St. Augustine Beach Police Department
APPLICATION FOR EMPLOYMENT
2300 A1A South
St. Augustine Beach, Florida 32080
(904) 471-3600 Office
(904) 471-0737 Fax
APPLICANT NAME:
EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
Revised 01/27/2017
APPLICATION INSTRUCTIONS & REQUIREMENTS
This application must be either typed or printed in legible form. Applications which are not legible or
complete will be considered unacceptable and given no further consideration. All required documents must
accompany your completed, notarized application. Return the application and attachments to the St. Augustine
Beach Police Department, 2300 A1A South, St. Augustine Beach, FL 32080.
Begining October 1, 2016 all applicant's (sworn law enforcement positions only), in addition to any other
listed requirements, must have a minimum of 60 college credit hours from a college or other institution
accredited by the Southern Association of Colleges and Schools, Commission on Colleges or three (3)
continuous years of law enforcement/police experience or two (2) continuous years of active military service
with an honorable discharge.
Answer all questions. If they do not apply, place a N/A by the number.
1.
Provide names, complete mailing addresses including zip codes, and telephone numbers of former
employers, date of employment (to include month and year) and your job title.
2.
References should be longtime friends but not neighbors, supervisors or co-workers.
Please attach copies of the following documents to your completed application.

Birth Certificate

Driver’s License and Social Security Card

Florida High School Diploma or State Equivalency (GED). If you have an equivalency diploma
from ANY state other than, Florida you MUST provide a copy of your transcript.

Police Standards Certification, if applying for a Law Enforcement Position. If you are an out of state
officer, Military Police Officer or Federal Officer who has requested exemptions from Florida Basic
Recruit Training Programs, you MUST provide an equivalency of training.(CJSTC 76 + CJSTC 76A
Forms).

Basic Recruit Exam scores, if certification date is after June 30, 1993.

BAT test results, if attended academy after January 1, 2002. This includes the successful completion
of the SABPD PAT and swim test refresher.

Form DD214, if you are former military (see the listed military requirements). Also complete
“Request Pertaining to Military Records” form (page 19 of this application).

College Degree (see the listed college requirements and sealed transcript(s) must be supplied).

Documents showing legal changes of name from birth to present (example: marriage
license, divorce papers, adoption papers, etc.).

Appropriate “Application Disqualifiers” form – Sworn or Civilian (page 3 or 4, whichever
applies – sworn or civilian).
Contact the St. Augustine Beach Police Department at (904) 471-3600 regarding any change in this
application such as: residency, phone number of employment (permanent or part-time), name changes, military
status, etc.
Please note that a thorough background investigation, including information as to your character, general
reputation, personal characteristics and mode of living will be part of your processing. This information is solely
for the purpose of evaluating your qualifications for employment within this agency. The submission of this
application carries the understanding that you are authorizing this agency to contact any and all available sources
for the purpose of obtaining information as to your qualifications.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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St. Augustine Beach Police Department
Chief Robert Hardwick
APPLICATION DISQUALIFIERS
Tattoos - (Sworn Applicants)
Effective October 1, 2013, no person will be considered for employment if they have tattoos or body art that is exposed and
visible on the body while wearing short sleeves and shorts, such as but not limited to; on the lower arms, elbows, hands,
neck, head, calves, knees or lower thighs .
Criminal Convictions
A person who after July 1, 1981 has pled guilty or nolo contendere to or has been found guilty of a felony is not eligible for
appointment as a law enforcement officer, regardless of whether adjudication was withheld or sentence was suspended. FSS
943.13(4)
A person who after July 1, 1981 has pled guilty or nolo contendere to or has been found guilty of a misdemeanor involving
perjury or false statement is not eligible for appointment as a law enforcement officer, regardless of whether adjudication
was withheld or sentence was suspended. Note: any such person who had been found guilty or entered a plea prior to
December 1, 1985 and has had the record sealed or expunged is considered eligible for appointment by operation of the
statute, FSS 943.13(4). However, the applicant may be deemed ineligible upon further review of the applicant’s application
and the case.
