thank you for your interest in a career with the lee county … · 2019-07-18 · 4. high school...

Thank you for your interest in a career with the Lee County Sheriff’s Office. The expected duration of the selection process is 90 days or more. If your application is denied, you MAY be eligible to reapply after a period of one (1) year.

CIVILIAN APPLICATION PACKET

Complete the packet in its entirety. If all required information is not completed when you turn in your application, you may be asked to reschedule your appointment to a later date, giving you time to gather the required information.

Documents: All documents submitted in person must be originals.

o Birth Certificate - Must be from Vital Statistics.

o High School Diploma - If you do not have the original, you will need to order sealed high school transcripts from the school you attended. If you attended high school in another country and have no college in the United States, your paperwork will need to be evaluated by Joseph Silny & Associates (www.jsilny.org).

o College Transcripts – Contact the college(s) you attended to order sealed college transcripts. When you receive them, DO NOT OPEN them.

o Marriage/Divorce Documents- Can be obtained from the Clerk of Court’s Office in the county where you were married or divorced in.

o If you have documents in a foreign language, they must be translated to English by a certified translator (not a notary public).

o If you are located out of the county or state, your application will be accepted by mail. Please include copies of the required documents and any sealed transcripts. The original documents will need to be presented when visiting our office in person during processing.

If something does not apply, please write N/A acknowledging that you have read the question and it does not apply to you.

Again, in order to process the application in a timely manner and enhance the efficiency of the hiring process, it is imperative that you provide accurate and complete information on the application.

Complete all paperwork in the application packet, then call Tari Jones at (239) 477-1233 to schedule an appointment to turn in your application. Appointments will be held in Human Resources at Lee County Sheriff’s Office, 14750 Six Mile Cypress Parkway, Fort Myers, FL 33912. Bring all original documents listed on page one (1) of the application (copies will be made) and all required testing results.

Sincerely,

Carmine D. Marceno, Jr., Sheriff

http://www.jsilny.org/

Carmine Marceno Sheriff

“Proud to Serve”

State of Florida

County of Lee

“The Lee County Sheriff’s Office is an Equal Opportunity Employer” 14750 Six Mile Cypress Parkway Fort Myers, Florida 33912-4406 (239) 477-1000

IMPORTANCE OF HONESTY STATEMENT

The Lee County Sheriff’s Office is seeking applicants who demonstrate certain characteristics. Honesty is the most important characteristic you must demonstrate. It is extremely important that you are completely honest in all of your answers. The importance of honesty as you complete paperwork and during all interviews cannot be overemphasized. Failure to respond to any question truthfully, whether orally or in writing, will result in disqualification. Many applicants have been disqualified for dishonesty. While filling out documents, you are cautioned to take your time, to be thorough, and to be specific in all your answers. If you have any doubt in your mind concerning a particular question or if you are unsure whether to include certain information, the answer is “Yes”; include it.

You may think that something you have done will disqualify you from further consideration; it may or may not. What will certainly disqualify you is lying or distorting the truth.

Applicant's interviews may be recorded.

Applicants should be aware that per Florida Administrative Code 11B-27.0011, titled “Moral Character” that falsifying an employment application may result in the suspension or revocation of your Florida law enforcement certification, thereby disqualifying you from employment as a law enforcement/correctional officer within the state of Florida.

I have read and understand the contents of this paper.

Applicant's Signature: X

Print Applicant’s Name: X

Date: X

Human Resources Signature:

Date:

Date Received: _________________ Office Use Only

LEE COUNTY SHERIFF’S OFFICE CIVILIAN POSITION - APPLICATION FORM

The Sheriff’s Office is an Equal Employment Opportunity Employer. We consider applicants for all positions without regard to race, color, national origin, sex, age, disability, marital status, religion or any other legally protected status.

