CITY OF ST. PETERSBURG APPLICATION PROCESS FOR EMPLOYMENT WITH THE

Transcription

CITY OF ST. PETERSBURG
APPLICATION PROCESS
FOR EMPLOYMENT WITH THE
ST. PETERSBURG POLICE DEPARTMENT
I.
APPLICATION AND PERSONAL HISTORY QUESTIONNAIRE
Applicants are encouraged to carefully read the applicable “Selection Standards for Police Officer Positions”
before completing an application. In addition to completing a standard City Employment Application, candidates
for employment with the City of St. Petersburg’s Police Department are also required to complete a Personal
History Questionnaire (PHQ).
To thoroughly complete the PHQ, applicants must provide complete mailing addresses (including zip codes) for
all places of residence since age fourteen (14), all schools attended, all places of employment for the last ten
(10) years, immediate family members (including date of birth), four (4) character references (not relatives) who
have known you for five years or more and three (3) personal friends (not relatives) with whom you are currently
associated.
The entire pre-employment selection process typically takes an average of ten (10) to twelve (12) weeks to
complete.
II
PROCESSING STEPS
** WARNING **
**FAILURE TO KEEP SCHEDULED PROCESSING APPOINTMENTS WITHOUT PRIOR NOTICE MAY BE
SUFFICIENT CAUSE FOR APPLICATION CLOSURE.**
The following steps (not necessarily in this sequence) comprise the pre-employment selection process for
POLICE OFFICER positions:
1.
2.
3.
4.
5.
6.
7.
Personal History Questionnaire Review
Polygraph
Mandatory Ride-along
Vocational Assessment and Psychological Evaluation
Physical Abilities Test
Background Investigation
Medical Examination and Drug Test
III.
REQUIRED DOCUMENTS
All applicants must submit copies of the following listed documents, with the exception of college and high
transcripts which must be "OFFICIAL", meaning sealed in an envelope.
1.
2.
3.
4.
Birth Certificate - Government issued (i.e. State, County, etc.), or a valid U.S. Passport.
Naturalization Certificate (if applicable): The original Certificate must be presented for review, as Federal
Law prohibits copying the certificate.
*Social Security Card (must be signed).
High School Diploma or State-Issued GED Certificate and an Official High School Transcript. Applicants
who are Florida certified, have worked for 12 consecutive months as a sworn full-time officer in another
state, or who are currently enrolled at St. Petersburg College are not required to provide an Official High
School Transcript.
****OVER***
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Two (2) Official College Transcripts showing at least 30 semester hours if non-certified or 60 semester
hours if certified, and have less than 2 years full-time law enforcement experience (or quarter hour
equivalents). Applicants who are Florida certified, enrolled in a Florida law enforcement academy, or
have at least 2 years sworn full-time law enforcement experience or are currently enrolled at St.
Petersburg College, are only required to submit one (1) Official College Transcript. (See Selection
Standards regarding Accrediting Institutions accepted).
Marriage Certificate (if applicable).
Divorce Decree(s) (if applicable).
Valid Driver’s License.
Military DD214 - Member - 4 - Copy (if applicable).
Selective Service Card (if applicable) or visit www.sss.gov .
Any other certificates that may reflect job qualifications should also be submitted.
A current driving record if you are holding an out-of-state driver’s license. If you’ve had a Florida driver’s
license for less than five (5) years you need to retrieve a driving record from the previous state.
If you are a certified Police Officer outside of the State of Florida, submit a copy of the curriculum
from the academy attended.
College Placement Test results, if applicable (For applicants meeting military or prior law
enforcement criteria, see Selection Standards for more information).
Bankruptcy discharge including list of creditors, if applicable.
Police report(s) and final disposition(s) of any arrest (felony or misdemeanor). This would include an
expungement, sealed record, dismissal of charges, etc. All domestic related cases whether
complainant or accused. Other sources for obtaining this information would be personal records,
personal attorney, arresting agency, county clerk’s office.
***Included in your Pre-employment Packet***
1.
2.
3.
4.
5.
6.
Notarized Waivers (Confidential, Liability, and Credit)
Background Investigation Worksheet
Military/Non-Military Service Affidavit
Law Enforcement Experience Affidavit, if applicable
Military Records Request
Neighborhood Survey
* Notification: It is requested that you provide your Social Security number as part of our employment
process. In accordance with Florida State Statute 119.071, we are requesting your Social Security number
for the following purposes: • tax reporting; • identification and for verifications such as former employment,
criminal records and credit worthiness; • benefit processing and identification; • reporting to other
government agencies; • as a unique identifier for search purposes.
IV.
RE-APPLICATION/RETESTING
1.
2.
Applicants will be provided three (3) opportunities to pass the Police physical abilities test.
Any applicant who is discontinued in the selection process may re-apply one (1) year from the date of
notification of removal from consideration. However, on a case-by-case basis, there may be exceptions
to this provision dependent upon the specific cause of removal.
V.
ADDITIONAL INFORMATION
If you have any questions please contact Officer Robert Page at 727-892-5555 in Police Recruitment.
R-11/19/04 R-05/25/05 R-12/02/05 R-08/09/06
R-11/30/06 R-10/01/07 R-12/21/07 R-02/05/08
Affirmative
Action and Equal
Opportunity
Employer
Application For Employment
City of St. Petersburg
Employment Office
P. O. Box 2842
St. Petersburg, FL 33731
(727) 893-7311
www.stpete.org/jobs
IRC# and position applied for
(Applications are only accepted for posted positions.)
Name
Last
First
Middle
Home address
City
State
Zip
State
Zip
Mailing address (If different)
City
Telephone number
Cell number
Business number
E-mail address
Are you a United States Citizen?
m Yes
m No
If no, attach the Employment Authorization Document issued by U.S. Citizenship and Immigration Services (USCIS).
Were you ever employed under another name? If yes, provide name(s)
Education (Verification of all levels of education may be required depending upon the position.)
High School*
GED*
Diploma?
School Name:
m Yes
City and State:
m No
Highest Grade Completed: (Circle)
Certificate?
School Name:
m Yes
City and State:
8
9
10
11
12
m No
Vocational,
Certificate?
School Name:
Technical or
m Yes
City and State:
Trade School
m No
Course of Study:
College or
Degree?
School Name:
University*
m Yes
City and State:
m No
Course of Study:
Type of Degree:
Number of Credits Earned:
College or
Degree?
School Name:
University*
m Yes
City and State:
m No
Course of Study:
Type of Degree:
Number of Credits Earned:
*If the answer is YES to any of the above, the City will hold the applicant responsible to demonstrate that the school or institution granting or conferring the
diploma, degree or certificate is credentialed or accredited by an agency recognized by the U.S. Department of Education as competent to issue such
credential or accreditation. At the City’s option, the applicant may also be required to submit additional educational information such as school transcripts.
Driving Record (Complete this section only if the position requires a valid driver's license.)
State Issued
License Type
m Class E
m Commercial Driver's License
m Commercial Driver's Permit
License Number
Commercial Type
m Class A
m Class B
m Class C
Endorsements
mS
mT
mX
mH
mN
mP
Expiration Date
Has your license ever been suspended or revoked?
m Yes
m No
Is your license currently suspended or revoked?
m Yes
m No
If your license is now or was previously suspended or revoked, provide dates and details:
Page 1 of 4
Licenses, Certificates, Special Skills, Languages or Equipment Operated (Provide licensing authority
such as State of Florida.)
Employment History
Do you have any objections to your present employer being contacted?
m Yes
Do you have any relatives currently employed with the City of St. Petersburg?
m No
m Yes
m No
If yes, list their name(s), position title, and their relationship to you
Have you previously been employed by the City of St. Petersburg?
Are you currently employed by the City of St. Petersburg?
m Yes
m Yes
m No If yes, provide details below.
m No If yes, provide details below.
Provide details of your employment history.
Date from (Month & Year)
Name of Employer & Telephone Number
Job Title
Address of Employer
Name of Supervisor
Date to (Month & Year)
Reason for Leaving
(Fired, resigned, laid off, temp, etc.)