Any applicant who has pled guilty or nolo contendere or been found guilty of the criminal offense of DUI within the last five
years while employed as a law enforcement officer, corrections officer, or military policeman is disqualified for employment
as a sworn member of this agency.
Any domestic violence convictions.
Driving
3 moving violations within the past 24 months.
Three (3) moving violations within the past 24 months.Any driver’s license suspensions / revocations in the last five
(5) years.(Suspensions for financial responsibility and failure to pay will be evaluated on a case-by-case basis.)
Unlawful Drug Activity
Any illegal drug use in the last 5 years prior to the date of application.
Any sale or delivery of any illegal drug / controlled substance, after the age of 17 (up to the 18th birthday.)
PAT & Swim Test (Sworn Applicants)
Required to complete the Annual SABPD Physical Abilities Test (PAT) and a periodic swim test refresher administered by St.
Johns County Marine Rescue. The Annual SABPD PAT is a basic physical assessment for all sworn members to ensure
compliance with the job requirements, recognize individual abilities and encourage a healthy lifestyle in the demanding field
of law enforcement. The periodic swim test refresher is a basic assessment for all sworn members to ensure compliance with
job requirements, recognize individual abilities and satisfy the demands associated with public safety in a beach community.
The successful passing of the PAT and swim test refresher will be required for all applicants actively processing for a sworn
law enforcement position with the SABPD after June 1, 2016.
Tobacco/Nicotine
The Tobacco/Nicotine use policy of the St. Augustine Beach Police Department (SABPD) is that all members shall not use
tobacco in their assigned vehicle, in public while in uniform or on any official SABPD business. Additionally, members will
not use tobacco, whether on or off-duty around any other on-duty SABPD member, City of St. Augustine Beach member or
in or around the SABPD building or any other government building anytime.
Military
Any discharge other than honorable or uncharacterized from any of the Armed Forces of the United States.
Other
If the applicant has been notified of deficiencies regarding the application and has not complied with request.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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Statement of Understanding
I,
, have read the above-listed disqualifiers as a part of the application process
with the St. Augustine Beach Police Department. I acknowledge that I am qualified to apply with the St. Augustine Beach
Police Department. Further, should one of these disqualifiers be discovered during the background investigation / selection
process, I understand that my application process will be terminated immediately. I further understand that my arrest
history will be reviewed and that the facts and circumstances of any arrest will be considered in determining whether I can
be employed as a sworn law enforcement officer.
_____________________________________
Signature of Applicant
_______________________
Date
NOTICE TO PERSONS REGARDING
COLLECTION OF SOCIAL SECURITY NUMBERS
The St. Augustine Beach Police Department collects the Social Security number of persons who:
1.
Apply for employment or are employed by this agency;
2.
Apply to qualify with a firearm pursuant to HR 218, the Nationwide Concealed Carry Act for Retired
Law Enforcement Officers;
3.
Apply to volunteer with this agency; and
4.
Are arrested by this agency.
Social Security numbers are collected by the St. Augustine Beach Police Department for the following
reasons, which are imperative for the performance of duties and responsibilities prescribed by law:
1.
To verify identity;
2.
To conduct employment background investigations;
3.
To properly pay an employee and to credit the withholding of income taxes, social security and Medicare
taxes, retirement and other items pursuant to State and Federal law; and
4.
To determine criminal history and to verify wants, warrants, and/or capiases.
PUBLIC RECORD
Applications for employment with a government agency are, except for “Personal Information,” a matter of public
record and are not subject to confidentiality.
Examination questions and answers are not public record; but the applicant has the right to review his/her
application and any completed exams that he/she has taken.
The St. Augustine Beach Police Department determination of the qualifications of an applicant for employment is
final.
No employee of the St. Augustine Beach Police Department is required to render an opinion or explanation
beyond what is contained in the public record.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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St. Augustine Beach Police Department
Chief Robert Hardwick
AFFIRMATIVE ACTION
FOR STATISTICAL USE ONLY
Dear Applicant:
It is the policy of this agency that no member (sworn, non-sworn or volunteer) of, or applicant to, the SABPD is
to be discriminated against on the basis of race, color, sex, sexual orientation, political affiliation, religion,
national origin, age, handicap or marital status.