This employment application shall become the property of the Sheriff's Office and the information received in the application process are public record, pursuant to Florida State Statute 119.071

NOTICE: Please provide originals of the following documents if applicable:

1. Valid Florida Driver’s License 2. Social Security Card 3. Birth Certificate (From Vital Statistics) (If from

another country, must be translated by a certified translator) 4. High School Diploma, Official High School

Transcripts in a Sealed Envelope, and/or G.E.D. (If from another country, must be translated by a certified translator and evaluated by Joseph Silny)

5. Proof of marriage(s), divorce(s), adoption, or legal name change) (If from another country, must be translated by a

certified translator) 6. Military discharge (s) and all DD-214’s 7. Selective Service Card 8. Official sealed college transcripts 9. Naturalization papers or Permanent Resident Card 10. United States Passport (We do not accept expired passports)

POSITION APPLYING FOR:

Corrections Clerk Community Service Aide

Communications Operator Other:

Are you willing to work the following:

Days: Yes No Nights: Yes No Weekends: Yes No Holidays: Yes No Evenings: Yes No

INSTRUCTIONS Application must be handwritten legibly in ink or typed by the applicant. All questions must be answered. If space provided is not sufficient for complete answers or if you wish to furnish additional information, attach sheets of the same size as this application and number answers to correspond with questions.

I understand that the submission of this application does not constitute acceptance of employment or appointment with the Lee County Sheriff's Office. Moreover, I understand the Lee County Sheriff's Office is under no obligation to sponsor me as a candidate for any training program.

PERSONAL HISTORY

1. Full Name (as it appears on your Social Security Card)

Last Name First Middle Suffix

2. Social Security Number:

- -

3. Date and Place of Birth:

Date of Birth City County State Country (If not USA)

CIVILIAN LEE COUNTY SHERIFF'S OFFICE APPLICATION PAGE 1

4. Aliases: List all other names you have used including circumstances and time periods you used them. (For example: maiden name, former name(s), alias(es), or nickname(s).

Name Circumstances Dates From MM/YY Dates To MM/YY

5. Are you a United States citizen? Yes No If naturalized, please provide:

Date Place Court Naturalization No.

6. Current Address, Phone Number and Email Address

Address:

City: County: State: Zip:

Home Phone: Cell Phone:

Email Address:

7. Alternate Address, Phone Number and Email Address

Address:



Email Address:

8. Marital Status: Married Divorced Single

9. Spouse’s Name, Current Address, Phone Number and Email Address

Name:

Address:



Email Address:

10. Most Recent Former Spouse Name, Address and Phone Number:

Name:

Address:



11. Children’s Names and Ages:

Name Age Address


12. Are you currently related to any person employed by the Lee County Sheriff’s Office? Yes No

Name Current Position Held Relationship

DRIVING HISTORY

13. Do you have a Florida driver’s license? Yes No

License Number Expiration Date Restrictions License CDL

14. Do you hold or have you ever held a driver’s license in another state? Yes No

License CDL State Name Used / License Number (if available) Approximate Date License Held

15. Have you ever been denied issuance of a driver’s license or have you ever had a license suspended or revoked? Yes No If yes, please provide complete details including why license was denied, suspended or revoked.


EDUCATION/TRAINING

16. Please complete all fields below regarding your education:

High School Name and Address

Dates Attended Month/Year

From To Years Completed Did You

Graduate? Type of Diploma

College/University Name and Address


From To

Credit Hours Earned

Qtr. Sem.

Did You Graduate?

Type of Diploma

Major: Minor:

Other Schools (Trade, Vocational, Business or Military) Name and Address


From To

Credit Hrs

Earned Area Of Study

Did You Graduate?

Type of Degree or Certificate

17. Are you now able to participate with or without accommodation in defensive tactics, firearms, physical training, operation of a motor vehicle, or otherwise perform the duties set forth in the job description of the position for which you applied? Yes No

18. This position may require a physical abilities test. If such a test is required, would you need special accommodations to perform the physical abilities test? Yes No

19. Explain what accommodation(s) you would need to perform these tasks or take the test/examination.


RESIDENCES

20. Provide ALL addresses for the last ten (10) years. Start with your current address and work backwards. If you cannot provide the exact address, please provide at the least the approximate years you lived at the residence, including the city, state and country other than the United States. List additional residences on a separate page.

Dates Month/Year

From To

Apt. #

Street Address

City

County

State / Country

(not U.S.)

Current


EMPLOYMENT HISTORY

21. Provide ALL past and current employers for the last ten (10) years. Start with your current employer and continue back in chronological order. Account for ALL dates for the last ten (10) years. Include all employers, periods of unemployment, or full-time schooling. Give complete addresses and phone numbers for each, even if the school/business is now closed. Complete all fields. If you do not want your CURRENT employer to be contacted, please check the “Do Not Contact” box, and they will not be contacted until after you have been made a contingent job offer.

