supplemental law enforcement application i. …4. the agency authorizes both oc spray and an...

SUPPLEMENTAL LAW ENFORCEMENT APPLICATIONI. PERSONAL

Last Name:

First Name:

Middle Name:

Maiden Name:

Other Former Names:

Nicknames:

Social Security Number*:

E-mail Address:

Birthplace:

City State Country

Citizen of the United States? Yes No Naturalization Certificate #

*Applicant Notification of Social Security Number Collection and Usage:

In compliance with Florida Statute 119.071(5)(a)6, this document serves to notify you of the purpose for the collection and usage of your Social Security number. The Division of Investigative & Forensic

Services may use your Social Security number to conduct an employment background check in accor-dance with Chapter 110, F.S. and 11B-27.0022 F.A.C.

II. GENERAL INFORMATION AND INSTRUCTIONS

A background investigation will be required of all applicants of the Division of Investigative & Forensic Services. The information you provide in the State Employment Application and this supplemental application will be used to determine your eligibility and suitability for a law enforcement position with the agency.

Please complete this application accurately and neatly, without errors, omissions, or misleading information. Any misrepresentation, falsification, omission, or concealment of a material fact may be considered grounds for exclusion from employment with the Division of Investigative & Forensic Services.

Questions must be answered with a Yes, No, or None answer, and all questions must be answered. Applications that are incomplete and/or are not typed or printed legibly in ink will not be processed for consideration. If space is insufficient for complete answers, use additional sheets, the same size as the application, and number the answers to correspond with the questions.

III. WILLINGNESS QUESTIONNAIRE

This position with the Division of Investigative & Forensic Services may require the performance of the duties described below. Please respond to each of the following questions:

1. Are you willing to accept this position at the base salary stated in the position ☐ Yes ☐ Noannouncement?

2. Are you willing to work flexible hours, including nights and weekends? ☐ Yes ☐ No

3. If applicable to your position, are you willing to be placed in a scheduled “on- ☐ Yes ☐ Nocall” capacity where you will be required to respond to requests for service attimes other than during normal office hours?

4. Are you willing to travel and remain outside of your assigned duty station for ☐ Yes ☐ Noextended periods of time?

5. Are you capable and willing to perform the job duties and responsibilities as ☐ Yes ☐ Nothey are outlined in the position announcement?

6. Are you willing to work under the direction of a Field Training Officer (FTO) ☐ Yes ☐ Nothroughout your training period?

7. Are you willing to wear a long-sleeved shirt while on duty if you possess tattoos ☐ Yes ☐ Noon the upper and lower arm in accordance with agency policy?

8. Are you willing to perform special assignments as needed? ☐ Yes ☐ No

9. Are you willing to accept hazardous assignments consistent with the law ☐ Yes ☐ Noenforcement function to investigate criminal activity, or in times of a disasterresponse?

10. Are you willing to lift heavy objects and equipment as needed during the ☐ Yes ☐ Nocourse of an investigation, or as part of a disaster response?

11. Are you willing to work in adverse conditions during times of disaster ☐ Yes ☐ Noresponse, which may include having to sleep on cots in tents, not havingpower, or adequate restroom facilities?

12. Are you willing to be randomly tested for drug and alcohol use? ☐ Yes ☐ No

13. Are you willing to regularly dress for the office, or other related duties in ☐ Yes ☐ No acceptable business attire?

14. Are you willing to attend required training which may involve extended ☐ Yes ☐ No overnight travel?

15. If applicable to your position, are you willing to train in the use of the bureau’s ☐ Yes ☐ No specialized equipment, including a bobcat front-end loader, driving a dual- wheel, operating a vehicle while towing a trailer, driving the surveillance van, and driving the arson van.

16. Are you willing to place licensure deemed to be a conflict of interest in inactive ☐ Yes ☐ No status as a condition of employment? (e.g. Class D Security, Private Investigator, Insurance, etc.)

IV. ADDITIONAL SCREENING CRITERIA

1. Are you currently certified as a Law Enforcement Officer in Florida? ☐ Yes ☐ No

2. Is your law enforcement certification active? ☐ Yes ☐ No

3. Have you served as a law enforcement officer for the Federal Government or ☐ Yes ☐ No any other state for at least 2 years (statute says 1) and are eligible to comply with Chapter 943.13(9), F.S.?

4. Do you understand that successful completion of a background investigation, ☐ Yes ☐ No drug screen, psychological evaluation, medical evaluation, and polygraph examination are conditions of employment?