Description of Duties
Hours per Week
Job Title
Address of Employer
Name of Supervisor
Reason for Leaving
Hours per Week
Job Title
Address of Employer
Name of Supervisor
Reason for Leaving
Hours per Week
Page 2 of 4
Job Title
Address of Employer
Name of Supervisor
Reason for Leaving
Hours per Week
Criminal History
This application will not be accepted unless this section has been completed.
In accordance with Florida Statutes 112.011, a prior record of conviction will not necessarily disqualify you from employment.
However, providing false or misleading information on this application may result in termination if you are hired.
Have you ever been convicted or found guilty of, pled guilty or no contest (nolo contendere) to, regardless of adjudication
(including adjudication withheld), a violation of any law that constitutes a felony or misdemeanor? Do not include any offense
m No
committed prior to your 18th birthday. m Yes
If your answer above is Yes, you must complete the table below and provide details for each separate offense. Additional
space is provided on page 4 of this application. If you have more than four offenses, attach another page to this application.
Required Details
Offense One
Offense Two
Charge
City & State
Year of offense
Disposition
(type of plea entered)
Number of counts
Adjudicated guilty
m Yes
m No
m Yes
m No
m Yes
m No
m Yes
m No
Dates served in prison/jail
Dates of probation
Fine paid
(Criminal History continued on the next page)
Page 3 of 4
Find vacancy details and apply online at www.stpete.org/jobs, or deliver or mail a resume/application to arrive
no later than 4 p.m. on the posted “Close Date” to the City of St. Petersburg Employment Office
One Fourth Street North, Fourth Floor, St. Petersburg, Florida 33701 • Tel: (727) 893-7311• TDD (727) 892-5259
Operating hours Monday, Wednesday & Friday • 8 a.m. to 4 p.m.
DFWP • Veterans’ Preference • Affirmative Action/Equal Opportunity Employer
Required Details
Offense Three
Offense Four
Charge
City & State
Year of offense
Disposition
(type of plea entered)
Number of counts
Adjudicated guilty
m Yes
m No
m Yes
m No
m Yes
m No
m Yes
m No
Dates served in prison/jail
Dates of probation
Fine paid
Criminal history, continued on attachment(s):
m Yes
m No
Veterans’ Preference
Veterans’ Preference will be given to eligible veterans and in certain instances spouses of eligible veterans in accordance
m No
with Chapter 295 of the Florida Statutes. Are you claiming veterans’ preference? m Yes
If yes, you must complete a Veterans’ Preference Form available from the Employment Office. You must submit this form and
required documentation no later than 4 p.m. on the closing date of the job posting.
Attention - Please Read Carefully
Your signature below affirms that you acknowledge and agree to the following:
1.
The applicant agrees that all information provided on this application or on any other employment
related form is correct, current and complete and that any false, incomplete or incorrect statements or
representations made by the applicant could result in termination from employment.
2.
The applicant agrees to present verification of employment eligibility in the United States, a social security card,
verification of date of birth and proof of education prior to employment.
3.
The applicant agrees to submit to a medical examination and a controlled substance test for the position, if required.
4.
The applicant authorizes the City of St. Petersburg, Florida to conduct a criminal history check and other
verification of information contained in this application or on any other employment related forms.
Applicant Signature
Date
Page 4 of 4
Rev. 2/2013
Statistical Use Only
Completion of this portion of the application is voluntary. This data will not be kept with the application, or used in the decision to hire
or not to hire.
Race:
m Black or African American
m White
m Native Hawaiian/Other Pacific Islander
Sex:
m Male
m Female
U.S. Military Service Veteran m Yes
m Hispanic or Latino
m Asian
m American Indian or Alaska Native
m Two or More Races
Registered Disabled: mYes
m No
Date of Birth:
m No
Rev. 2/2013
POLICE OFFICER
REFERRAL FORM
If you are being referred by a current City employee, please complete the information below and
return the form along with your completed application package to:
Police Training
1300 1st Avenue North, 2nd Floor
St. Petersburg, Florida 33705
A city employee is entitled to receive eight (8) hours of annual leave upon the successful completion of
the Police Officer screening process and your subsequent hiring.
·
Name of Applicant: ___________________________________________________
·
Address: ____________________________________________________________
·
Name of City Employee: _______________________________________________
·
Payroll Number and Department: _______________________________________
____________________________________________________________________
For additional information, contact Officer Robert Page at 727-892-5555.
PERSONAL INQUIRY WAIVER
AUTHORITY FOR RELEASE OF CONFIDENTIAL INFORMATION
TO THE CITY OF ST. PETERSBURG, FLORIDA
To: Whom It May Concern, Authorized Representative of Any Organization, Institution, or Repository
of Records, regarding:
NAME:
DATE OF BIRTH:
ADDRESS:
OTHER NAMES USED (such as maiden name):
SOCIAL SECURITY #:
* RACE:
SEX:
By my signature below, I have authorized the City of St. Petersburg, Florida (City) to conduct a criminal history
check and verification of other personal information. This is to serve as an authorization to release information to
the City, as requested by the City, in order to verify my qualifications and fitness for employment with the City. The
release of information that I hereby authorize includes: FDLE State Criminal History and/or local police background
check; employment record, including performance evaluations and disciplinary actions; school record; records
affecting character or reputation; divorce record (if applicable); arrest records; criminal records; records from any
law enforcement agency; driver’s license details and history; driving history; recorded polygraph examination history
or application status; any and all information of a confidential, privileged, non-confidential, and non-privileged
nature; and photocopies of same, if available. I further hereby release the record holder, his or her
organization/agency, and other related entities from any liability or damage which may result from furnishing to the
City the requested information.
I also acknowledge receipt of the notice regarding my Social Security number provided below.*
EMPLOYEE/APPLICANT SIGNATURE
DATE
AFFIDAVIT
STATE OF ___________
COUNTY OF ____________
The foregoing instrument was acknowledged before me by __________________________________________
who has produced ________________________________ as identification and who did not take an oath, and
who appeared before me at the time of notarization.
WITNESS, my hand and official seal, this __________ day of ___________________________, 20_________.
(SEAL)
NOTARY PUBLIC
PRINT
* The City of St. Petersburg Human Resources Department has requested your Social Security number as part of our employment process. In accordance with Florida State
Statute 119.071, this is to advise you that your Social Security number will be used for one or more of the following purposes: tax reporting as provided under the United
States Tax Code Title 26, Chapter 61, Section 6109; as a unique identifier to verify Employment Eligibility as provided under Code of Federal Regulations Title 8, Part
1274a.2; for search purposes to verify information such as former employment, criminal records and credit worthiness as authorized and/or mandated under Florida Statutes
Chapter 166-Section 166.0442, Chapter 435-Sections 435.03 and 435.04, Chapter 633-Section 633.34, Chapter 943-Sections 943.13 and 943.133; and for reporting to
other government agencies, as required to accomplish the foregoing purposes.
PERSONAL INQUIRY WAIVER
AUTHORITY FOR RELEASE OF CREDIT INFORMATION
TO THE CITY OF ST. PETERSBURG, FLORIDA
To: Whom It May Concern, Authorized Representative of Any Organization, Institution, or Repository
of Records, regarding:
NAME:
DATE OF BIRTH:
ADDRESS:
OTHER NAMES USED (such as maiden name):
SOCIAL SECURITY #:
* RACE:
SEX:
By my signature below, I have authorized the City of St. Petersburg, Florida (City) to conduct a credit history check.
This is to serve as an authorization to release information to the City, as requested by the City, in order to verify my
qualifications and fitness for a particular assignment with the City. The release of information that I hereby authorize
includes all information that you may have concerning my financial credit status and photocopies of same, if
available. I further hereby release the record holder, his or her organization/agency, and other related entities from
any liability or damage which may result from furnishing to the City the requested information.