Name & Address of Employer

Dates Worked Month/Year

From To Salary

Your Title/Position

Name of Supervisor Reason for Leaving

CU

RR

ENT

Name Address City, State, Zip Part Time

Area Code & Phone Full Time Do Not Contact

Name Address City, State, Zip Part Time Area Code & Phone Full Time









22. Have you ever been fired or dismissed from a job or had any disciplinary action taken against you from any employment or position you have held? Yes No

If yes, explain:

23. Have you ever been forced to resign from a job (or else be fired), or left a job by mutual agreement after alleged misconduct or unsatisfactory performance? Yes No

If yes, explain:

24. What other law enforcement agencies have you applied to?

Name of Agency State Application Date Application Status

25. Have you ever been a volunteer in any capacity for a law enforcement agency, i.e. Explorer, Auxiliary, Internship, or Community Volunteer? Yes No If yes, please provide details:

Name of Agency Year Position Held

MILITARY HISTORY

26. Have you ever served on active duty in the Armed Forces of the United States? Yes No

Branch of Service Highest Rank Service Number Duty Dates

From To

Type of Discharge: Honorable Dishonorable General Medical Honorable Condition Uncharacterized

27. Are you now or have you ever been a member of a reserve unit or the National Guard? Yes No

If yes, please provide details:

Branch of Service Name of Unit Location of Unit Attends Drills,

Meetings, or Camps


28. Have you ever been subject to a trial by court-martial (general, special, or summary)? Yes No

If yes, please provide details: Date Location of Court Charge/Offense Disposition/Punishment

29. Have you ever been subject to, or accepted, any non-judicial punishment (NJP) following allegations of misconduct, including: Article 15, Captain’s Mast, Office Hours, or any other form of NJP? Yes No

Date Location Offense Punishment

30. VETERANS’ PREFERENCE: Check the appropriate block if you are claiming veterans’ preference. Documentation substantiating your claim must be furnished at the time of application.

NOTE: Under Florida law, veterans’ preference in employment is not uniformly applicable to all positions in the Sheriff’s office; therefore, further information may be obtained from the Division of Veterans Affairs, P.O. Box 1437, St. Petersburg, Florida 33731.

31. Are you claiming veterans’ preference? Yes No

32. Have you claimed and been employed using veterans’ preference since October 1, 1987? Yes No

If “yes”, please give name of employer:

BUSINESS INTERESTS AND LICENSES

33. Do you currently own a business or have a partnership in a business? Yes No

If yes, please provide details:

Business 1 Business 2 Business 3

Name of Business:

Type of Business:

Website/URL:

Address:

Phone:

Email:

Business License Number:


ARREST HISTORY/COURT DATA

34. Have you ever received a ticket or been charged with a traffic violation (excluding parking tickets)? Yes No

Date City & Department Charge/Offense Disposition/Result

35. Have you ever been arrested, charged or received a notice or summons to appear for any criminal violation, regardless if the record was sealed or expunged? Yes No

If yes, provide details, including disposition paperwork for any arrests, which needs to be obtained from the Clerk of Courts in the County where you were arrested. Include your juvenile record and records of your arrest(s), which have been sealed or expunged, if any. F.S. 943.0585(4)(a) expunged criminal records shall be made available to criminal justice agencies when the subject of record is a candidate for employment with a criminal justice agency. An applicant whose record is expunged may NOT deny or fail to acknowledge the arrest and the charge covered by the expunged record.

Date City & Department Charge/Offense Disposition/Result

Details of arrest(s):

36. To your knowledge, has any member of your family ever been arrested for anything other than traffic violations? Yes No

Relative’s Name City & Department Charge/Offense Disposition/Result

37. Have you or your spouse ever been a plaintiff or defendant in a civil court action? Yes No

If yes, please provide details.

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

If yes, please provide details.


DRUG USE AND HISTORY

39. In the past ten (10) years, have you EVER possessed, used, bought, sold, delivered, made/grown, packaged/weighed what you knew, or believed to be, an illegal substance/drug including synthetic drugs? Yes No If you answered yes, please list all drugs and check ALL yes or no boxes.

Drug First Used

Last Used

# of Times Used

Bought Sold Delivered Made / Grown

Weighed/ Packaged

Yes No Yes No Yes No Yes No Yes No

40. In the past ten (10) years, have you EVER possessed, used, bought, sold, delivered, packaged/weighed what you knew, or believed to be, prescription drugs for non-medical purposes? Yes No If you answered yes, please list all drugs and check ALL yes or no boxes.