5. Do you have documented experience as a full-time certified law enforcement ☐ Yes ☐ No officer or Federal Law Enforcement Agent of at least three years?

6. Do you have prior law enforcement experience? ☐ Yes ☐ No

If yes: Years Months

7. Do you have prior investigative experience? ☐ Yes ☐ No


8. Do you have prior financial auditing experience? ☐ Yes ☐ No (e.g. Certified Fraud Examiner, etc.)


9. Do you have at least one-year prior experience in the insurance industry? ☐ Yes ☐ No (e.g. adjuster, investigator, examiner, etc.)


10. Do you have specific fire investigation experience? ☐ Yes ☐ No

If yes, provide details:

11. Are you a (select those that apply): ☐ Certified Fire Investigator (I.A.A.I.) ☐ Fire Investigator I ☐ Fire Investigator II (S.F.M.)

12. Select the highest level of education in which you have obtained a diploma/degree: ☐ High School ☐ Trade/Technical School ☐ AA / AS ☐ BA / BS ☐ Graduate Degree

13. Do you have Law Enforcement management or supervisory experience as a ☐ Yes ☐ No certified police officer or Federal Law Enforcement Agent?


14. Are you currently a State of Florida Law Enforcement Certified Instructor? ☐ Yes ☐ No


15. Have you ever been bonded? ☐ Yes ☐ No

Have you ever been refused in an attempt to be bonded? ☐ Yes ☐ No


16. If employed by the Division of Investigative & Forensic Services, will you ☐ Yes ☐ No receive, or do you anticipate receiving, any income other than your agency salary and agency additives?


17. List all languages in which you speak fluently:

18. List all languages in which you read fluently:

19. List all languages in which you write fluently:

V. CONDITIONS OF EMPLOYMENT NOTICE

Please place your initials next to each item to acknowledge that you are aware and understand and agree that, if employed: INITIALS

1. You may be required to attend training which may involve extended overnight travel?

2. You will be on probation for one year beginning with the date of employment as a certified Law Enforcement Officer with the Department of Financial Services.

3. Sworn members shall reside within the allowed distance from his or her assigned office. For Broward, Dade, Monroe and Palm Beach counties the allowed distance is within a 50-mile radius. For all other counties, the allowed distance is within a 35-mile radius. The Director may grant a waiver to this mileage requirement when it is in the best interest of the Division.

4. The agency authorizes both OC Spray and an Expandable Baton as a non-lethal weapon. You must show proof of training and exposure for the OC Spray and show proof of training for the Expandable Baton. If you cannot show these proofs, upon hire you will be trained in their use and receive exposure to the OC Spray.

I, , acknowledge that I have read the above statements and agree to each of the conditions in the event that I am hired by the FDFS.

Applicant Signature Date

VI. RESIDENCES1. Current Address:

Street Apt. No. City State

2. Current Telephone Numbers:

Home Work Cell

3. List all places of residence for the past 10 years: List chronologically all addresses, including residences while at school, in the military and family owned vacation homes. For college on campus residences, give college name, dormitory name and complete address. If military address cannot be shown as a street address, indicate military unit designation,locationbycityandstate,andifpostofficebox,thelocationofthepostoffice.

4. List all email, instant messenger, and social media accounts you have used or are presently using:

Dates (Mo / Yr) Street Address Apt. #

City County State

From:

To:From:

To:From:

To:From:

To:From:

To:From:

To:

VII. EMPLOYMENT HISTORY

May we contact your present employer? ☐ Yes ☐ No

If no, at what point do you want your present employer contacted?

List all employment during the past ten (10) years not already listed on the State of Florida Employment Application. Begin with the most recent. If you only had one employer during the last ten (10) years, also list the next most recent job. List all employment with any criminal justice agencies or fire agencies you have ever held, no matter how long ago. Include military service, internships, and volunteer work.

Name of Employer:

Address:

Supervisor’s Name: Supervisor’s Title:

Your Job Title: Supervisor’s Phone:

From: To:

Annual Starting Annual EndingSalary: Salary:

Your Name:(If different from application)

Duties and Responsibilities:

Reason(s) for Leaving:

Name of Employer:

Address:



From: To:





Name of Employer:

Address:



From: To:





Name of Employer:

Address:



From: To:



Name of Employer:

Address:



From: To:







From:

To:From:

To:From:

To:From:

To:From:

To:From:

To:

Have you ever applied to or been employed by a criminal justice agency and/or ☐ Yes ☐ No fire service agency – whether or not you were hired?