I also acknowledge receipt of the notice regarding my Social Security number provided below.*
EMPLOYEE/APPLICANT SIGNATURE
DATE
AFFIDAVIT
STATE OF ______________
COUNTY OF _______________
(SEAL)
NOTARY PUBLIC
PRINT
* The City of St. Petersburg Human Resources Department has requested your Social Security number as part of our employment process. In accordance with Florida State
Statute 119.071, this is to advise you that your Social Security number will be used for one or more of the following purposes: tax reporting as provided under the United
States Tax Code Title 26, Chapter 61, Section 6109; as a unique identifier to verify Employment Eligibility as provided under Code of Federal Regulations Title 8, Part
1274a.2; for search purposes to verify information such as former employment, criminal records and credit worthiness as authorized and/or mandated under Florida Statutes
Chapter 166-Section 166.0442, Chapter 435-Sections 435.03 and 435.04, Chapter 633-Section 633.34, Chapter 943-Sections 943.13 and 943.133; and for reporting to
other government agencies, as required to accomplish the foregoing purposes.
APPLICANT=S WAIVER OF LIABILITY
In consideration of the Agreement of the City of St. Petersburg, Florida, herein allowing me to perform the physical
tests, including any polygraph tests indicated hereon required by the Employment Division of the City of St.
Petersburg, upon my own application and for other good and valuable consideration, I do hereby voluntarily and
knowingly assume full responsibility for all injuries and damages which might be incurred by me in the performance
of said tests. I have reviewed the materials regarding the physical abilities test, am aware of the extent of and rigors
of such test, and voluntarily agree to undertake this portion of the hiring process. I have also been advised to consult
with a physician to determine if I am capable of safely performing all the tasks of the Physical Abilities Test. I do
this hereby for myself, my personal representatives, heirs and assign release, discharge, and acquit the City of St.
Petersburg, Florida, and its employees and officers, and all persons or companies which might be liable on its
account for any and all claims for loss, damage or injury of any nature whatsoever, whether to person or property
resulting from the performance of said tests whether caused by the negligent acts of the City of St. Petersburg,
Florida, its agents or servants or otherwise.
_______________________________________________
APPLICANT=S SIGNATURE
__________________________
DATE
AFFIDAVIT
STATE OF
COUNTY OF
(SEAL)
NOTARY PUBLIC
PRINT
R-01/03
MILITARY/NON MILITARY
SERVICE AFFIDAVIT
I, _________________________________ hereby swear and affirm that I have (please check the following that apply):
Never served in the military of the United States of America or any foreign country.
Served active military duty*:
__________________________ from _____________ to _____________
__________________________ from _____________ to _____________
__________________________ from _____________ to _____________
(Branch of Service)
Served reserve/guard military duty**:
(mm/dd/yy)
(mm/dd/yy)
__________________________ from _____________ to _____________
__________________________ from _____________ to _____________
__________________________ from _____________ to _____________
(Branch of Service)
(mm/dd/yy)
(mm/dd/yy)
*Active Duty Military – A DD-214 (Long Form) for each period of active duty service is a required document. A DD-214 must
support each period of active duty, or you are required to provide a letter from the military branch of service stating the
reason a DD-214 was not issued.
**Reserve/Guard Duty – A DD-214 or documentation to support all listed dates of reserve/guard service must be provided to
verify service periods (i.e. enlistment contracts, transfer orders, discharge orders, or letters from the Branch or Unit).
_______________________________________________
__________________________
DATE
AFFIDAVIT
STATE OF
COUNTY OF
The foregoing instrument was acknowledged before me by __________________________________________________
who has produced __________________________________________ as identification and who did not take an oath, and
WITNESS, my hand and official seal, this ____________ day of ______________________________, 20___________.
(SEAL)
NOTARY PUBLIC
PRINT
msaffidavit-01/2007
R 07/2007
LAW ENFORECEMENT EXPERIENCE
AFFIDAVIT
I, _________________________________ hereby swear and affirm that I have two (2) years of full-time,
sworn and certified law enforcement experience. The previous experience was completed at:
(Agency)
(Address)
_______________________________________________
(mm/dd/yy)
(mm/dd/yy)
__________________________
DATE
AFFIDAVIT
STATE OF
COUNTY OF
The foregoing instrument was acknowledged before me by __________________________________________________
who has produced __________________________________________ as identification and who did not take an oath, and
WITNESS, my hand and official seal, this ____________ day of _____________________________, 20___________.
(SEAL)
NOTARY PUBLIC
PRINT
leaffidavit-01/07
BACKGROUND INVESTIGATION WORKSHEET
AUTHORIZED BY:__________________________________POSITION:____________________________
NAME:____________________________________________ALIASES:______________________________
(First)
(Middle)
(Last)
ADDRESS:_______________________________________________________________________________
(Street
(City)
(State)
(Zip)
DOB:_____________________ POB_________________________________SS#______________________
HOME PHONE:_____________WORK PHONE:_____________ OCCUPATION:_____________________
SEX:________RACE:________ HEIGHT:________WEIGHT:________ EYES:________ HAIR:_________
DRIVER’S LICENSE NUMBER:______________________________________STATE:________________
FINGERPRINT CLASSIFICATION:
FCIC/NCIC:___________________________________
SPOUSE:_________________________________________________DOB:___________________________
SPOUSE’S MAIDEN NAME (IF APPLICABLE)________________________________________________
FATHER:________________________________________________ DOB:___________________________
MOTHER:_______________________________________________ DOB:___________________________
SISTER:_________________________________________________ DOB:___________________________
_________________________________________________ DOB:___________________________
_________________________________________________ DOB:___________________________
_________________________________________________ DOB:___________________________
BROTHER:_______________________________________________DOB:___________________________
________________________________________________ DOB:___________________________
________________________________________________ DOB:___________________________
________________________________________________ DOB:___________________________
CHILDREN:_____________________________________________ DOB:___________________________
________________________________________________ DOB:___________________________
________________________________________________ DOB:___________________________
________________________________________________ DOB:___________________________
NEIGHBORHOOD SURVEY
Applicant’s Name
A component of each background investigation for the position of Police Officer is a survey of your current neighbors or
former neighbors. Please list your current residence below:
City
State
Zip
If you have lived at the above address two months or less, list previous residence:
_
City
State
Zip
List four (4) neighbors, along with addresses and phone numbers that reside within a one (1) block radius of the
neighborhood where you currently live (must be different addresses). If you have lived at this residence for less than
two (2) months, list neighbors at your previous address. Do not list relatives.
Name
Telephone Number
Address
City _____________________________________________ State ______________________ Zip
Name
Telephone Number
Address
City _____________________________________________ State ______________________ Zip
Name
Telephone Number
Address
City _____________________________________________ State ______________________ Zip
Name
Telephone Number
Address
City _____________________________________________ State ______________________ Zip
Revised 03/17/06
Revised 07/06/07
TATTOO POLICY
Employees of the St. Petersburg Police Department must comply with department policy governing tattoos. Policy
compliance may directly impact eligibility for employment; therefore, applicants considered for employment are
required to review the policy and complete this form.
POLICY:





Tattoos on the hands, face, neck and scalp are prohibited.
Tattoos on any other body part are required to be covered. Regardless of their location, tattoos that are
potentially offensive to the community, as determined by the Chief of Police, are prohibited.
Exception: one tattoo is permitted to be visible and may remain uncovered on the arm between the wrist and
two inches above the inside bend of the elbow if the maximum dimensions are less than 3”x 5” (as tested by
placing a standard 3”x 5” note card over the tattoo); and the visible tattoo must not be potentially offensive to
the community, as determined by the Chief of Police.
Covering tattoos in order to meet the standard must be done using apparel approved by the department.
Exceptions to the tattoo policy must be authorized by the Chief of Police.
APPLICANT:
Do you have any tattoos?
Yes
No
IF YOU ANSWERED YES, PLEASE CHECK ALL STATEMENTS THAT APPLY TO YOU AND PROVIDE
NECESSARY DETAILS:
I do not have any tattoos on my hands, face, neck or scalp.