All members are entitled to work in an environment free of offensive or disparaging conduct. Therefore, it is the
policy of this agency to strictly prohibit any conduct by its members which defames or demeans the nationality,
culture, color, creed, belief, sex or sexual orientation of any person.
The information required in this portion is requested only so that we meet our Equal Opportunity / Affirmative
action obligations. Your completion of this form is purely voluntary and will not in any way affect your
consideration for employment. This insert will be separated from your application and will be separately
maintained. Thank you for your assistance.
1. Sex:
2. Ethnicity
Male
Female
Hispanic
Latino
Neither
If you checked “neither” for ethnicity, please identify your race by checking one of the boxes below.
3. Race
White
Black or African American
Native Hawaiian or other Pacific Islander
Asian
American Indian or Alaska Native
Two or more races
4. Handicapped
Yes
No
Yes
No
5. Veteran
6. Age
7. How were you referred to our agency?
Media (specify)
Career/Job Fair
Walk In
Agency (specify)
Employee (whom)
Internet
Other
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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St. Augustine Beach Police Department
Chief Robert Hardwick
PERSONAL DATA
Email Address: _____________________________
Date:
1. Position Sought:
Sworn
Non-Sworn
Volunteer
I understand that misrepresentation is sufficient cause for rejection of employment or dismissal.
Signature ___________________________________________ Date ______________________
2. Social Security:
3. Name:
(Last, First, Middle)
4. Other: List all other names you have used including circumstances and time periods you used them.
(For example: maiden name, former name(s), alias(s), or nickname(s).
Name
Circumstances
Dates From
(Mo/Year)
Dates To
(Mo/Year)
5. Residence Address:
(Street)
(Mailing Address)
(City, State, Zip Code)
(Area Code and Phone Number)
6. Date of Birth:
7. U. S. Citizen:
8.
/
/
(Mo.) (Day) (Year)
Yes
(Cell Number)
Place of Birth:
(City and State)
No
Naturalized?
Yes
No
(If yes, provide the certificate number of your naturalization papers)
Do you have any relatives working for the City of St. Augustine Beach?
If yes, Name:
Yes
No
Relationship:
9. Have you ever worked for or applied to the St. Augustine Beach Police Department before?
Yes
No
If yes, please give the year and position applied for:
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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10. Have you ever applied to any other law enforcement agency?
If yes, list name of agency and date of application:
Yes
No
* If you apply to any other law enforcement agency after having turned in this application, please notify this agency
11. Are you now on any eligibility lists?
If yes, list the name(s) of the agency:
Yes
No
12. Have you had any law enforcement training by any local, state or federal agency?
Did you receive a certificate for this training?
Yes
No If yes, the date?
In what state?
Type of certificate:
Yes
No
13. Has your law enforcement certificate ever been suspended, revoked, relinquished or subject to
discipline or investigation by the CJSTC?
Yes
No If yes, please explain:
ARREST HISTORY / COURT DATA
14. Have you ever been convicted of a felony or misdemeanor?
If yes, please explain (list name of agency and date):
Yes
No
15. Have you ever been arrested, received a notice or summons to appear, charged, convicted, pled nolo
contendere or pled guilty to any criminal violation, regardless if the record was sealed or expunged?
Yes
No If yes, please explain (list name of agency and date) :
16. Have you ever been detained, questioned, interviewed or in any way been contacted by a law
enforcement agency for any reason (including investigative purposes)?
Yes
No If yes, please
explain (list name of agency and date):
17.
Have you ever been a respondent in an injunction for protection, domestic violence injunction or
a restraining order?
Yes
No If yes, please explain (list name of agency and date):
18.
Have you ever been a plaintiff or defendant in a court action?
(list name of agency and date):
Yes
No
If yes, please explain
____________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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U. S. MILITARY RECORD
19.
20.
Are you registered for Selective Service?
If yes, you’re Selective Service Number:
Yes
No
(www.sss.gov to verify)
Have you ever served on active duty in the Armed Forces of the United States?