If yes, list agencies and approximate dates:

Provide the dates (month and year) and a brief explanation for any gaps in your employment history in the last five (5) years:

Dates (Mo / Yr) Explanation

1. Have you ever been dismissed, suspended, asked to resign, demoted, ☐ Yes ☐ No received a reprimand, or had any disciplinary action taken against you by any employer or supervisor?


2. Have you ever quit a job after being told you would be fired or left a job by ☐ Yes ☐ No mutual agreement following allegations of misconduct or unsatisfactory job performance?


3. Have you ever left a job for other reasons under unfavorable circumstances? ☐ Yes ☐ No


4. Have you ever had a formal complaint filed against you or been the subject of ☐ Yes ☐ No an internal investigation?


5. How many days have you been absent from work during the past twelve months, other than planned vacations?

6. Have you ever applied to carry a concealed weapon? ☐ Yes ☐ No


7. Have you ever been denied an application to carry a concealed weapon? ☐ Yes ☐ No


8. Have you ever applied for any county, state or federal license, excluding ☐ Yes ☐ No drivers’ license, hunting or fishing licenses?

License Type:

VIII. CONFLICT OF INTEREST

List all stocks, bonds securities or other direct or indirect ownership interest in any business entity currently regulated by the Department of Financial Services:

1. Have you or your spouse ever held a direct or indirect interest in a business ☐ Yes ☐ Nolicensed to sell insurance or regulated by the Department of Financial Services?

If yes, providedetails:

2. Have you or your spouse ever been employed by anyone regulated by the ☐ Yes ☐ NoDepartment of Financial Services?


3. Do you have any household members and/or relatives that work in the ☐ Yes ☐ Noinsurance industry or hold a license to interact with the insurance industry?


4. Do you own a business or are you a partner or corporate officer in any ☐ Yes ☐ Nobusiness or organization not listed above as a current or former employee?


5. Have you or any member of your immediate family ever experienced any loss ☐ Yes ☐ Noto real or personal property as a result of a fire or explosion?


☐ Yes ☐ No6. Have you or your spouse ever filed a claim for payment with an insurance


Company Nature of Business Nature of Interest

company for anything other than health-related medical services?

IX. ARREST HISTORY / COURT RECORDS

SEALED AND EXPUNGED RECORDSFlorida law (943.0585 & 943.059) requires law enforcement applicants to list any expunged or sealed re-cord(s), whether adult, juvenile, civilian or military.

1. Have you ever been arrested, charged or received a notice or summons to ☐ Yes ☐ No appear for any criminal violation?

If you answered “yes” to the above, give details in the following space, even if not formally charged, no courtappearance, not found guilty, or the matter was settled by payment of a fine or forfeiture of collateral. Include your juvenile and/or any expunged or sealed record(s).

2. Have you ever been placed on court probation? ☐ Yes ☐ No


3. Have you ever been required to appear before a juvenile court for an act that ☐ Yes ☐ No would have been a crime if committed as an adult?


4. Have you ever been charged or convicted of a misdemeanor crime of ☐ Yes ☐ No domestic violence?


5. Including duties which may have been performed while acting in a law ☐ Yes ☐ No enforcement capacity, have you ever sold, transported, delivered, used, or possessed ANY illegal drugs?


Date Police Agency Charge Court/Location Disposition

6. Have you ever, as a juvenile or adult, committed a crime – whether a felony ☐ Yes ☐ No or misdemeanor – that was either never detected or you were never caught or arrested?


7. Have you ever been charged, arrested or convicted of perjury or making a ☐ Yes ☐ No false statement, regardless of whether or not adjudication of guilt was withheld or a suspended sentence was issued?


8. Have you ever been a plaintiff, defendant, or witness in ANY court action, ☐ Yes ☐ No whether or not as a result of your employment?

Details, if yes: (give date, place, name of parties involved, nature of action including divorce proceedings and final disposition)

9. Have you ever been penalized by a government regulatory agency in ☐ Yes ☐ No conjunction with a license or permit?


10. Have you ever been detained by any law enforcement officer for investigative ☐ Yes ☐ No purposes or to your knowledge have you ever been the subject or a suspect in any criminal investigation?