I have only one (1) tattoo on my arm that is between the wrist and 2” above the inside bend of the elbow
which is smaller than 3”x 5” and is not potentially offensive to the community. I understand that, if I am
employed in the Police Department, this single tattoo can remain visible.
I have one or more tattoos that, pursuant to the City's tattoo policy, do not impact my eligibility for
employment. I understand that, if I am employed in the Police Department, I must cover all tattoos using
approved items.
I have one or more tattoos that may be considered offensive to the community. I am providing the
following description for evaluation. This description includes the image(s) depicted by the tattoo(s), the
size(s) of the tattoo(s), and the location(s) of the tattoo(s) on my body:
I, the undersigned applicant, acknowledge: 1) I have read the tattoo policy; 2) I have properly disclosed the
information required; and 3) I understand that failure to answer truthfully will make me ineligible for any future
City employment for five (5) years; or, if hired, could result in termination from employment.
Applicant Signature
Applicant Printed Name
Date
INSTRUCTION AND INFORMATION SHEET FOR SF 180, REQUEST PERTAINING TO MILITARY RECORDS
1. General Information. The Standard Form 180, Request Pertaining to Military Records (SF180) is used to request information from
military records. Certain identifying information is necessary to determine the location of an individual's record of military service. Please
try to answer each item on the SF 180. If you do not have and cannot obtain the information for an item, show "NA," meaning the
information is "not available." Include as much of the requested information as you can. Incomplete information may delay response time.
To determine where to mail this request see Page 2 of the SF180 for record locations and facility addresses.
Online requests may be submitted to the National Personnel Records Center (NPRC) by a veteran or deceased veteran’s next of kin using
eVetRecs at http://www.archives.gov/veterans/military-service-records/.
2. Personnel Records/Military Human Resource Records/Official Military Personnel File (OMPF) and Medical Records/Service
Treatment Records (STR). Personnel records of military members who were discharged, retired, or died in service less than 62 years
ago and medical records are in the legal custody of the military service department and are administered in accordance with rules issued by
the Department of Defense and the Department of Homeland Security (DHS, Coast Guard). STR’s of persons on active duty are generally
kept at the local servicing clinic, and usually are available from the Department of Veterans Affairs approximately 40 days after the last
day of active duty. (See item 3, Archival Records, if the military member was discharged, retired or died in service over 62 years ago.)
a. Release of information: Release of information is subject to restrictions imposed by the military services consistent with
Department of Defense regulations and the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The
service member (either past or present) or the member's legal guardian has access to almost any information contained in that
member's own record. An authorization signature, of the service member or the member's legal guardian, is needed in Section III of
the SF180. Others requesting information from military personnel records and/or STR’s must have the release authorization in
Section III of the SF 180 signed by the member or legal guardian. If the appropriate signature cannot be obtained, only limited
types of information can be provided. If the former member is deceased, surviving next of kin may, under certain circumstances, be
entitled to greater access to a deceased veteran's records than a member of the general public. The next of kin may be any of the
following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. Requesters must provide proof of death,
such as a copy of a death certificate, newspaper article (obituary) or death notice, coroner’s report of death; funeral
director’s signed statement of death, or verdict of coroner’s jury.
b. Fees for records: There is no charge for most services provided to service members or next of kin of deceased veterans. A
nominal fee is charged for certain types of service. In most instances service fees cannot be determined in advance. If your request
involves a service fee, you will be notified.
3. Archival Records. Personnel records of military members who were discharged, retired, or died in service 62 or more years ago have
been transferred to the legal custody of NARA and are referred to as “archival” records.
a. Release of Information: Archival records are open to the public. The Privacy Act of 1974 does not apply to archival records,
therefore, written authorization from the veteran or next of kin is not required. However, in order to protect the privacy of the
veteran, his/her family, and third parties named in the records, the personal privacy exemption of the Freedom of Information Act (5
U.S.C. 552 (b) (6)) may still apply and preclude the release of some information.
b. Fees for Archival Records: Access to archival records is granted by offering copies of the records for a fee (44 U.S.C. 2116 (c)).
You will be notified if there is a charge for photocopies of documents contained in the record you are requesting. For more
information see http://www.archives.gov/st-louis/archival-programs/military-personnel-archival/ompf-archival-requests.html.
4. Where reply may be sent. The reply may be sent to the service member or any other address designated by the service member or other
authorized requester.
5. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; SERVICE TREATMENT RECORD
(STR) -- The chronology of medical, mental health and dental care received by service members during the course of their military career
(does not include records of treatment while hospitalized); TDRL – Temporary Disability Retired List.
6. Service completed before World War I. National Archives Trust Fund (NATF) forms must be used to request these records. Obtain
the forms by e-mail from [email protected] or write to the Code 6 address on page 2 of the SF 180.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
The following information is provided in accordance with 5 U.S.C. 552a(e)(3) and applies to this form. Authority for collection of the information is 44
U.S.C. 2907, 3101, and 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. If
the requested information is not provided, it may delay servicing your inquiry because the facility servicing the service member's record may not have all of
the information needed to locate it. The purpose of the information on this form is to assist the facility servicing the records (see the address list) in locating
the correct military service record(s) or information to answer your inquiry. This form is then retained as a record of disclosure. The form may also be
disclosed to Department of Defense components, the Department of Veterans Affairs, the Department of Homeland Security (DHS, U.S. Coast Guard), or
the National Archives and Records Administration when the original custodian of the military health and personnel records transfers all or part of those
records to that agency. If the service member was a member of the National Guard, the form may also be disclosed to the Adjutant General of the
appropriate state, District of Columbia, or Puerto Rico, where he or she served.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
Public burden reporting for this collection of information is estimated to be five minutes per request, including time for reviewing instructions and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 207406001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS AS INDICATED IN THE ADDRESS LIST ON
PAGE 2 OF THE SF 180.
Standard Form 180 (Rev. 5/12) (Page 1)
Prescribed by NARA (36 CFR 1228.168(b))
Authorized for local reproduction
Previous edition unusable
OMB No. 3095-0029 Expires 01/31/2015
REQUEST PERTAINING TO MILITARY RECORDS
* Requests from veterans or deceased veteran’s next-of-kin may be submitted online by using eVetRecs at http://www.archives.gov/veterans/military-service-records/*
(To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. Please print clearly or type.)
SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much as possible.)
1. NAME USED DURING SERVICE (last, first, and middle)
5. SERVICE, PAST AND PRESENT
2. SOCIAL SECURITY NO.
3. DATE OF BIRTH
4. PLACE OF BIRTH
(For an effective records search, it is important that all service be shown below.)
SERVICE NUMBER
DATE RELEASED
OFFICER
ENLISTED
BRANCH OF SERVICE
DATE ENTERED
(If unknown, write “unknown”)
a. ACTIVE
COMPONENT
b. RESERVE
COMPONENT
c. NATIONAL
GUARD
6. IS THIS PERSON DECEASED? If “YES” enter the date of death.
NO
YES
7. IS (WAS) THIS PERSON RETIRED FROM MILITARY SERVICE?
NO
YES
SECTION II – INFORMATION AND/OR DOCUMENTS REQUESTED
1. CHECK THE ITEM(S) YOU ARE REQUESTING:
✘
DD Form 214 or equivalent. When was the DD Form(s) 214 issued? YEAR(S): ___________________________________________________
If more than one period of service was performed, even in the same branch, there may be more than one DD214.
This form contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran’s next of kin, or
other persons or organizations if authorized in Section III, below. An UNDELETED DD214 is ordinarily required to determine eligibility for
benefits. Sensitive items, such as, the character of separation, authority for separation, reason for separation, reenlistment eligibility code,
separation (SPD/SPN) code, and dates of time lost are usually shown.
An undeleted copy will be sent unless you specify a deleted copy. Indicate here if you want a deleted copy of the DD Form 214 . .
The following items are deleted: authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and for
separations after June 30, 1979, character of separation and dates of time lost.
