligibility requirements, please visit http://www.leegv.cm/gv/dept/humanresurces/dcuments/veterans%27%20preference%20- %20Guidelines%202014.pdf 11. Disabled Veteran- Requires a DD214, military discharge papers, r equivalent certificatin frm the Department f Veteran Affairs listing military status, dates f service, type(s) f discharge. Spuse (f disabled r MIA veteran)- Requires a DD214, certificatin frm Department f Defense r the VA shwing ttal r permanent disability, prf that veteran cannt qualify fr emplyment because f the service-cnnect disability, evidence f marriage and a statement that spuse is still married t Veteran. Unmarried Widw r Widwer- Requires dcument frm the Department f Defense shwing the death f service member while n duty r a letter frm VA ffice certifying the service- cnnected death f veteran and evidence f marriage. Veteran f Wars- Requires a DD214, military discharge papers, r equivalent certificatin frm the Department f Veteran Affairs listing military status, dates f service, type(s) f discharge. Mther, Father, Legal Guardian-Requires dcument frm the Department f Defense shwing the death f service member while n duty Natinal Guard Member- Requires a letter frm the Cmmanding Officer stating dates f military service t establish they are currently active. Any Hnrably Discharged Veteran Nt Applicable
12. Please list all residences fr the past 10 years. Cmplete addresses and dates are required. 13. Hw did yu learn abut this psitin? 14. Are yu retired frm the Flrida Retirement System (FRS) pensin plan r have yu taken a distributin frm the FRS Investment Plan? If yes, please be aware that individuals re-emplyed with an FRS-cvered emplyer are nt eligible fr re-enrllment in either f the FRS retirement plans. Jb Specific Supplemental Questins **** Please refer t the specific psitin yu are applying fr t btain the Jb Specific Supplemental Questins. Yu must print and attach it t this applicatin. Failure t attach the supplemental questins will make yur applicatin invalid.**** The fllwing terms were accepted by the applicant upn submitting the nline applicatin: APPLICANT'S CERTIFICATION AND AGREEMENT Please Read Carefully Befre Signing By clicking n the 'Accept' buttn belw I UNDERSTAND AND AGREE that, except as specifically prhibited by state law r Cunty rdinance r regulatin, all Cunty plicies and prcedures d nt create any prperty rights in emplyment; and that emplyment may be terminated by either the emplyee r the Cunty with r withut cause. I CERTIFY that all infrmatin given ut in this emplyment applicatin, in related dcuments and in all interviews is true and crrect. I understand that the Cunty may make a thrugh investigatin f my character, reputatin, past emplyment and ther relevant histry. I authrize the giving and receiving f any such infrmatin requested by the Cunty and hereby relieve and release all frmer emplyers and their agents f any liability fr any infrmatin they may give t the Cunty. I als authrize educatinal institutins t furnish any recrds f my educatin, cursewrk, and/r degrees granted while attending that institutin. I hereby waive any rights r claims I may have whether present fully develped r nt against Lee Cunty r its agents r emplyees arising ut f r resulting frm the release, authrized r unauthrized, f the fllwing infrmatin received pursuant t r in cnnectin with the Cunty's handling, prcessing, investigatin, etc., f my applicatin fr emplyment with the Cunty. I UNDERSTAND that if hired, I will be placed n a 6-mnth prbatinary perid. I further understand that if in accrdance with the Flrida Statute 443.131(3)(a)(2), I am terminated fr unsatisfactry wrk perfrmance within 3 mnths, the emplyer's unemplyment accunt shall nt be charged fr any unemplyment benefits paid t me. I AGREE that if Lee Cunty emplys me, a future ptential emplyer may cntact the Cunty r its representatives cncerning my wrk recrd and my wrk perfrmance at the Cunty. I hereby cnsent t and authrize persns emplyed by the Cunty t divulge any and all infrmatin they cnsider relevant t any persn representing himself r herself t be an emplyer r ptential emplyer f mine with respect t my wrk recrd and/r perfrmance f my jb at Lee Cunty. I understand that all infrmatin prvided herein is public recrd and is subject t review upn request. I AGREE t submit t any apprpriate testing, including t determine the presence f alchl r illegal cntrlled substances in my bdy, under whatever plicies r prcedures Lee Cunty has in effect at the time testing is required. I AGREE t pre-emplyment testing if requested and understand that failure t meet any jb-related medical and/r health requirements fr the psitins may prevent emplyment by the Cunty. I UNDERSTAND that all emplyees wh d nt have a written emplyment cntract with a limited and specified duratin are emplyed at the will f the Cunty and that all ffers f emplyment are cntingent upn successful cmpletin f all backgrund investigatins; which may include, but are nt limited t, emplyer and nn-emplyer references and, where applicable, preemplyment testing. I UNDERSTAND that Lee Cunty will nt tlerate sexual and any ther frm f unlawful harassment. I understand that I have the affirmative bligatin t reprt incidents and participate in any investigatin as requested. I als understand that unlawful harassment is grunds fr disciplinary actin up t and including immediate dismissal. I UNDERSTAND that falsificatin f any infrmatin s given r ther infrmatin that, either singly r cumulatively, wuld tend t negatively impact the hiring decisin discvered as a result f any backgrund check r investigatin may be grunds fr nt hiring
an applicant r may subject me t immediate dismissal if emplyed. EOE/At-Will/Veteran's Preference I AGREE that if hired by Lee Cunty, upn terminatin f emplyment, I shall return all Cunty prperty. Signature Date PLEASE NOTE: Attachment f the supplemental questins and Veteran Preference dcumentatin, if applicable, are required. Please ask the receptinist fr the apprpriate supplemental questins frm. Incmplete applicatins will nt be prcessed.