Branch of Service:
Duty Dates:
Yes
No
Highest Rank:
From:
From:
From:
From:
To:
To:
To:
To:
21.
Date and type of discharge:
22.
Are you now or have you ever been a member of a reserve unit or the National Guard?
Yes
No
If yes, state the branch of service, name and location of your unit and whether you attend drills,
meetings, etc.:
23.
Was any type of disciplinary action taken against you in the service?
please provide:
Date:
Place:
Nature of Offense:
Action Taken:
Yes
No
If yes,
MOTOR VEHICLE OPERATOR RECORD
24. Do you possess a valid driver license?
Driver license type:
Chauffeurs
Yes
No
Operators
Number
State
25. Do you hold or have you ever held an operator or chauffeur license in another state?
Yes
No
If yes, please provide state(s), name used, driver license(s) number and approximate dates license(s)
was/were held.
26.
Have you ever had a driver license suspended or revoked?
If yes, explain below: List the state and details.
If yes, was your license ever restored?
27.
Yes
Yes
No
No
Have you ever received a traffic citation (other than parking)?
Yes
No
If yes, list below the city, county, state, name of agency issuing the citation, date, charges and final
disposition. Complete information must be supplied.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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CREDIT DATA
28.
Have you been involved in any bankruptcy proceedings?
If so, what year?
Yes
No
29.
Are you currently involved in any pending litigation?
If so, list case number and county.
Yes
No
INTERNET INFORMATION
30. Do you have, under your name or any other name or identifier, any current or previous social media accounts,
websites, blogs, dating sites or any other form of electronic communication, including but not limited to Facebook,
MySpace, Twitter, Instagram, SnapChat, LinkedIn, YouTube, Google+, Pinterest, Tumblr, Flickr, Periscope,
Reddit, Zoosk, Plenty of Fish, Craigslist, Backpage, Tinder, Match or any and all other form of electronic or
internet posting or receiving capability? Yes
No
Please list any and all accounts or sites for
content review.
The St. Augustine Beach Police Department recognizes free speech and expression but requires all members to adhere to the strict guidelines of the
SABPD Social Media Policy. Any failure to identify or the concealment of any social media site as defined may terminate the application process.
REFERRAL INFORMATION
The St. Augustine Beach Police Department rewards all full-time employees for their recruitment efforts. If you
were recruited by an existing employee, please list their name below. This will allow us to track your progress
and reward them accordingly.
Referred by:
DRUG USE (Illegal Drugs, Prescription Drugs, Alcohol & Tobacco/Nicotine)
Both applicants and members of the St. Augustine Beach Police Department are prohibited, as defined in
Florida State Statute Chapter 893, from the use, possession or sale of any illegal drug or substance. This includes
the use, possession or sale of any legal prescription drug not prescribed to the applicant or member. Applicants
will not be considered for employment for use of any illegal drug or legal drug prescribed to another person
within 5 years of application to the St. Augustine Beach Police Department. Any applicant may be disqualified
regardless of the 5 year limit or have the 5 year time limit extended due to extenuating circumstances (frequency
of use and/or specific type of illegal or prescribed drug used) at the discretion of the Chief of Police.