✘
All Documents in Official Military Personnel File (OMPF)
Medical Records (Includes Service Treatment Records, Health (outpatient) and dental records.) If hospitalized (inpatient), the facility name and
date for each admission must be provided: _________________________________________________________________________________
Other (Specify):
2. PURPOSE: (An explanation of the purpose of the request is strictly voluntary; however, such information may help to provide the best possible
response and may result in a faster reply. Information provided will in no way be used to make a decision to deny the request.) Check appropriate box:
Benefits
Employment
VA Loan Programs
Medical
Genealogy
Correction
Personal
Other, explain:
SECTION III - RETURN ADDRESS AND SIGNATURE
1. REQUESTER IS: (Signature Required in # 3 below of veteran, next of kin, legal guardian, authorized government agent or ”other” authorized representative. If
“other” authorized representative, provide copy of authorization letter.) No signature required for Archival records.
✘
Military service member or veteran identified in Section I, above
Next of kin of deceased veteran:
(Relationship)
MUST HAVE PROOF OF DEATH - See item 2a on instruction sheet.
2. SEND INFORMATION/DOCUMENTS TO:
(Please print or type. See item 4 on accompanying instructions.)
Legal guardian (Must submit copy of court appointment.)
Other (specify)
3. AUTHORIZATION SIGNATURE WHEN REQUIRED (See items 2a or 3a
on accompanying instructions.) I declare (or certify, verify, or state) under penalty
of perjury under the laws of the United States of America that the information in
this Section III is true and correct. No signature required for Archival records.
City of St. Petersburg, Public Safety Screening Division
Name
Signature Required - Do not print
P.O. Box 2842
Street
St. Petersburg
City
Apt.
FL
State
(
)
Daytime phone
Date
(
)
Fax Number
33731
Zip Code
Email address
*This form is available at http://www.archives.gov/research/order/standard-form-180.pdf on the National Archives and Records Administration (NARA) web site.*
RESET
Standard Form 180 (Rev. 5/12) (Page 2)
Prescribed by NARA (36 CFR 1228.168(b))
Authorized for local reproduction
Previous edition unusable
OMB No. 3095-0029 Expires 01/31/2015
LOCATION OF MILITARY RECORDS
The various categories of military service records are described in the chart below. For each category there is a code number which indicates the address
at the bottom of the page to which this request should be sent. Please refer to the Instruction and Information Sheet accompanying this form as needed.
ADDRESS CODE
BRANCH
CURRENT STATUS OF SERVICE MEMBER
Personnel Record
Discharged, deceased, or retired before 5/1/1994
AIR
FORCE
COAST
GUARD
MARINE
CORPS
ARMY
NAVY
PHS
Discharged, deceased, or retired 5/1/1994 – 9/30/2004
Discharged, deceased, or retired on or after 10/1/2004
Active (including National Guard on active duty in the Air Force), TDRL, or general officers retired with pay
Reserve, retired reserve in nonpay status, current National Guard officers not on active duty in the Air Force, or
National Guard released from active duty in the Air Force
Current National Guard enlisted not on active duty in the Air Force
Discharge , deceased, or retired before 1/1/1898
Active, reserve, or TDRL
Discharged, deceased, or retired before 1/1/1905
Individual Ready Reserve
Active, Selected Marine Corps Reserve, TDRL
Discharged, deceased, or retired before 11/1/1912 (enlisted) or before 7/1/1917 (officer)
Discharged, deceased, or retired 11/1/1912 – 10/15/1992 (enlisted) or 7/1/1917 – 10/15/1992 (officer)
Discharged, deceased, or retired after 10/16/1992
Active enlisted, officers
Former National Guard/USAR personnel
14
14
1
1
Medical or
Service
Treatment
Record
14
11
11
2
Discharged, deceased, or retired before 1/1/1886 (enlisted) or before 1/1/1903 (officer)
Discharged, deceased, or retired 1/1/1886 – 1/30/1994 (enlisted) or 1/1/1903 – 1/30/1994 (officer)
Active, reserve, or TDRL
13
6
14
14
3
6
14
14
4
5
4
6
14
14
7
14
6
14
14
10
10
Public Health Service - Commissioned Corps officers only
12
14
11
14
11
11
11
14
11
11
ADDRESS LIST OF CUSTODIANS (BY CODE NUMBERS SHOWN ABOVE) – Where to write/send this form
1
2
3
4
5
Air Force Personnel Center
HQ AFPC/DPSIRP
550 C Street West, Suite 19
Randolph AFB, TX 78150-4721
6
National Archives & Records Administration
Old Military and Civil Records (NWCTB-Military)
Textual Services Division
700 Pennsylvania Ave., N.W.
Washington, DC 20408-0001
11
Department of Veterans Affairs
Records Management Center
P.O. Box 5020
St. Louis, MO 63115-5020
7
US Army Human Resources Command
ATTN: AHRC-PDR-V
1600 Spearhead Division Ave., Dept 420
Fort Knox, KY 40122-5402
[email protected]
12
Division of Commissioned Corps Officer Support
ATTN: Records Officer
1101 Wooton Parkway, Plaza Level, Suite 100
Rockville, MD 20852
8
Reserved.
13
Reserved.
Headquarters U.S. Marine Corps
Manpower Management Support Branch
(MMSB-10)
2008 Elliot Road
Quantico, VA 22134-5030
9
Reserved.
14
National Personnel Records Center
(Military Personnel Records)
1 Archives Dr.
St. Louis, MO 63138-1002
Marine Forces Reserve
4400 Dauphine St.
New Orleans, LA 70146-5400
10
Air Reserve Personnel Center
Records Management Branch
(DPTARA)
18420 E. Silver Creek Ave.
Bldg. 390 MS 68
Buckley AFB, CO 80011
Commander, Personnel Service Center
(PSD-MR) MS7200
US Coast Guard
4200 Wilson Blvd., Suite 1100
Arlington, VA 29598-7200
http://uscg.mil/psc/adm
Navy Personnel Command (PERS-312E)
5720 Integrity Drive
Millington, TN 38055-3120
eVetRecs!
http://www.archives.gov/veterans/military-service-records/
Veterans’ Preference Form
Instructions: Complete this two-page form and provide the required documentation if you are claiming veterans’
preference. Print the requested information in the spaces provided and sign below. Documentation from the
Department of Defense (DD) and/or the Department of Veterans’ Affairs (VA) is required. Preference may only be
provided to qualified applicants who have participated in a selection procedure and have submitted the required form
and documentation no later than the closing of the application period. Preference will not be awarded retroactively.
Position applied for _____________________________________________________________________________
Applicant's name (first, middle, last) ___________________________________________________________________
Veteran’s name (first, middle, last) _____________________________________ Branch of service ________________
Type of discharge ___________________ Date of discharge ________________ Is the veteran retired? _________
Does the veteran have a compensable service connected disability? ___________ Percent of disability __________%
Type of documentation submitted __________________________________________________________________
CATEGORIES OF PROTECTED INDIVIDUALS - DOCUMENTATION REQUIRED - Check all that apply (  )
(_____) 1. A veteran with a service-connected disability who is eligible for or receiving compensation, disability
retirement, or pension under public laws administered by the U.S. Department of Veterans Affairs and the
Department of Defense. If checked, the percentage of disability is ________ percent.
 Provide copy of DD-214 or equivalent from the VA showing military status, dates of service, discharge
type; and copy of document from the DD, or VA certifying the veteran has a compensable service
connected disability.
(_____)
2. The spouse of a veteran who cannot qualify for employment because of a total and permanent serviceconnected disability, or the spouse of a veteran missing in action, captured, or forcibly detained by a
foreign power.

Spouses of Disabled Veterans provide copy of spouse’s DD-214 or equivalent from the VA showing
military status, dates of service, discharge type; copy of document from the DD, or VA certifying the
veteran is totally and permanently disabled; and copy of marriage certificate along with proof that the
veteran cannot qualify for employment because of service connected disability.
