WALTON BOARD OF COUNTY COMMISSIONERS
HUMAN RESOURCES OFFICE
650 E NELSON AVENUE
DeFUNIAK SPRINGS, FL 32433
www.co.walton.fl.us
EMPLOYMENT APPLICATION FORM
Walton County 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, veterans’ status or any other legally protected status.
INSTRUCTIONS
Application must be typewritten or printed legibly in ink. All questions must be answered. Applications that are not complete will not be
considered. If space provided is not sufficient for complete answers or you wish to furnish additional information, attach sheets of the
same size as this application, and number answers to correspond with questions.
DATE: ______________________________________
POSITION (S) APPLYING FOR: _______________________________________________________________________________
LOCATION:_______________________________EXPECTED SALARY (HOURLY) OR SALARY RANGE: ________________
.
PERSONAL HISTORY
1.
Full Name:
________________________________________________________________________________________________
Last Name
First
Middle
________________________________________________________________________________________________
Residence Address
________________________________________________________________________________________________
City
County
State
Zip Code
(____)_____________________________________________________(____)_________________________________
Telephone Number (Home)
(Other)
_________________________________________________________________________________________________
Optional Phone Number
Email Address (op tional)
2.
Please provide name and address of person to be contacted in case of an emergency:
_________________________________________________________________________________________________
Name
__________________________________________________________________________________________________
Address
City
State
Zip Code
_(___)__________________________________________(
)_____________________________________________
Home Phone
Business Phone
1
3.
Social Security Number:_______________-__________-________________
4.
Are you now able to perform the duties set forth in the job description or task analysis related to the position for which you
have applied, with or without accommodation? Yes
No
5.
On what date are you available for work?____________________________________________
6.
Are you available to work full-time?  Yes  No - Part Time?  Yes  No - Temporary  Yes  No
The Immigration Reform and control Act of 1986 makes illegal for employers to knowingly hire any unauthorized or illegal alien. Therefore,
employers must verify the employment eligibility of all applicants hired. Applicants selected for hire must show an employer documentation to
establish United State Citizenship or that they are legal permanent resident alien or an alien authorized to be employed in the United States.
This documentation is required on the date of hire.
If you have any questions, regarding what documentation will be required to meet this federal requirement, please check with the Human
Resources Office.
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes
Are you able to provide legal authorization to be employed in the USA? Yes No
1.
2.
No
EDUCATION/TRAINING
High School
Name / Address
1.
2.
Years
Completed
College and/or University
Name / Address
3.
Did You
Graduate?
Credit Hours
Qtr. / Sem
Did You
Graduate?
Area of
Study
Did You
Graduate?
Type of Diploma
Type of
Degree
Job Related Training (Trade, Vocational, Business or Military):
Name / Address
4.
Credit
Hours
Describe any word processing or computer skills and list all software used:
______________________________________________________________________________________________________
5. State approximate number of words per minute: Typing ________ _
6.
Type of Degree
or Certification
Shorthand _________
Indicate any special skills you possess and equipment you can use which may be related to job applied for:
_____________________________________________________________________________________________________________
2
EMPLOYMENT HISTORY
1. List chronologically all employment beginning with present employment, including summer and part-time employment while attending
school. All time must be accounted for. If unemployed for a period, set forth dates of unemployment.
Name & Address of
Employer
Dates
Employed
Performed
Duties
Salary
Title
or
Position
Name
of
Supervisor
Reason
for
Leaving
From - To
Name
Address
City
State
Zip
Area Code & Phone No.
___Full
___Part-Time
Name
Address
City State
Zip
Area Code & Phone No.
___Full
___Part-Time
Name
Address
City
State
Zip
Area Code & Phone No.
___Full
___Part-Time
Name
Address
City
State
Zip
Area Code & Phone No.
___Full
___Part-Time
Name
Address
City
State
Zip
Area Code & Phone No.
___Full
___Part-Time
2.
Have you ever been dismissed or asked to resign or had any disciplinary action taken against you from any employment or
position you have held? ____ Yes ____No
3.
Have you resigned, or left a job by mutual agreement following allegations of misconduct or unsatisfactory job performance?
____Yes
____No
4.
May we contact your present employer? _____Yes
______No
DRIVING HISTORY
1.
Are you a licensed Florida automobile operator?
____ Yes ____ No
License No.: ____________________________ License Class: _______ Date of Expiration: _________________
2.
Do you hold or have you ever held an operator or CDL license in another state? ____ Yes ____No
If yes, please provide state(s), name used and approximate dates license(s) was/were held.
3
State____
ARREST HISTORY/COURT DATA
1.