11. Have you ever been fingerprinted for any reason (arrest, job application, ☐ Yes ☐ No military, etc.)?


X. MILITARY HISTORY

1. Are you registered for Selective Service? ☐ Yes ☐ No If yes, Selective Service #:

2. Have you ever served on active duty in the Armed Forces of the United ☐ Yes ☐ No Sates? (if yes, list below:)

3. Are you now or have you ever been a member of a reserve unit or the ☐ Yes ☐ No National Guard? (if yes, list below:)

4. Have you ever had any type of disciplinary action taken against you while in ☐ Yes ☐ No the military?


XI. DRIVING HISTORY

1. Do you have a valid Florida Drivers’ License? (if yes, list below:) ☐ Yes ☐ No

Dates (Mo=/=Yr) Branch Highest Rank Serial Number

From:

To:From:

To:From:

To:From:

ToFrom:

To:

Dates (Mo=/=Yr) Branch Location

From:

To:From:

To:From:

To:

License Number Expiration Date Restrictions

2. List all other states or countries where you have been granted a license to operate a motor vehicle:

3. Have you ever been denied issuance of a driver’s license or have you ever ☐ Yes ☐ No had a driver’s license suspended or revoked?


4. Have you ever had automobile insurance withdrawn or revoked or have you ☐ Yes ☐ No ever been refused automobile insurance?


5. Have you ever been involved in a motor vehicle crash, as either a driver or ☐ Yes ☐ No passenger, whether in a private vehicle or a work vehicle?


6. List all traffic citations or tickets, excluding parking violations, which you have received within the past seven (7) years regardless of state:

City/State or Country Name Type Date

Date Location Agency Violation Disposition

XII. MARITAL STATUS

1. Mark one (1) of the following boxes to show your current marital status. If you were previously married, provide the requested information concerning your former spouse(s). If you are engaged to be married or contemplating marriage in the near future, complete information must be provided regarding your future spouse. (Use the space provided for current spouse to record information about your current spouse and clearly indicate that such relationship is a future one.)

☐ Never Married ☐ Married ☐ Engaged ☐ Separated ☐ Legally Separated ☐ Divorced ☐ Widowed

Complete the following about your spouse/future spouse:

☐ Spouse ☐ Future Spouse

Full Name:

Occupation:

Date of Birth: Place of Birth: Race/Sex: SSN(Opt):

Other Names Used (maiden name, names by other marriages, etc.). Include dates:

Country of Citizenship: Date Married: Place Married (Include country if outside U.S.): State:

If divorced, date of Divorce: Court of Record, City (Country): State:

Address of Spouse (Street, City, Country): State: Zip Code:

Former Spouse(s): Complete the following about your former spouse(s):

Full Name:

Date of Birth:

XIII. FINANCIAL STATUS

1. Have you, your spouse, or a company controlled by you ever filed ☐ Yes ☐ No for bankruptcy?


2. Have you, your spouse, or a company controlled by you ever been ☐ Yes ☐ No declared bankrupt?


3. Have you, your spouse, or a company controlled by you had legal judgment ☐ Yes ☐ No rendered against you for a debt?


4. Have you ever been rejected when attempting to obtain insurance? ☐ Yes ☐ No


5. List all outstanding debts, including credit cards, charge accounts, mortgages, contracts, loans, etc.

Creditor / Company City / State Amount

Creditor / Company City / State Amount

7. Have you ever had any debts turned over to a collection agency? ☐ Yes ☐ No


8. Have you ever had any goods you purchased repossessed? ☐ Yes ☐ No


9. Have you ever had your wages garnished? ☐ Yes ☐ No


10. Have you, your spouse, or a company controlled by you ever been subject to ☐ Yes ☐ No a tax lien or other lien or had a judgement rendered against you for a debt?


6. List all outstanding debts, which are currently 30 days past due:

Drug How Taken Circumstances First Used Last Used Total Number of Times Used

2. Do you now, or have you ever abused or illegally obtained any ☐ Yes ☐ No prescription drug?


3. Have you ever sold, transported, delivered or used any illegal drugs? ☐ Yes ☐ No


4. Have you ever been a member, officer or employee of any organization, ☐ Yes ☐ No association or group which: 1) advocates the overthrow of our government, 2) advocates or approves of committing acts of force or violence to deny others their constitutional rights, or 3) wants to change our form of government by unconstitutional means? ***If yes, please answer questions 5-8 below***

5. Have you ever made a financial or other material contribution to any ☐ Yes ☐ No ☐ N/A organization of the type described in #4 above?

6. If yes, at the time of your membership, participation or contribution, ☐ Yes ☐ No ☐ N/A did you know of any unlawful aims of the organization?