(_____) 3. 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. Any Armed Forces Expeditionary Medal, as well as the Global
War on Terrorism Expeditionary Medal are qualifying for Veterans’ Preference. A veteran who served
honorably but who has not met the criteria for the award of a campaign or expeditionary medal for service
in Operation Enduring Freedom or Operation Iraqi Freedom qualifies for preference in appointment,
effective July 1, 2007.

Provide copy of DD-214 or equivalent from the VA showing military status, dates of service, discharge
type.
(_____) 4. The un-remarried widow or widower of a veteran who died of a service-connected disability.

Veteran’s spouse must provide copy of spouse’s DD-214 or equivalent from the VA certifying the
service connected death of the veteran; copy of marriage certificate; and copy of the veteran’s death
certificate.
Important Notice:
Chapter 295, Florida Statutes, sets forth certain requirements for public employers to accord preferences, in
appointment, retention, and promotion, to certain veterans and spouses of veterans who are Florida residents.
Preference in appointment and employment shall be given by the state and its political subdivisions, first to those
persons included in categories 1 and 2 and second to those persons included under categories 3 and 4 (as shown on
page one of this form). Preference in appointment and employment requires that a preferred applicant be given special
consideration at each step of the employment selection process, but does not require the employment of a preferred
applicant over a non-preferred applicant who is the most qualified for the position.
An applicant who is eligible for veterans’ preference who believes he or she was not afforded employment preference
in accordance with Florida law may file a complaint with: Florida Department of Veterans' Affairs (FDVA), PO Box
31003, St. Petersburg, FL 33731, telephone (727) 319-7462, requesting an investigation. When the applicant has
received notice of a hiring decision from a covered employer, the complaint shall be filed within 21 calendar days from
the date that the notice is received by the applicant. When the applicant has not received notice of a hiring decision
within two calendar months of the receipt of the application by the employer, the applicant shall contact the employer
to determine if the position has been filled by the appointment of a non-preferred applicant. After having determined
from information supplied by the employer that the position has been filled by the appointment of a non-preferred
applicant, the preferred applicant may file a complaint within three calendar months of the date the application was
received by the employer. If the position has not been filled, the time period for filing a complaint is extended to
provide the preferred applicant one calendar month after having determined that the position has been filled. It is the
responsibility of the preferred applicant to maintain contact with the employer to determine if a position has been filled.
Chapter 98-33, s. 2, Laws of Fla., exempts from the law positions that are exempt from the state career service system
under Section 110.205 (2), Florida Statutes. The 2001 session of the Florida Legislature enacted a significant change
to the law concerning exempt positions for veteran's preference at the political subdivision level effective July 1, 2001.
Chapter 2001-273, Laws of Florida, eliminates the exemption for some of the previously exempted positions. As of the
effective date of the law, city managers, county managers, and management and policymaking positions of political
subdivisions of the state are now eligible for preference in appointment and retention as provided in s. 295.07(1).
Signature of Applicant (required):
I, the undersigned veteran or eligible spouse, acknowledge that I have provided true and correct information on this
form and any related documentation; and that I have read and understand the rights expressed in the foregoing notice.
Signature __________________________________________________ Date _______________________________
Wartime Eras – to determine veterans’ preference based on wartime era service, these periods qualify:
Operation Iraqi Freedom - March 19, 2003 to a date to be determined
Operation Enduring Freedom - October 7, 2001 to a date to be determined
Persian Gulf War - August 2, 1990 to January 2, 1992
Vietnam Era - February 28, 1961 to May 7, 1975
Korean Conflict - June 27, 1950 to January 31, 1955
World War II - December 7, 1941 to December 31, 1946
th
th
Submit completed form and documentation to: City of St. Petersburg, Employment Office, One 4 Street North, 4 Floor,
Phone (727) 893-7311 — Fax (727) 893-4128
Open 8 am to 4 pm on Monday, Wednesday and Friday.
Revised 06/2013
PRE-EMPLOYMENT
PERSONAL HISTORY QUESTIONNAIRE
INSTRUCTIONS
THIS PERSONAL HISTORY QUESTIONNAIRE MUST BE COMPLETED BY THE APPLICANT.
ALL ANSWERS MUST BE HAND PRINTED IN INK OR TYPED AND BE COMPLETELY
LEGIBLE.
READ ALL QUESTIONS COMPLETELY. ANSWER ALL QUESTIONS FULLY AND TRUTHFULLY.
ALL INFORMATION CONTAINED HEREIN WILL BE SUBJECT TO VERIFICATION.
IF A QUESTION DOES NOT APPLY, MARK N/A IN THE APPROPRIATE SPACE. IF THE ANSWER
REQUIRES MORE SPACE, USE THE BACK OF THE PAGE. COMPLETE MAILING ADDRESSES,
INCLUDING ZIP CODES FOR RESIDENCES, SCHOOLS, EMPLOYERS, AND CHARACTER
REFERENCES ARE MANDATORY.
FAILURE TO PROVIDE COMPLETE ADDRESSES, INCLUDING ZIP CODES, MAY SLOW
DOWN THE PROCESS UNTIL THE NECESSARY ADDRESSES ARE PROVIDED TO THE
EMPLOYMENT OFFICE.
** WARNING **
APPLICANTS ARE EXPECTED TO ANSWER EVERY QUESTION TRUTHFULLY AND WITHOUT
EVASION.
FALSIFICATION AND/OR THE OMISSION OF INFORMATION IN THIS QUESTIONNAIRE MAY
SUBJECT THE APPLICANT TO DISQUALIFICATION.
APPLICANT'S FULL NAME (PRINT)
APPLICANT'S SIGNATURE
DATE SUBMITTED
POSITION APPLIED FOR
DATE
REVIEWER
THE CITY OF ST. PETERSBURG IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY
EMPLOYER
U:\PD_App\Documents for PD Applicants\Current Application Forms\Police Application 2014\PHQ for SPPD.wpd
Revised 5/1/08
I.
PERSONAL DATA
1.
Full Name
LAST
2.
3.
FIRST
MIDDLE
Date of Birth
/
/
Mo. Day Year
MAIDEN
/
/
Social Security Number
Place of Birth
City
4.
Citizen of
5.
Present Statistics:
Weight
County
State
Country
Alien #
Height
Eyes
Hair
Race
6.
List all names used (real and nicknames)
7.
Present Address (Include name of apartment or condominium complex)
Street Number
Sex
Apt./Lot#
City
State
Zip Code
How long have you lived at this address?
Years/Months
Home Phone (
Cell Phone (
)
)
Business Phone (
Pager (
)
)
List all persons other than your spouse and children, who currently reside with you
at the above address
Full Name
Date of Birth
Relationship
Revised 5/1/08
Page 2
8.
List chronologically all previous places of residence since age 14, including places of residence while
attending college, vocational school, or during military service.
DATES
Example:
8/85 - 4/98
ADDRESS
175 5th Street North
CITY
St. Petersburg
COUNTY
STATE
Pinellas
FL
ZIP
33705
USE THE BACK OF THIS PAGE IF ADDITIONAL SPACE IS NEEDED.
REVISED 5/01/08
Page 3
9.
DRUG AND ALCOHOL USE
a) How frequently do you currently consume alcoholic beverages? Check one:
daily
weekly
monthly
holidays and special occasions
never
When you drink alcoholic beverages, how much do you consume?
.
b) Have you ever used or experimented with HEROIN, commonly known as BLACK TAR,
BOY, SMACK, CODEINE, MORPHINE, or METHADONE?
. If yes, how many
times?
. If yes, list date of last use
.
c) Have you ever used or experimented with PSILOCYBIN, commonly known as
MUSHROOMS?
. If yes, how many times?
. If yes, list date of last
use
.
d) Have you ever inhaled, sniffed, or breathed GLUE, GASOLINE, FREON, NITROUS
OXIDE, or any other substance in order to obtain an euphoric effect?
. If yes,
how many times?
.
e) Have you ever used or experimented with MARIJUANA, or HASHISH, commonly known
as DOG WEED, GRASS, GREEN, GREENBUD, or SINSE?