Have you ever been convicted of, or pled guilty or no contest to a crime; had adjudication withheld for a criminal offense;
entered a pre-trail intervention program, or been placed on court-ordered probation? This is not necessarily a disqualifier
____Yes (if yes, please explain and include dates and locations)
2.
____No
Have you had any criminal record/or records sealed or expunged? _____Yes
____No
____________________________________________________________________________________________________________
*Note: If you do not understand this question, you must ask for clarification
ORGANIZATION / MEMBERSHIP
List all job related professional, trade, business activities and offices held.
Name
City & State
Present Position
(List positions held & describe activity)
PERSONAL REFERENCES & ACQUAINTANCES
Personal References: Give three (3) references (not relatives, former or present employers, fellow employees, or school teachers) who are
responsible adults of reputable standing in their communities, such as property owners, business or professional men or women, who have
known you well for the past three (3) years. If retired, give former occupation.
Complete Name:
___________________________________
(Last, First, Middle)
Occupation:
Complete Name:
____________________________________________________
(Last, First, Middle)
Occupation:
Complete Name:
_____________________________________________________
(Last, First, Middle)
Occupation:
Home Address: ________________________________________________________
City & State: ___________________________________________________________
Home Phone: (
) _______________________________________
Business Address: __________________________________________
City & State: _______________________________________________
Business Phone: (
) _____________________________________
Years Acquainted: __________________________________________
Home Address: ________________________________________________________
City & State: ___________________________________________________________
Home Phone: (
) _______________________________________
Business Address: __________________________________________
City & State: _______________________________________________
Business Phone: (
) _____________________________________
Years Acquainted: __________________________________________
Home Address: ________________________________________________________
City & State: ___________________________________________________________
Home Phone: (
) _______________________________________
Business Address: __________________________________________
City & State: _______________________________________________
Business Phone: (
) _____________________________________
Years Acquainted: __________________________________________
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AUTHORITY FOR RELEASE OF INFORMATION
TO:
Concerned Person or
Authorized Representative of
Any Organization, Institution
or Repository of Records
APPLICANT’S NAME: ____________________________________________
SOCIAL SECURITY NO: _________________________________________
I respectfully request and authorize you to furnish the Walton County Human Resource Office any and all information that you may have
concerning my work record, school record, military record and reputation. Please include any and all reports including all information of
a confidential or privileged nature, and photo stats of same, if requested. This information is to be used to assist in determining my
qualifications and fitness for the position I am seeking with Walton County.
This shall authorize the procurement of a consumer report by the County as part of the per-employment background investigation. If
hired, this authorizes the County to procure consumer reports at any time during my employment period.
I hereby release you, your organization or others from any liability or damage, which may result from furnishing the information
requested above.
_________________________________________________________________
Applicant’s Signature
________________________
Date
_________________________________________________________________
Address
_________________________________________________________________
City
State
Zip Code
AFFIDAVIT
STATE OF FLORIDA
COUNTY OF ______________________
Subscribed and sworn to (or affirmed) before me on _________________________________________ (date) by
_____________________________________________ (name of affiant). He/She is personally known to me or
has presented _______________________________________________ (type of identification) as identification.
(SEAL)
Signature: _______________________________________
Name: ___________________________________________
Title: _________NOTARY PUBLIC___________________
Commission No.:________________Expires: ___________
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Applicant’s Statement
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment
decision.
This application for employment shall be considered active for a period of time not to exceed (2) years. Any applicant wishing to be
considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
I hereby understand and acknowledge that any employment relationship with this organized is of an “at will” nature, which means that the
Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further
understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is
specifically acknowledged in writing by an authorized representative of the County. I further understand and acknowledge that, if hired,
my employment will be for no definite duration.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may
result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
___________________________________________________
Signature of Applicant
________________________
Date
You may mail, fax or email your application to:
Walton Board of County Commissioners
Human Resources Office
650 East Nelson Avenue
DeFuniak Springs, Florida 32433
Telephone: (850) 892-8586
Facsimile: (850) 892-8590
We encourage you to log onto our webpage at www.co.walton.fl.us for future vacancy announcements.
Revised 02/16/2012
Revised 05/02/2012
6
ADDENDUM
Date: ____________________________
Full Name: ________________________________________________________________________________________
First
Middle
Last\
** Please check all equipment with which you consider yourself experienced. Be sure to
include length of time.
SECTION I
LIGHT DUTY EQUIPMENT
Chain Saw
Limb Trimmer
Weed Eater/Edger
Push Mower
Tamper
Power Tools
LENGTH OF TIME
__________
__________
__________
__________
__________
__________
years
years
years
years
years
years
LENGTH OF TIME
__________
__________
__________
__________
__________
__________
months
months
months
months
months
months
SECTION II
MEDIUM DUTY EQUIPMENT
Farm Tractor/Attachments
Power Broom
Dump Truck, 6 yards and less
Ditch Witch
Riding Lawn Mower
Power Auger
Hay Blower
Hydro Seeder
LENGTH OF TIME
__________
__________
__________
__________
__________
__________
__________
__________
years
years
years
years
years
years
years
years
LENGTH OF TIME
__________
__________
__________
__________
__________
__________
__________
__________
months
months
months
months
months
months
months
months
SECTION III
HEAVY DUTY EQUIPMENT
Tandem Axle Roll-off Truck
Dozier (Size) _______________
Rubber Tire Loader (Bucket Size) ___
Track Hoe Excavator
Rubber Tire Excavator
Grader (Blade Size) __________
Steel Wheel Roller
Stump Grinder
Bucket Truck
Tandem Axle Dump
Tri-Axle Dump
Lo-Boy Truck and Drop-Deck Trailer
Paver
Paver Distributor
Backhoe Loader
Fork Lift
Crane (Weight Class)
Steel Wheel Compactor
Scraper Pan
Side-Mount Mower/Trimmer
Tractor with Bush Hog/Bat Wing
Tractor with Bionic Blade
Raco Tiller
Chipper
LENGTH OF TIME
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
years
LENGTH OF TIME
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
months
Do you currently hold a valid CDL License? _________ License# ________________________ License Class ______
7
8
Removal Document
WALTON COUNTY BOARD OF COUNTY COMMISSIONERS
Human Resources Office
650 E Nelson Avenue
DEFUNIAK SPRINGS, FL 32433
(850) 892-8586
Dear Applicant:
In order for the County to comply with Equal Employment Opportunity and Affirmative Action regulations, we are required to compile
summary data on the sex, ethnicity, and age of all applicants. The information solicited is collected for the sole purpose of providing data
to be used for statistical analysis; therefore, you should not identify yourself on this form. It should also be clearly understood that you
have the option of supplying or not supplying the information requested. This information, if provided, will neither enhance nor detract
from your opportunity for employment with the County. The information provided on this form will not be made available to those
making employment decisions.
Ethnic Background: please check appropriate box.
□
□
□
□
□
□
American Indian/ Alaskan Native
Asian/ Pacific Islander
Black
Hispanic
White
Other
Sex: ______Male ______Female
Date of Application: _______________
DOB: ____/ ____/ ____.
____________________________________________________________________________________________________________
Walton County is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, national origin,
sex, age, disability, marital status, religion, veterans’ status or any other legally protected status.
9
Removal Document
WALTON COUNTY BOARD OF COUNTY COMMISSIONERS
Human Resources Office
650 E Nelson Avenue
DEFUNIAK SPRINGS, FL 32433
(850) 892-8586
INVESTIGATIVE REPORT DISCLOSURE STATEMENT
By this document, Walton County discloses to you that a consumer report, including an investigative consumer
report containing information as to your character, general reputation, personal characteristics, and mode of
living, may be obtained for employment purposes as part of the pre-employment background investigation and,
if hired, at any time during your employment. Should an investigative consumer report be requested, you will
have the right to demand a complete and accurate disclosure of the nature and scope of the investigation
requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to
signify receipt of the foregoing disclosure.
________________________________________
Name of Applicant
________________________________________
Signature of Applicant
________________________________________
Signature of Human Resources Representative
________________________________________
Date
10
Removal Document
WALTON COUNTY BOARD OF COUNTY COMMISSIONERS
Human Resources Office
650 E. Nelson Ave
DEFUNIAK SPRINGS, FL 32433
(850) 892-8586
YOUR NAME: ____________________________________________________________________DATE: ___________________
POSITION TITLE FOR WHICH YOU ARE APPLYING: ___________________________________________________________
VETERANS’ PREFERENCE INFORMATION:
Completion of the Veterans’ Preference section below is made on a voluntary basis and kept confidential in accordance with the
Americans with Disabilities Act. Veterans’ Preference is only available to Florida residents. Listed below are the five Veterans’
Preference categories.
1.
2.
3.
4.
5.
A veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement, or pension
under public laws administered by the US Department of Veterans’ Affairs and the Department of Defense, or
The spouse of a veteran who cannot qualify for employment because of a total and permanent service-connected disability,
or the spouse of a veteran missing in action, captured, or forcibly detained by a foreign power, or
A veteran of any war who has served on active duty for one day or more during a wartime period, excluding active duty for
training, and who was discharged under honorable conditions from the Armed Forces of the United States of America, or
The un-remarried widow or widower of a veteran who died of a service-connected disability.
Any veteran who has served in a qualifying campaign or expedition for which a campaign badge has been authorized. Any
Armed Forces Expeditionary Medal qualifies for veterans’ preference. The Global War on Terrorism Expeditionary Medal
also qualifies for veterans’ preference.
Persons in categories 1-5 shall furnish a DD214 or comparable document. Required documentation shall be furnished at time of
application, or prior to the closing date of the vacancy announcement. Applicants claiming category one (1) shall furnish a document from
the Department of Veteran Affairs (DVA) certifying that the veteran has a service-connected disability. Category two (2) shall furnish I.D.
card or document from DVA certifying that the veteran is totally and permanently disabled; spouses shall also furnish evidence of
marriage to the veteran and a statement that the spouse is still married to the veteran; spouse shall submit proof that that disabled veteran
cannot qualify for employment because of the service-connected disability. Category four (4) shall furnish documents from the DVA
certifying the service-connected death of the veteran, also evidence of marriage and a statement that the spouse is not remarried. Wartime
periods are defined in §1.01, F.S. (See Reverse this document) Veterans’ preference in appointment shall be given to those persons in
categories one (1) and two (2) and then those in categories three (3), four (4), and five (5).
If an applicant claiming Veterans’ Preference for a vacant position is not selected, he/she may file a complaint with the Florida
Department of Veterans’ Affairs 11351 Ulnerton Road, Largo, and Florida 33778-1630. A complaint must be filed within 21 days of the
applicant receiving notice of the hiring decision made by the employing agency or 3 months of the date the application is filed with the
employer if no notice is given.
VETERANS’ PREFERENCE CLAIM:
I AM NOW AWARE OF THE VETERANS’ PREFERENCE INFORMATION ABOVE.
□ YES
□ NO
□ YES
□ NO
IF ELIGIBLE, WHICH VETERANS’ PREFERECE CATEGORY ARE YOU CLAIMING?
(Please indicate number from Veterans’ Preference Information section above.)
ARE YOU A RESIDENT OF THE STATE OF FLORIDA?
11
Removal Document
DEPARTMENT OF VETERANS’ AFFAIRS
TECHNICAL BULLETIN 4: WARTIME SERVICE GUIDELINES
Chapter 295.07, Florida Statutes, as amended by Chapter 92-80, laws of Florida, effective April 8, 1992, defines the terms “veteran” and
the periods of wartime service as follows:
“1.01 Definitions.
(14)
The term “veteran” means a person who served in the active military, naval, or air service and who was discharged
or released there from under honorable conditions only or who later received an upgraded discharge under honorable
conditions, notwithstanding any action by the United States Department of Veterans Affairs on individuals discharged
or released with other than honorable discharges. To receive benefits as a wartime veteran, a veteran must have served
during one of the following periods of wartime service:
(a)
Spanish-American War: April 21, 1898 to July 4, 1902, and including the Philippine Insurrection and the Boxer
Rebellion.
(b)
Mexican Border Period: May 9, 1916 to April 5, 1917, in the case of a veteran who during such period served in
Mexico, on the borders thereof, or in the waters adjacent thereto.
(c)
World War I: April 6, 1917 to November 11, 1918; extended to April 1, 1920 for those veterans who served in
Russia; also extended through July 1, 1921, for those veterans who served after November 11, 1918, and before July
2, 1921, provided such veterans had at least one day of service between April 5, 1917, and November 12, 1918.
(d)
World War II: December 7, 1941 to December 31, 1946
(e)
Korean Conflict: June 27, 1950 to January 31, 1955
(f)
Vietnam Era: February 28, 1961 to May 7, 1975
(g)
Persian Gulf War: August 2, 1990 to January 2, 1992
(h)
Operation Enduring Freedom: October 7, 2001 – TBD
(i)
Operation Iraq Freedom: March 19, 2003 – TBD
The applicant must have served at least one day during a wartime period to be eligible for veterans’ preference.
Active duty for training does not qualify for veterans’ preference.
Chapter 98-33, Laws of Florida, states veterans’ preference is only available to Florida residents.
Revised 7/23/2008
12
Removal Document
WALTON COUNTY BOARD OF COUNTY COMMISSIONERS
Human Resources Office
650 E. Nelson Ave
DEFUNIAK SPRINGS, FL 32433
(850) 892-8586
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT
By this document, Walton County discloses to you that we are asking you to provide your social security
number (SSN). The decision to provide your SSN is at your option and if you provide your SSN, Walton
County BCC will use it for purposes of identification and may share the information with other agencies for the
same purpose. Walton County’s request for your SSN is authorized by state law. The decision to provide your
SSN is at your option, but, failure to provide your SSN may result in a delay in processing your application or
request.
Walton County BCC Human Resources Department
____________________________________
Name of Applicant
________________________________________
Signature of Applicant
________________________________________
Date
1/14/08
Revised 02/16/12
13