7. Did you intend to promote any unlawful aims of the organization(s)? ☐ Yes ☐ No ☐ N/A

XIV. PERSONAL DECLARATIONS AND ASSOCIATIONS

1. Do you now, or have you ever used, experimented with, or possessed, any ☐ Yes ☐ No narcotic or dangerous drug such as, but not limited to, marijuana, hashish, cocaine, crack, LSD, amphetamines, heroin, GHB, Ecstasy or “RAVE club” or drugs of a similar nature? (If yes, complete information below for EACH drug used)

Organization Involvement / Activities

9. An investigation will be conducted of all information listed on this application. ☐ Yes ☐ NoBecause of this, are you aware of any information about yourself or anyperson with whom you are or have been closely associated (includingrelatives and roommates) which might tend to reflect unfavorably on yourreputation, morals, character, ability, or loyalty?

If yes, provide your version of the incident(s):

XV. EDUCATION

1. List all training courses, registrations, licenses, certifications, special skills, etc., not already listed on theState of Florida Employment Application:

8. List each organization and provide an explanation of your involvement ☐ Yes ☐ No ☐ N/Aand activities with each one.

3. Have you ever participated in a criminal justice intern program? ☐ Yes ☐ No

If yes:

XVI. HONORS, AWARDS AND LEADERSHIP POSITIONS

List any honors and/or awards you have received and list all leadership positions you have held during your schooling and career:

Dates (Mo=/=Yr) Agency Name Intermediate Supervisor Agency Address Phone Number

2. Have you ever been suspended, expelled or had any kind of ☐ Yes ☐ Nodisciplinary action taken against you during any course, college,university, technical school or training center?


1

Name: Occupation:

Address: City / Sate / Zip

Home Telephone: Work Telephone2

Name: Occupation:



Name: Occupation:



Name: Occupation:


Home Telephone: Work Telephone

XVII. REFERENCES

List four (4) individuals who have known you well for the past five (5) years, excluding relatives, co-workers and supervisors:

XVIII. AUTHORIZATION

I, ______________________________________, understand that any position offered will be contingent upon the results of a complete background investigation. I am also aware that withholding information or making false statements on this supplemental application will be the basis for exclusion from employment with the Department of Financial Services. I agree to these conditions and certify that all statements on this supplemental application are true. I further fully understand and consent to a polygraph examination concerning the veracity of my responses to the information requested on this application.

I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous or current employment, education, or any other information they might have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing such information to you.

I agree to conform to the rules and regulations of the department and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by the department at any time, at the department’s sole option, and without any prior notice to me.

Signature of Applicant Date (as usually written)

Print Legal Name

STATE OF __________________________________________

COUNTY OF _________________________________________

Before me personally appeared the said applicant, ________________________________________ who says that he/she executed the above instrument of his/her own free will and accord with full knowledge of the purpose therefore. Sworn and subscribed in my presence this ________________ day of ________________, ___________________. Affiant is personally known to me ___________ or has produced ________________ as identification.

Notary Public

My Commission Expires: ___________________________________________________________________

An incomplete application may result in your application not being processed.

The following documents are required and must be attached to this application. If any of the documents are not available, an explanation must be provided

1. Copy of high school diploma or equivalency.

2. Copy of college diploma, if applicable.

3. Sealed and Certified college transcripts, if applicable.

4. A copy of D214 military discharge documents, if applicable.

5. Copy of birth certificate.

6. Two copies of social security card

7. Two copies of driver’s license.

8. Copy of Florida Police Standards Certificate.

9. Copy of applicable Training certificates, licenses, and registrations earned or received.

10. One recent photograph (within past 6 months) no smaller than 3 ½ x 5 ½ and no larger than 5x7. This photograph should be in business attire. No uniforms.

11. If you encounter any situation in your personal or professional life which requires the updating of the information you have provided in either the state or supplemental application (change of address, job, etc.) you are required to provide the updated information, in written form, to the Bureau Personnel Manager.

**FAILURE TO FOLLOW DIRECTIONS WILL BE REGARDED AS AN ACT OF OMISSION THAT COULD JEOPARDIZE YOUR EMPLOYMENT OPPORTUNITIES WITH THIS AGENCY. **

SUPPORTING DOCUMENTATION If selected to continue in the assessment process, a full background investigation will be conducted. You will be required to provide supporting documentation regarding your age, citizenship, education, licenses, certifications, military service, job evaluations, letters of recommendation and any other documentation deemed necessary to verify any information you have provided during the application process.

Please review this page and provide the requested documentation.

supplemental law enforcement application i. …4. the agency authorizes both oc spray and an...

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