Drug First Used

Last Used

# of Times Used

Bought Sold Delivered Weighed/ Packaged

Yes No Yes No Yes No Yes No

Applicant Signature: Signature Date:


LEE COUNTY SHERIFF'S OFFICE APPLICANT REFERRAL FORM

Applicant's Name: Date:

How Did You Learn About This Vacancy?

Social Media: Facebook Instagram Twitter YouTube

Other:

Referred by LCSO member name:

Radio: T.V.: Job/Career Websites:

Walk-In

Called Human Resources for Job Openings

Web – Lee County Sheriff’s office internet web site

Criminal Justice Academy

College/University

High School/Technical School

Government Employment Agency:

Minority Group Organization:

Professional Publication/Magazine:

Job Fair Where:

Ethnic/National Origin

Black / African American White Hispanic / Latino Asian

Native Hawaiian / Pacific Islander American Indian / Alaska Native

Two or More Races:


Carmine Marceno Sheriff

“Proud to Serve”

State of Florida

County of Lee

“The Lee County Sheriff’s Office is an Equal Opportunity Employer” 14750 Six Mile Cypress Parkway Fort Myers, Florida 33912-4406 (239) 477-1000

COLLECTION AND USE OF SOCIAL SECURITY NUMBERS

Effective October 1, 2007, in accordance with FSS 119.071, the Lee County Sheriff’s Office may collect Social Security numbers for the following purposes:

Application Process – for the purpose of collecting information related to background investigations, to include fingerprints, NCIC/FCIC checks, Credit Bureau reports, verification of employment, local and state records checks, clarification for duplicate names, verification of Military Service.

Payroll – for reporting wages to Internal Revenue Service, Division of Retirement and New Hire Reporting.

Insurance – for medical, dental, flexible spending, life insurance policies, and long-term disability enrollment and reporting.

Medical Leave – for Worker’s Compensation reporting and medical purposes associated with Workers’ Compensation.

ACKNOWLEDGMENT: I, , do solemnly attest that I have read the above and understand the Waiver for Social Security Number Notice of as set forth above. (Applicant’s Signature) (Date) (Witness)

CERT Rev 01/19 19-11.009 F.A.C. EMPLOYERS: RETAIN THIS FORM IN THE EMPLOYEE’S PERSONNEL FILE. DO NOT SEND THIS FORM TO THE FRS, UNLESS REQUESTED.

This form is not an offer of employment or an enrollment form. If hired, a Retirement Choice kit may be mailed to your home with enrollment instructions. Florida Retirement System (FRS) - Certification Form

Name SSN (last 4 digits) Agency Name

Previous or Current FRS Employer

Complete Section I if you have never been a member of a State of Florida administered retirement plan. Complete Section II if you are a current or previous member AND Section III if not retired OR Section IV if retired.

I. I have never been a member of a State of Florida administered retirement plan.

SIGNATURE DATE

II. I was or currently am a member of the following State of Florida administered retirement plan (also complete Section III or IV)1 FRS Pension Plan (incl. DROP) FRS Investment Plan State University System Optional Retirement Program (SUSORP) State Community College System Optional Retirement Program (SCCSORP) Senior Management Service Optional Annuity Program (SMSOAP) Other

III. I am not retired from any State of Florida administered retirement plan. I understand that if it is later determined that I was a retiree and was reemployed during the first 6 calendar months after I retired or after my DROP termination date, or at any time during the 7th through the 12th months after I retired or

after my DROP termination date, I must repay all unauthorized benefits received (see Section IV for de-

tails), or, if in the Investment Plan, terminate my employment. My employer may also be liable for repaying any unauthorized benefits I received.

SIGNATURE DATE

Retiree Definition

You are considered retired if:

1. You have re-ceived any bene-fits under the FRS Pension Plan including DROP (does not include a with-drawal of em-ployee contribu-tions), or

2. You have taken any distribution (including a roll-over) from the FRS Investment Plan, or other state adminis-tered retirement programs offered by state universi-ties (SUSORP), state community colleges (SCCSORP), state govern-ment for senior managers (SMSOAP), or local govern-ments for senior managers.