. If yes, how many
times?
. Date of last use?
.
f) Have you ever used or experimented with COCAINE, commonly known as COKE, FLAKE,
SNOW, ROCK, ROXANNE, WHITE, GIRL, BOLO, CRACK, COOKIE, WEASEL,"C",
or STARDUST?
.
If yes, list date of last
use
.
g) Have you ever used or experimented with LSD, commonly known as ACID, SUGAR, BIG
"D", CUBES, TRIPS, BLOTTER, or MICRODOT?
.
h) Have you ever used or experimented with PHENCYCLIDINE or its derivatives, commonly
known as PCP, PCPY, PEC, or ANGEL DUST?
.
i) Have you ever, while not under the care of a physician, tried, used, or experimented with
METHAQUALONE, commonly known as LUDES, 714's, or LEMONS?
. If
yes, how many times?
.
j) Have you ever, while not under the care of a physician, tried, used, or experimented with
HYDROMORPHONE, commonly known as DILAUDID or D's?
. If yes, how
many times?
.
k) Have you ever, while not under the care of a physician, tried, used, or experimented with
DIAZEPAM, commonly known as VALIUM?
.
If yes, list date of last use
.
l) Have you ever, while not under the care of a physician, tried, used, or experimented with
OXYCODONE, also known as PERCODAN, commonly known as PERKS?
If yes, how many times?
.
.
REVISED 5/01/08
Page 4
DRUG AND ALCOHOL USE (CONTINUED)
m) Have you ever, while not under the care of a physician, tried, used, or experimented with any
drugs classified as depressants commonly known as GOOFBALLS, GOOFERS, BARBS,
YELLOW JACKETS, BLUES, BLUEBIRD, REDS, RED DEVILS, TUES, RAINBOWS,
also known as TUINAL, BUTABARBITAL, PHENOBARBITAL, NEMBUTAL,
SECONAL, and AMYTAL?
. If yes, list date
of last use
.
n) Have you ever, while not under the care of a physician, tried, used, or experimented with any
drugs classified as stimulants, commonly known as BENNIES, DEXIES, SPEED, WAKEUPS, PEP PILLS, METH, CRYSTAL, or CRYSTAL METH, also known as
BENZEDRINE, DEXE, DRINE, DESOXYN, MEDRINE, METHAMPHETAMINE,
PHENTENMINE, PHENMETRZINE, or PHEN-DI-METRZINE?
. If yes, how
many times?
.
o) Have you ever, while not under the care of a physician, tried, used, or experimented with any
drugs classified as STEROIDS?
. If yes, list date
of last use
.
p) Have you ever, while not under the care of a physician used, experimented with, or possessed
the drug FLUNITRAZEPAM, also known as ROHYPNOL or ROOFIES?
If yes,
how many times?
. If yes, list date of last contact and explain
.
q) Have you ever tried, used, experimented with, or possessed the drug KETAMINE, commonly
known as SPECIAL K?
. If yes, list date of
last contact and explain
.
r) Have you ever used or experimented with METHYLENEDIOXYMETHAMPHETAMINE
commonly known as ECSTASY?
. If yes
list date of last use
.
s) Have you ever tried, used, experimented with, or possessed the drug GAMMA-HYDROXY
BUTYRATE commonly known as GHB ?
.
If yes, list date of last contact and explain
.
t) Have you ever, while not under the care of a physician, tried, used, or experimented with any
other controlled or illegal drug not listed above?
. If yes, what?
u) Have you ever, while not under the care of a physician, tried, used, or experimented with a
prescribed drug that was not prescribed to you?
. If yes, explain including date(s)
used, how many times, type of medication, who medication prescribed to, and reason for use.
__________________________________________________________________________
REVISED 5/01/08
Page 5
II.
MARITAL STATUS
1.
2.
Check One:
Married
Single
Separated
Widowed
Present spouse's full name:
Last
First
Date of birth:
Date of marriage:
/
Year
/
Day
Year
Location of marriage:
/
City
5.
Maiden
/
Day
Month
4.
Middle
/
Month
3.
Divorced
/
County
State
Because of marital problems, have you ever separated legally or other-wise?
yes, why?
If
.
6.
Is your spouse in favor of your applying for this position?
7.
Is spouse employed?
. If not, why?
If so, where?
Phone
LIST ALL OF YOUR CHILDREN
DATE
OF BIRTH
PLACE
OF BIRTH
NAME
COMPLETE ADDRESS (INCLUDING ZIP)
REVISED 5/01/08
Page 6
MARITAL STATUS - PAST
1.
Former spouse's name:
Last
First
2.
Full current address, if known:
3.
Date and location of former marriage:
Date
City
4.
Your address at time of dissolution:
5.
Spouse's address at time of dissolution:
6.
Reason for dissolution:
7.
Grounds for legal action:
8.
Filing party:
9.
Date of action:
10.
Middle
Widowed
Maiden
State
Annulled
Divorced
Title and location of court issuing divorce or annulment:
a)
Are you paying ( ) receiving ( ) support checks? If yes, how much?
b)
Are you paying ( ) receiving ( ) alimony? If yes, amount:
To ( ) From ( ) Whom:
c)
Have you had legal action taken against you for delaying or failing to make payment?
If yes, why?
d)
Have you ever been named in a divorce suit as a correspondent?
If yes, explain
IF MORE THAN ONE PREVIOUS MARRIAGE, PROVIDE SAME INFORMATION ON BACK OF
PAGE.
REVISED 5/01/08
Page 7
III.
EDUCATION BACKGROUND (List all schools, public, special, etc. since eighth (8th) grade. Use
the back of this page if additional space is needed.
DATES
Example:
8/81-6/83
SCHOOL NAME
St. Pete High
ADDRESS
2501 5th Ave. N.
St. Pete, FL, 33713
MAJOR/MINOR
During your educational period, were you ever expelled, suspended or placed on probation?
explain
IV.
GRAD.?
Yes/No
If yes,
MILITARY
1.
Have you ever served in the Armed Forces?
From
To
Branch
Rank
Serial#
Type of Discharge
Reason for discharge:
(Reasons other than normal ETS must be explained on the back of this page).
2.
During your military term, were you ever given letters of counseling, punished, reprimanded, fined or
reduced in rank for infractions of rules?
If yes, give date(s):
Charges:
Result of actions:
USE BACK OF PAGE IF ADDITIONAL SPACE IS REQUIRED
REVISED 5/01/08
Page 8
MILITARY (Continued)
3.
Are you connected with any reserve force or national guard unit?
From
To
Location:
Unit
Rank
Type of Discharge:
List all areas where stationed, and approximate dates:
NAME OF BASE
4.
NEAREST CITY, COUNTY & STATE
Current Selective Service#:
Classification
Local#:
*5.
Have you ever had any draft deferments?
*6.
Have you ever been rejected for military service for non-medical reasons?
explain:
7.
DATES
Why?
. If yes,
Have you ever served with any military or paramilitary of any country other than the United States?
Where
Rank
Dates (From):
(To)
Type of Discharge:
* USE BACK OF PAGE IF ADDITIONAL SPACE IS REQUIRED
REVISED 5/01/08
Page 9
V.
EMPLOYMENT RECORD
A. List all places of employment for the past ten (10) years. List present to past.
DATES
FROM-TO
BUSINESS NAME
& ADDRESS
Example:
6/98- Present
JRA Corporation
1005 54th Ave. No.
St. Pete, FL 33713
REASON FOR
LEAVING
"Fired"
"Asked to resign"
"Voluntarily Resigned"
"Laid off"
POSITION
SUPERVISOR'S
NAME
Crew Leader
Bill Davis
USE THE BACK OF THIS PAGE IF ADDITIONAL SPACE IS REQUIRED
REVISED 5/01/08
Page 10
EMPLOYMENT RECORD (CONTINUED):
B.
Do you have any objection to your present employer being contacted in reference to your application?
If yes, why?
C.
Have you ever applied for employment or volunteer auxiliary/reserve appointment with any public
safety agency, police, or fire department prior to this?