Marijuana: Yes ( ) No ( ) How many times used: _______________ Date(s): _________________________
Cannabinoids (Marijuana, Hashish, THC): Yes ( ) No ( ) How many times used: _______________________
Date(s): _______________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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Cocaine: Yes ( ) No ( ) How many times used: _______________ Dates(s): __________________________
Crack Cocaine: Yes ( ) No ( ) How many times used: _______________ Dates(s): _____________________
Opioids (Heroin, Opium): Yes ( ) No ( ) How many times used: _________________ Date(s): ____________
____________________
Mescaline or Psilocybin (Mushrooms): Yes ( ) No ( ) How many times used: _______________ Date(s): ___
____________________
Amphetamines (speed): Yes ( ) No ( ) How many times used: _______________ Date(s): ________________
Methamphetamine (Meth): Yes ( ) No ( ) How many times used: _______________ Date(s): _____________
MDMA (Molly, Ecstasy): Yes ( ) No ( ) How many times used: _______________ Date(s): _____________
LSD (Acid), PCP, GHB: Yes ( ) No ( ) How many times used: _______________ Date(s): ______________
Any other illegal drug not mentioned and/or defined in FSS Chapter 893: Yes ( ) No ( ) How many times used:
__________________________________________________ Date(s): ________________________________
Prescription Drugs prescribed to you within the previous 2 years: Yes ( ) No ( ) Name(s): ________________
_______________________________________ Date(s) Used: ______________________________________
Prescription Drugs used prescribed to another person (anytime): Yes ( ) No ( ) Name(s): _________________
_________________________________ How many times used: ___________________________ Date(s) and
circumstances used: _________________________________________________________________________
__________________________________________________________________________________________
Alcohol Consumption: Yes ( ) No ( ) How often: _______________________________ Type(s): ___________
_____________________________ Date & time last consumed: ______________________________________
Have you ever been intoxicated/impaired: Yes ( ) No ( ) How many times (estimate): _____________________
Date, time and circumstances last intoxicated/impaired: _____________________________________________
Tobacco/Nicotine: Yes ( ) No ( ) Are you a current user of tobacco/nicotine (all forms of tobacco, E-cigarettes,
Nicotine patches or other smoking cessation drugs or implements): _____________________________________
Are you a former tobacco user: Yes ( ) No ( ) When was the last time you used tobacco/Nicotine (Dates): _____
____________________________ Do you fully understand the SABPD policy on tobacco use as outlined on page
three (3) of this application: Yes ( ) No ( )
EMPLOYMENT HISTORY
May we contact your present employer?
[
] Yes
[
] No
Begin with your most recent employer and list all (back to high school or 25 years, whichever applies)
previous employers (including temporary, volunteer work, part-time and any period of unemployment.)
Include complete addresses and phone numbers.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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1. Employer:
Dates of Employment
From:
To:
Month / Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
2. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month / Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
3. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month / Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
4. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
Ending:
Per
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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5. Employer:
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
6. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
7. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
8. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
Ending:
Per
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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9. Employer:
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
10. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
11. Employer:
Ending:
Per
Dates of Employment
From:
To:
Month/Year
Month / Year
Address:
Street
City
Position Held:
State
Zip
Area Code/Phone Number
Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting:
Per
Ending:
Per
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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RESIDENCY
Chronologically list all previous places of residence for the past 15 years (begin with present address and
work backward). Include all places you have resided either temporarily, part-time, military housing, or
dual residence using the format shown below.
Dates
Month/Year
From
To
Street Address
City
County
State
EDUCATIONAL RECORD
High School (Last):
Name:
City
Dates Attended: From:
Did you graduate?
State:
State
To:
Yes
No If no, do you have a general education diploma (G.E.D.) or a high school equivalency?
Year:
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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Yes
No
College:
Name:
City
Dates Attended: From:
Degree?
State
To:
Course of Study:
Yes
No If no, how many credits did you complete?
College (Post Graduate)
Name:
City
Dates Attended: From:
Degree?
State
To:
Course of Study:
Yes
No If no, how many credits did you complete?
Other Schools or Significant Training (Academy / Trade / Technical / Business)
Name:
City
Dates Attended: From:
Did you graduate?
State
To:
Course of Study:
Yes
No If no, describe the training you received:
PERSONAL HISTORY
List any honors or awards you have received:
Indicate any foreign language proficiency:
Language:
Ability
Read
Speak
Write
Fair
Good
Fluent
Read
Speak
Write
List all professional clubs, societies, associations of which you have been a member:
Name of Organization
City and State
Position Held
Currently Active
Yes
No
Yes
No
Yes
No
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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PERSONAL REFERENCES
List four (4) references, other than family members, giving complete information on each reference.
References should be longtime friends. Do not include family members, neighbors, supervisors, or coworkers as references.
1.
Name:
Relationship:
Address:
City:
State:
Home Phone:
2.
Zip:
Cell Phone:
Name:
Relationship:
Address:
City:
State:
Home Phone:
3.
Zip:
Cell Phone:
Name:
Relationship:
Address:
City:
State:
Home Phone:
4.
Zip:
Cell Phone:
Name:
Relationship:
Address:
City:
State:
Home Phone:
Zip:
Cell Phone:
EXPLANATION AND CONTINUATION SHEET
(If needed)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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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:
AGENCY REQUESTING BACKGROUND INFORMATION:
St. Augustine Beach Police Department
ADDRESS:
Having made application for certification or employment as a law enforcement, correctional, or correctional probation officer within the state of Florida, I hereby authorize for one year, from the
date of execution hereof, any authorized representative of a Florida criminal justice agency or a Regional Criminal Justice Selection Center bearing this release to obtain any information
pertaining to my employment, credit history, education, residence, academic achievement, personal information, work performance, background investigations, polygraph examinations, any and
all internal affairs investigations or disciplinary records, including any files that are deemed to be confidential and/or sealed.
I also authorize release of any criminal justice records of arrests, citations, detentions, probation and parole records, or any police reports or other police records in which I may be named for
any reason, including any files that are deemed to be juvenile and confidential. I hereby direct you to release this information upon the request of the bearer, whether in person or by
correspondence. I further authorize the bearer to make copies of these records.
This release is executed with the full knowledge and understanding that these records and information are for the official use of a Florida criminal justice agency or Regional Criminal Justice
Selection Center in fulfilling official responsibilities, which may include sharing the records or information with other criminal justice agencies. Regional Criminal Justice Selection Centers or the
State of Florida or release to third parties as may be required by Florida public records laws. I hereby release you, as the custodian of such records, and employer, educational institution,
physician, hospital or other repository of medical records, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively,
from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release
information, or any attempt to comply with it. A copy of this form will be as effective as the original.
I hereby 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 denoting discharge status or current active military status to:
Section 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former or current employee’s 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 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 FLORIDA, COUNTY OF
The foregoing instrument was acknowledged before me this date
By:
who is personally known
or who has produced identification Type of identification:
Notary’s Signature
Print, type, or stamp Commissioned Name of Notary
Notary Seal:
complete the notary block.
. Upon witnessing the applicant signing of this affidavit, the notary public shall
Effective: 8/9/2001 Pursuant to
Original – Employing Agency
Sections 943.134(2)(a) and (4), F.S.
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Commission-Approved Revision: 8/6/2009
Form Effective Date: 06/03/2010
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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RELEASE OF INFORMATION AUTHORITY
TO WHOM IT MAY CONCERN:
I respectfully request and authorize you to furnish the St. Augustine Beach Police Department any and all
information that you may have, in the areas listed below. Please include all records and reports (including
all information of a confidential or privileged nature), and photostats of same, if requested. This information
is being used in conjunction with an official investigation. Consent is granted for the St. Augustine Beach
Police Department to furnish to third parties, if requested.
I hereby release you, your organization or others (individually and collectively) from any liability or damage
which may result from furnishing the information requested by the St. Augustine Beach Police Department.
I further release the St. Augustine Beach Police Department and all its agents or employees, both
individually and collectively, from any and all liability for damages of whatever kind, which may at any
time result to me, my heirs, family or associates because of compliance with this authorization to release
information, or any attempt to comply with it. Should there be any questions as to the validity of this
release, you may contact me as indicated below.
INITIAL the specified areas below:
___________________
Criminal History
___________________
Credit History
___________________
Education History
___________________
Employment History
___________________
Medical History (including physical, mental and laboratory records)
___________________
Military History
___________________
All of the above
Printed Name :
Signature:
_________________________________________________________________
Address:
Telephone:
(Home)
(Work)
Acknowledged before me this ________Day of ____________, 20 _____, who is personally known to me or
who produced
as identification and who
(did / did not) take an oath.
____________________________________________ ______________________________________
Printed Name of Notary Public
Signature of Notary Public
_____________________________________________
NOTARY STAMP
The St. Augustine Beach Police Department is an Equal Opportunity Employer
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The St. Augustine Beach Police Department is an Equal Opportunity Employer
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