IV. I am retired from a State of Florida administered retirement plan. My FRS Pension Plan retirement ef-fective date, DROP termination date, or date I received my first distribution from the FRS Investment Plan, SUSORP, SCCSORP, SMSOAP, or other plan was ______________________.

Effective July 1, 2017, retirees of the Investment Plan, SUSORP, SCCSORP, and SMSOAP are eligible for renewed membership in the Investment Plan, SUSORP, or SCCSORP. I understand that as a Pension Plan retiree: a. If I am employed by an FRS-covered employer in any type of position2 during the first 6 calendar

months after I retired or after my DROP termination date, my retirement and DROP status are

voided, all retirement and DROP benefits I received must be repaid,3 and I must reapply for retirement in order to receive future benefits.

b. If I am reemployed by an FRS-covered employer at any time during the 7th through the 12th months after I retired or after my DROP termination date, my monthly retirement benefit must be

suspended4 and any unauthorized benefits received must be repaid.3 My employer may also be liable for repaying any unauthorized benefits I received.

I understand that as an Investment Plan, SUSORP, SCCSORP, or SMSOAP retiree: a. If I am employed by an FRS-covered employer in any type of position2 during the first 6 calendar

months after I retired, I must repay3 any benefits received or terminate employment for an additional period to satisfy the 6 calendar month termination requirement.

b. If I am reemployed by an FRS-covered employer at any time during the 7th through the 12th months after my retirement, I will not be eligible for additional distributions until I terminate employment or complete 12 calendar months of retirement.4

SIGNATURE DATE

1If you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirement plan you were enrolled in when you

terminated FRS-covered employment. You may have a one-time 2nd Election to switch FRS retirement plans. Also, alternative retirement programs are available to certain employ-ees. Contact your employer for deadline and other information. 2Positions include OPS, temporary, seasonal, substitute teachers, adjunct professors, part-time, full-time, regularly established, etc. 3Florida law requires a return of all unauthorized Pension Plan benefit payments or Investment Plan distributions received by a member who has violated the FRS termination or

reemployment provisions. Similar provisions apply to unauthorized SUSORP, SCCSORP, or other state-administered plan distributions – contact that plan’s administrator for details. 4 There is one exception to the restrictions on reemployment limitations after retirement. If you are a retired law enforcement officer, you may only be reemployed as a school re-

source officer by an FRS-covered employer during the 7th through 12th months after your retirement date or after your DROP termination date and receive both your salary and re-tirement benefits.

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Dear Applicant,

Attached please find a waiver packet, which is part of the application process.

If you live outside of Lee County, Florida, or out of state, please print the following pages,

complete them, then arrange to sign before a Notary Public.

If you have an appointment to turn in your applications, these can be completed and notarized in

our office.

Please mail the originals with the application to:

Lee County Sheriff’s Office

Human Resources Department

14750 Six Mile Cypress Parkway

Fort Myers, FL 33912

Sincerely,

Human Resources Administrator

239-477-1360

CMT/

AUTHORITY FOR RELEASE OF INFORMATION, Background Investigation Waiver,

Civilian and Volunteer Positions

Carefully read this authorization to release information about you, then sign and date it in ink.

To: Concerned Person or

Authorized Representative of

any Organization, Institution

or Repository of Records

APPLICANT'S NAME:

DATE OF BIRTH:

LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER:

1. I Authorize any investigator of the Lee County Sheriff’s Office, 14750 Six Mile Cypress Parkway, Fort Myers, Florida 33912 , conducting my

background investigation, to obtain any information relating to my activities from individuals, education, academic achievement,

employment, personal information, work performance, residential management agents, criminal justice agencies, retail business

establishments, background investigations, polygraph exams, or other sources of information. I authorize the Lee County Sheriff’s

Office to obtain this information for making a determination of suitability or eligibility for a position of trust and confidence with the

Lee County Sheriff’s Office.

2. I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security

Number, and date of birth with information in SSA records and provide the results of the match) to the Lee County Sheriff’s Office

requesting my information for the purposes outlined above. I authorize SSA to provide explanatory information to agency requesting or

conducting my background investigation, in the event of a discrepancy.

3. I Understand that I may request a copy of such records as may be available to me under the law.

4. I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the Lee

County Sheriff’s Office investigator authorized above regardless of any previous agreement to the contrary.