If yes, list which one(s) below.
AGENCY NAME
DATE OF
APPLICATION
POSITION
APPLIED FOR
STATUS OF
APPLICATION & LAST
STEP COMPLETED
REVISED 5/01/08
Page 11
VI.
FINANCIAL HISTORY
A. List all companies, banks, corporations, or organizations to which you owe money (including any
loans on which you are the co-signer), and indicate if payments are current. Use the back of this
page if additional space is required.
NAME &
ADDRESS
TYPE OF
LOAN
BALANCE
PAYMENT
AMOUNT
DATE OF
LAST PMT.
LIST ANY ADDITIONAL CREDITORS ON BACK OF PAGE
B. Answer all of the following. Explain any yes answers on the back of this page.
1. Have you ever been threatened with any legal action due to an outstanding debt?
YES
NO
.
2. Have you ever had your wages attached or garnished? YES
3. Have you ever been subject to small claims court? YES
4. Have you ever been subject to Circuit Civil Court? YES
5. Do you or your spouse have any pending civil action? YES
6. Have you ever filed bankruptcy? YES
NO
NO
NO
NO
7. Have you ever been refused credit? YES
8. Have you ever been bonded? YES
NO
NO
NO
9. Have you ever been refused bonding? YES
NO
10. Will your financial situation require income other than that earned through employment
with the City of St. Petersburg Police Department? YES
NO
REVISED 5/01/08
Page 12
VII.
CRIMINAL HISTORY
NOTE: Pursuant to Florida State Statute 943.0585(4)(a.)1.: an applicant for employment with a
law enforcement agency may not lawfully deny/withhold information concerning arrests
or convictions, regardless of adjudication being withheld or the sealing or expungement
of arrest or conviction records. Further, a misdemeanor arrest or conviction may not
necessarily disqualify you for employment.
Answer all of the following. Explain any yes answers below.
1. Have you ever (adult or juvenile) been arrested?
2. Have you ever (adult or juvenile) been taken into custody, or detained by a law enforcement
agency?
3. Have you ever been questioned or had any contact with a law enforcement officer?
4. Have you ever (adult or juvenile) been issued a Notice To Appear in court?
5. Have you ever (adult or juvenile) been a defendant in criminal court?
6. Have you ever (adult or juvenile) had a criminal record?
7. Have you ever (adult or juvenile) been convicted for violation of any law or ordinance other than
minor traffic violations?
8. Have you ever (adult or juvenile) had adjudication withheld?
9. Have you ever (adult or juvenile) been on criminal probation, supervised or unsupervised?
10.
Have you ever been fined (other than traffic)?
11.
Have you ever filed for a restraining order or had a restraining order filed against you for any
reason?
VII.
CRIMINAL HISTORY (Explanations; include specific charges, dates, and locations)
REVISED 5/01/08
Page 13
VIII
INTERNET
If you answered yes to any of the below questions please explain.
1.
Have you ever violated any Federal or State law involving Internet use?
2.
Have you ever used the Internet for any type of child pornography?
3.
Have you ever been involved in commercial pirating of computer software?
4.
While employed by a company have you ever violated any company policy regulating the
use of the company’s Internet?
EXPLAIN:
IX.
TRAFFIC - Complete this section only if the position you are applying for requires
possession and maintenance of a valid driver's license.
List all citations and violations incurred during the last five (5) years.
DATE
MONTH/YEAR
CITATION(S)/VIOLATION(S)
CITY & STATE FINDINGS
A. Do you have a valid driver's license?
State
D/L#
Expires
B. Have you ever held a valid driver's license in another state?
State
D/L#
C. Have your driving privileges ever been suspended, canceled, or revoked?
why?
State
. If yes,
Year
D. Have you been involved in any traffic accidents, as a driver, in the last five (5) years?
yes indicate date, and location
. If
REVISED 5/01/08
Page 14
X.
A.
FAMILY
List family information
NAME
ADDRESS
DATE OF BIRTH
ADDRESS
DATE OF BIRTH
Father:
Mother:
NAME
Brother(s):
Sister(s):
B.
Do you have any relatives currently employed with the St. Petersburg Police Department? _________
If so, please list name(s), position title, and their relation to you ______________________________
_________________________________________________________________________________
_________________________________________________________________________________
IF ADDITIONAL SPACE IS NEEDED USE BACK OF THIS PAGE
REVISED 5/01/08
Page 15
XI.
A.
1.
REFERENCES (DO NOT LIST THE SAME PERSON TWICE)
List four character references (not relatives) who have known you for five years or more and who could
appraise your character, abilities, experiences, personality, and other qualities.
Name
Res. Phone (
)
Address
Bus. Phone (
)
Name
Res. Phone (
)
Address
Bus. Phone (
)
Name
Res. Phone (
)
Address
Bus. Phone (
)
Name
Res. Phone (
)
Address
Bus. Phone (
)
City/State/Zip
Place of Employment
2.
City/State/Zip
Place of Employment
3.
City/State/Zip
Place of Employment
4.
City/State/Zip
Place of Employment
B.
1.
List three personal friends (not relatives), including girlfriends and boyfriends with whom you are
currently associated.
Name
Res. Phone (
)
Address
Bus. Phone (
)
Name
Res. Phone (
)
Address
Bus. Phone (
)
City/State/Zip
Place of Employment
2.
City/State/Zip
Place of Employment
REVISED 5/01/08
Page 16
REFERENCES (CONTINUED)
3.
Name
Res. Phone (
Address
Bus. Phone (
)
)
City/State/Zip
Place of Employment
XII.
A.
LOYALTY
Do you now or have you ever belonged to any organization which engages in, advocates, or teaches
the overthrow or destruction of the constitutional form of U.S. or State government by force, violence,
or other unlawful means?
If yes, which organization(s)?
Present member?
Date
Past member?
Date
B.
Do you currently bear any intentionally inflicted scar, insignia, tattoo or other permanent bodily
marking depicting symbols or words which are commonly associated with any subversive,
paramilitary organization or gang?
If yes, please explain?
C.
Have you ever knowingly collected, donated or solicited funds for any subversive organization?
Yes
No
If yes, when?
Which
organization(s)?
D.
Do you now or have you ever belonged to, served with, applied to join, or associated with any gangs,
or organized groups dealing in illegal activities?
If yes, which organizations?
.
Are you presently a member?
. Are you a past member?
.
E.
Do you belong to any organizations?
Are you presently a member?
. Are you a past member?
.
.
F.
If you become a law enforcement officer with the St. Petersburg Police Department you will be
required to give an oath of allegiance. Is there any reason you couldn’t?
. If yes,
explain
G.
During the course of your duties, if you were required to lawfully take a human life, would you have
any reluctance to do so?
H.
Have you read the Florida State Statute 943.16 or the Police Officer New Employment Cost
Allocation Agreement, and fully understand the conditions contained therein, and willingly agree
to abide by the State Statutes or sign said contract if hired?
. (Leave Blank)
REVISED 5/01/08
Page 17
I affirm that this questionnaire contains no false statements, misrepresentations, or omissions; nor did I intentionally
conceal any material which would knowingly make me ineligible. I further understand that during investigation, should
any information be discovered as not factual, I will become ineligible for the position applied for and will not be eligible
for any other positions with the St. Petersburg Police Department.
SIGNATURE
(Do NOT sign prior to returning this
questionnaire to the Recruitment Office)
STATE OF FLORIDA
COUNTY OF PINELLAS
, who is personally known to me or
The foregoing instrument was acknowledged before me by
has produced
as identification and who did/did not take an oath, and who
appeared before me at the time of notarization.
WITNESS, my hand and official seal, this
day of
, A.D., 20
NOTARY PUBLIC
My Commission Expires:
Revised: 5/92
8/96
06/03
02/06/06
09/15/06
5/01/08
REVISED 5/1/08
Page 18

CITY OF ST. PETERSBURG APPLICATION PROCESS FOR EMPLOYMENT WITH THE

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