5. I Understand that the information released by records custodians and sources of information is for official use by the Lee County

Sheriff’s Office for the purposes provided in the Lee County Sheriff’s Application For Employment and that it may be disclosed by Lee

County Sheriff’s Office only as authorized by law.

6. Photocopies of this authorization that show my signature are valid. This authorization is valid for one (1) year from the date signed or

upon the termination of my affiliation with the Lee County Sheriff’s Office, whichever occurs first.

7. I Authorize the National Records Center, St. Louis, Missouri, or other custodian of my military record to release information or copies

from my military personnel and related medical records, including a copy of my DD 214, Report of Separation, or other official

documents from the United States Military and discharge status or current active military status to: Lee County Sheriff’s Office,

Background Investigation Unit, Human Resources Division, 14750 Six Mile Cypress Parkway, Fort Myers, Florida 33912

8. Section 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former or current employees states:

An employer who discloses information about a former or current employee to a prospective employer of the former or current

employee upon request of the prospective employer or of the former or current employee, is immune from civil liability for such

disclosure of its consequences, unless it is shown by clear and convincing evidence that the information disclosed by the former or

current employer was knowingly false or violated any civil right of the former or current employee protected under chapter 760, Florida

Statutes. Pursuant to Sections 943.134(2)(a) and (4), F.S., Chapter 2001·94, Laws of Florida, disclosure of information is required

unless contrary to state or federal law. Civil penalties may be available for refusal to disclose non-privileged legally obtainable

information.

Applicant's Signature Date

Applicant's Address

AFFIDAVIT

STATE OF _____________, COUNTY OF ________________.

The foregoing instrument was acknowledged before me this date

By: who is personally known or who has produced identification. Type of ID:

Signature of Notary – State of Florida

Print, type or stamp commissioned name of Notary Public

CONDITIONAL OFFER OF APPOINTMENT

You are hereby presented a Conditional Offer of Appointment for the position/eligibility list with the Lee County

Sheriff's Office described below subject to, but not limited to, completion of the following and available funding:

Initial Polygraph Examination

Follow up Polygraph (if applicable)

Background Investigation

Psychological Evaluation

Oral Board Interview

Final Review at Executive Level

Drug Test

Medical Questionnaire

Medical Examination

Arrangements for these procedures will be scheduled through the Human Resources Division. Please notify us within

48 hours of appointment time if you must cancel.

Conditional Offer of Appointment is defined as follows: should you satisfactorily complete all testing and

examinations required by the Lee County Sheriff’s Office you will be placed in the Applicant Pool, which will

enable you to be eligible for an offer of appointment by the Sheriff for a period of one (1) year from date of

completion. We expect that, should such an offer be made and accepted, you will be available to begin work within

90 days. Placement in the aforementioned Applicant Pool does not assure appointment by the Sheriff and does not,

and is not intended to create any property right of contractual obligation of any kind. All positions, both filled and

vacant, are subject to budget authorization and fund availability. The Sheriff is the only person who has the

authority to make the final decision to appoint you as a member of the Lee County Sheriff’s Office.

Florida Statutes Section 943.16 provides that a trainee who attends an approved criminal justice training program at

the expense of the law enforcement agency remain in the agency for not less than two (2) years following the

completion of training or reimburse the agency for the cost of the training.

Applicant agrees that all information learned during the interview process shall be kept confidential and agrees to all

testing and examinations required by Lee County Sheriff’s Office.

Good luck during the application process. If you have any questions, call the Human Resources Division at

(239) 477-1323.

Cari Turner

Human Resources Administrator

I, (applicant):

verify that I have read and understand the conditions of my placement in the Applicant Pool for the following:

Position Applying For:

By my signature I accept this conditional offer of appointment.

Applicant’s Signature Date

STATE OF _______________ COUNTY OF _______________

The foregoing instrument was executed before me this day of , 20

by ,

who is personally known to me or has produced _________________________ as identification and who took an oath.

Signature of Notary

Notary Public State of at large

Name of Notary (Type or Print)

STATEMENT OF NON-MILITARY SERVICE

Date: __________________

I, __________________________________, have never served in the armed

forces of the United States of America or any foreign nation.

Signature: __________________________________

AFFIDAVIT

STATE OF __________________ COUNTY OF ____________

The forgoing instrument was acknowledged before me this date_______________.

By ________________________________________ who is personally known to me or

who has produced identification. Type of identification: __________________.

Signature of Notary Printed Name of Notary

Notary Seal: