Sheriff Scotty Rhodebakerso.com/resources/BCSO-EMPLOYEMENT-APPLICATION_v2.pdf · Career Fair...

BCSO-A001 (Rev 2/17)

APPLICATION FOR EMPLOYMENT

EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER

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BAKER COUNTY SHERIFF’S OFFICE Sheriff Scotty Rhoden

BCSO-A001

APPLICATION INSTRUCTIONS

This application must be either typed or printed in legible form. Applications which are not legible 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 Baker County Sheriff’s Office Receptionist at, 1 Sheriff’s Office Drive, Macclenny, FL 32063

At such time that an opening becomes available in which you are qualified, you may be contacted for a personal interview.

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 employees, dates of employment and your job title.2. References should be long time friends but not neighbors, supervisors or co-workers.

Contact Human Resources regarding any change in application such as: residency, phone number of employment (permanent or part-time), name changes, military status, etc.

You are hereby informed 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 Baker County Sheriff’s Office does not discriminate on the basis of disability in its hiring or employment practices and complies with all regulations promulgated by the U.S. Equal Employment Opportunity Commission under title I of the Americans with Disabilities Act.

The Baker County Sheriff’s Office is an Equal Opportunity Employer

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Birth CertificateDriver’s License and Social Security CardRecent photo (passport size within the last 6 months)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 or Corrections 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. Basic Recruit Exam scores, if certification date is after June 30, 1993.BAT test results, if attended academy after January 1, 2002.Form DD214, if you are former military. Also complete “Request Pertaining to Military Records” form(located at end of application.)College Degree (sealed transcript must be supplied)Documents showing legal changes of name from birth to present (example: marriage license, divorce papers, adoption papers, etc.)Employee Eligibility Verification (I-9)Appropriate “Application Disqualifiers” form – Sworn or Civilian (located at end of application)

FOR OFFICIAL USE ONLY

INITIAL & DATE:_____________________________

Your application WILL NOT be considered if you do not provide a copy of all the following documents.

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NOTICE TO PERSONS REGARDING COLLECTION OF SOCIAL SECURITY NUMBERS

The Baker County Sheriff’s Office 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 LawEnforcement Officers;

(3) Apply to volunteer with this agency; and

(4) Are arrested by this agency.

Social Security Numbers are collected by the Baker County Sheriff’s Office 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 Medicaretaxes, retirement and other items pursuant to State and Federal law; and

(4) To determine criminal history and to verify wants, warrants, and/or capiases.

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BAKER COUNTY SHERIFF’S OFFICESheriff Scotty Rhoden

AFFIRMATIVE ACTION FOR STATISTICAL USE ONLY

Dear Applicant:

Our agency is an Equal Opportunity / Affirmative Action employer and subject to certain reporting and affirmative action requirements. The information required on this insert is requested only so that we may 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: Male Female

2. ETHNICITY: 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

HANDICAPPED: Yes No

VETERAN: Yes No

AGE: ______

How were you referred to our agency?

Newspaper Ad (specify) _____________________ Other Ad (radio, TV, etc.) _____________________ Career Fair (specify) _____________________ Walk In _____________________ Agency (specify) _____________________ Employee (whom) _____________________ State Employment Service _____________________ Internet _____________________ Other _____________________

EQUAL EMPLOYMENT OPPORTUNITY EMPLOYEE

BCSO-A001

BAKER COUNTY SHERIFF’S OFFICEBaker County, Fl. 32063

PERSONAL DATA

Date: ________________________ 1. Position Sought: ________________________________________________________________________

2. Social Security: ___________________ 3. Name: _____________________________________________(Last, First, Middle)

4. Residence Address: _________________________________________________________________ (Street)

_________________________________________________________________ (Mailing Address)

_________________________________________________________________ (City, State, Zip Code)

__________________________________________________________________ (Area Code and Phone Number) (Cell Number)

5. Date of Birth: ____ ____ ____ 6. Place of Birth: _______________________________(Mo.) (Day) (Year) (City and State)

7. U. S. Citizen: [ ] Yes [ ] No 8. Naturalized? [ ] Yes [ ] No (If yes, provide the certificate number of your

naturalization papers)

9. Do you have any relatives working for the Baker County Sheriff’s Office? [ ] Yes [ ]

No If yes, Name: ______________________________ Relationship:

10. Have you ever worked for or applied to the Baker County Sheriff's Office before? [ ] Yes [ ] NoIf yes, Please give the year and position applied for: ______________________________________

11. Have you ever applied to any other law enforcement agency? [ ] Yes [ ] NoIf yes, list name of agency and date of application: ______________________________________________________________________________________________________________________________________________________________________________________________________

* If you apply to any other law enforcement agency after having turned in thisapplication, please notify this agency

12. Are you now on any eligibility lists? Yes No If yes, list the name(s) of the agency:__________________________________________________________________________________

13. Have you had any law enforcement training by any local, state or federal agency? [ ] Yes [ ] NoDid you receive a certificate for this training? [ ] Yes [ ] No If yes, the date? _______________In what state? _________________ Type of certificate: ____________________________________

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ARREST HISTORY / COURT DATA

Have you ever been convicted of a felony or misdemeanor? [ ] Yes [ ] NoIf yes, Please explain (Dates, Places, Agency involved)

________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________

Have you ever been arrested, received a notice or summons to appear, charged, convicted, pled nolocontendre pled guilty to any criminal violation, regardless if the record was sealed or expunged?If yes, Please explain: Yes No__________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

Have you ever been detained, questioned, interviewed or in any way been contacted by a lawenforcement agency for any reason (including investigative purposes)? (list name of agency andReason for contact) Yes No

Please explain: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been a respondent in an injunction for protection, domestic violence injunction ora restraining order? Yes NoPlease explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been a plaintiff or defendant in a court action? Yes NoPlease explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

U. S. MILITARY RECORD

19. Draft Status: _______________Reserve Status: _____________National Guard Status: _____________

Selective Service Number: _______________________ (www.sss.gov to verify)

20. Active Service From: ____________________ To: _______________ Branch: ___________________

Highest Rank: ______________________Type of Discharge: __________________________________

Date of Discharge: ___________________Military Specialization and Duties: _____________________

_____________________________________________________________________________________

21. I, ____________________________________________, have never served in the U. S. Armed Forces.

______________________________________________________________________________________Signature Date

BCSO-A001 of 25

http://www.sss.gov/

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no laterthan the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

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/ /

Form I-9 11/14/2016 N

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge theemployee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishescontinuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

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LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or AlienRegistration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains atemporary I-551 stamp or temporaryI-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Documentthat contains a photograph (FormI-766)

5. For a nonimmigrant alien authorizedto work for a specific employerbecause of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States ofMicronesia (FSM) or the Republic ofthe Marshall Islands (RMI) with FormI-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe United States and the FSM or RMI

b. Form I-94 or Form I-94A that hasthe following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long asthat period of endorsement hasnot yet expired and theproposed employment is not inconflict with any restrictions orlimitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by aState or outlying possession of theUnited States provided it contains aphotograph or information such asname, date of birth, gender, height, eyecolor, and address

9. Driver's license issued by a Canadiangovernment authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant MarinerCard

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or localgovernment agencies or entities,provided it contains a photograph orinformation such as name, date of birth,gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

8. Employment authorizationdocument issued by theDepartment of Homeland Security

1. A Social Security Account Numbercard, unless the card includes one ofthe following restrictions:

2. Certification of Birth Abroad issuedby the Department of State (FormFS-545)

3. Certification of Report of Birthissued by the Department of State(Form DS-1350)

4. Original or certified copy of birthcertificate issued by a State,county, municipal authority, orterritory of the United Statesbearing an official seal

5. Native American tribal document

7. Identification Card for Use ofResident Citizen in the UnitedStates (Form I-179)

Documents that Establish Employment Authorization

6. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION

(3) VALID FOR WORK ONLY WITHDHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Form I-9 11/14/2016 N

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

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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 SF180. 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 therequested information as you can. Incomplete information may delay response time. To determine where to mail this request see Page 2 of the SF180 forrecord 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). STRs of persons on active duty are generally kept at the local servicing clinic. After the last day of active duty, STRs should be requested from the appropriate address on page 2 of the SF 180. (See item 3, Archival Records, if the military member was discharged, retired or died in service more than 62 years ago.)

a. Release of information: Release of information is subject to restrictions imposed by the military services consistent with Department of Defenseregulations, the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The service member (either past or present) orthe member's legal guardian has access to almost any information contained in that member's own record. The 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/orSTRs must have the release authorization in Section III of the SF 180 signed by the member or legal guardian. If the appropriate signature cannot beobtained, only limited types of information can be provided. If the former member is deceased, the 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 thefollowing: 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 ischarged for certain types of service. In most instances, service fees cannot be determined in advance. If your request involves a service fee, you willreceive an invoice with your records.

3. Archival Records. Personnel records of military members who were discharged, retired, or died in service 62 OR MORE YEARS AGO have beentransferred 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, writtenauthorization from the veteran or next-of-kin is not required. In order to protect the privacy of the veteran, his/her family, and third parties named inthe records, the personal privacy exemption of the Freedom of Information Act (5 U.S.C. 552 (b) (6)) may still apply and may preclude the releaseof some information.

b. Fees for Archival Records: Access to archival records are granted by offering copies of the records for a fee (44 U.S.C. 2116 (c)). If a fee appliesto the photocopies of documents in the requested record, you will receive an invoice. Photocopies will be sent after payment is made. For moreinformation 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 authorizedrequester. If the designated address is NOT registered to the addressee by the U.S. Postal Service (USPS), provide BOTH the addressee’s name AND “incare of” (c/o) the name of the person to whom the address is registered on the NAME line in Section III, item 3, on page 1 of the SF 180. The COMPLETEaddress must be provided, INCLUDING any apartment/suite/unit/lot/space/etc. number.

5. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; SERVICE TREATMENT RECORD (STR) -- Thechronology of medical, mental health, and dental care received by service members during the course of their military career (does not include records oftreatment 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 (ISSD), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE APPROPRIATE ADDRESS LISTED ON PAGE 2 OF THE SF 180.

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http://www.archives.gov/veterans/military-service-records/

http://www.archives.gov/st-louis/archival-programs/military-personnel-archival/ompf-archival-requests.html

Standard Form 180 (Rev. 11/2015) (Page 1) Authorized for local reproduction

Prescribed by NARA (36 CFR 1233.18 (d)) Previous edition unusable OMB No. 3095-0029 Expires 04/30/2018

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 LEGIBLY OR TYPE BELOW.

SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible.)

1. NAME USED DURING SERVICE (last, first, full middle) 2. SOCIAL SECURITY # 3. DATE OF BIRTH 4. PLACE OF BIRTH

5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.)

BRANCH OF SERVICE DATE

ENTERED

DATE

RELEASED OFFICER ENLISTED

SERVICE NUMBER (If unknown, write “unknown”)

a. ACTIVE

b. RESERVE

c. STATE

NATIONAL

GUARD

6. IS THIS PERSON DECEASED? NO YES - MUST provide Date of Death if veteran is deceased:

7. DID THIS PERSON RETIRE 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. Year(s) in which form(s) issued to veteran:

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. If you

request a DELETED copy, the following items will be blacked out: 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.

An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box: I want a DELETED copy.

Medical Records Includes Service Treatment Records, Health (outpatient) and Dental Records. IF HOSPITALIZED (inpatient) the FACILITY NAME and

DATE (month and year) for EACH admission MUST be provided:

Other (Specify):

2. PURPOSE: (Providing information about the purpose of the request is strictly voluntary; however, it 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.)

Benefits (explain) Employment VA Loan Programs Medical Genealogy Correction Personal Other (explain)

EExplain here:

SECTION III - RETURN ADDRESS AND SIGNATURE

1. REQUESTER NAME:

2. I am the MILITARY SERVICE MEMBER OR VETERAN identified in Section

I, above.

I am the VETERAN’S LEGAL GUARDIAN (MUST submit copy of Court

Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit copy of

Authorization Letter or Power of Attorney) I am the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit Proof of

Death. See item 2a on instruction sheet.) OTHER

(Relationship to deceased veteran) (Specify type of Other)

3. SEND INFORMATION/DOCUMENTS TO:

(Please print or type. See item 4 on accompanying instructions.)4. AUTHORIZATION SIGNATURE: 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 and

that I authorize the release of the requested information. (See items 2a or

3a on accompanying instruction sheet. Without the Authorization Signature

of the veteran, next-of-kin of deceased veteran, veteran’s legal guardian,

authorized government agent, or other authorized representative, only

limited information can be released unless the request is archival. No

signature is required if the request if for archival records. )

Name

Street Apt.

______________________________________________________________

City State Zip Code

* This form is available at http://www.archives.gov/veterans/military-service-

records/standard-form-180.html on the National Archives and

Records Administration (NARA) web site. *

Signature Required - Do not print Date

Daytime phone Fax Number

Email address

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TFECHHEL

Cross-Out

Standard Form 180 (Rev. 11/2015) (Page 2) Authorized for local reproduction

Prescribed by NARA (36 CFR 1233.18 (d)) Previous edition unusable OMB No. 3095-0029 Expires 04/30/2018

LOCATION OF MILITARY RECORDSThe 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.

BRANCH CURRENT STATUS OF SERVICE MEMBER ADDRESS CODEPersonnel

Record

Medical or Service

Treatment Record

AIR

FORCE

Discharged, deceased, or retired before 5/1/1994 14 14

Discharged, deceased, or retired 5/1/1994 – 9/30/2004 14 11


Discharged, deceased, or retired on or after 1/1/2014 1 13

Active (including National Guard on active duty in the Air Force), TDRL, or general officers retired with pay 1

Reserve, IRR, Retired Reserve in non-pay status, current National Guard officers not on active duty in the Air Force, or National Guard

released from active duty in the Air Force 2

Current National Guard enlisted not on active duty in the Air Force 2 13

COAST

GUARD

Discharge , deceased, or retired before 1/1/1898 6





Active, Reserve, Individual Ready Reserve or TDRL 3

MARINE

CORPS

Discharged, deceased, or retired before 1/1/1895 6



Discharged, deceased, or retired 1/1/1999 - 12/31/2013 4 11


Individual Ready Reserve 5

Active, Selected Marine Corps Reserve, TDRL 4

ARMY

Discharged, deceased, or retired before 11/1/1912 (enlisted) or before 7/1/1917 (officer) 6

Discharged, deceased, or retired 11/1/1912 – 10/15/1992 (enlisted) or 7/1/1917 – 10/15/1992 (officer) 14


Discharged, deceased, or retired (including TDRL) 10/1/2002 – 12/31/2013 7 11

Discharged, deceased, or retired (including TDRL) on or after 1/1/2014 7 9

Current Soldier (Active, Reserve (including Individual Ready Reserve) or National Guard) 7

NAVY

Discharged, deceased, or retired before 1/1/1886 (enlisted) or before 1/1/1903 (officer) 6

Discharged, deceased, or retired 1/1/1886 – 1/30/1994 (enlisted) or 1/1/1903 – 1/30/1994 (officer) 14 14




Active, Reserve, or TDRL 10

PHS Public Health Service - Commissioned Corps officers only 12

ADDRESS LIST OF CUSTODIANS and SELF-SERVICE WEBSITES (BY CODE NUMBERS SHOWN ABOVE) – Where to write/send this form

1

Air Force Personnel Center

HQ AFPC/DPSIRP

550 C Street West, Suite 19

Randolph AFB, TX 78150-4721

6

National Archives & Records Administration

Research Services (RDT1R)

700 Pennsylvania Avenue NW

Washington, DC 20408-0001

11

Department of Veterans Affairs

Records Management Center

ATTN: Release of Information

P.O. Box 5020

St. Louis, MO 63115-5020

2

Air Reserve Personnel Center

Records Management Branch (DPTSC)

18420 E. Silver Creek Avenue

Building 390 MS 68

Buckley AFB, CO 80011

7

US Army Human Resources Command’s web page:

https://www.hrc.army.mil/TAGD/Accessing%20or%20

Requesting%20Your%20Official%20Military%20Pers

onnel%20File%20Documents

or 1-888-ARMYHRC (1-888-276-9472)

12

Division of Commissioned Corps Officer Support

ATTN: Records Officer

1101 Wooton Parkway, Plaza Level, Suite 100

Rockville, MD 20852

3

Commander, Personnel Service Center

(BOPS-C-MR) MS7200

US Coast Guard

2703 Martin Luther King Jr Ave SE

Washington, DC 20593-7200

[email protected]

8

Navy Medicine Records Activity (NMRA)

BUMED Detachment St. Louis

4300 Goodfellow Boulevard, Building 103

St. Louis, MO 63120

13

AF STR Processing Center

ATTN: Release of Information

3370 Nacogdoches Road, Suite 116

San Antonio, TX 78217

14

National Personnel Records Center

(Military Personnel Records)

1 Archives Drive

St. Louis, MO 63138-1002

eVetRecs:


4

Headquarters U.S. Marine Corps

Manpower Management Records & Performance

(MMRP-10)

2008 Elliot Road

Quantico, VA 22134-5030

9

AMEDD Record Processing Center

3370 Nacogdoches Road, Suite 116

San Antonio, TX 78217

5 Marine Forces Reserve

2000 Opelousas Avenue

New Orleans, LA 70146-5400 10

Navy Personnel Command (PERS-313)

5720 Integrity Drive

Millington, TN 38055-3120

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https://www.hrc.army.mil/TAGD/Accessing%20or%20Requesting%20Your%20Official%20Military%20Personnel%20File%20Documents



mailto:[email protected]


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MOTOR VEHICLE OPERATOR RECORD

22. Do you possess a valid Driver’s License? [ ] Yes [ ] No

Drivers License Type: [ ] Chauffeurs [ ] Operators _____________________________________Number State

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.

Have you ever had a Drivers License Suspended or Revoked? [ ] Yes [ ] No

If Yes, Explain below: LIST THE STATE AND DETAILS _____________________________________________________________________________________

_____________________________________________________________________________________ _____________________________________________________________________________________

If Yes, was your license ever restored? [ ] Yes [ ] No

23. Have you ever received a traffic citation (other than parking)? [ ] Yes [ ] No

If Yes, list below the (1) City, (2) County, (3) State, (4) Name of Agency issuing the citation, (5) Date, (6) Charges and (7) Final Disposition. COMPLETE INFORMATION MUST BE SUPPLIED.________________________________________________________________________________________________________________________________________________________________________

INTERNET INFORMATION

Do you now have or have you ever had an account with Myspace.com, Facebook, Blog or any other similar website under your name or any fictitious name? [ ] Yes [ ] No If yes, please provide all information

_______________________________________________________________________________________

_______________________________________________________________________________________

REFERRAL INFORMATION

The Baker County Sheriff’s Office 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: ________________________________________________

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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 Baker County Sheriff’s Office determination of the qualifications of an applicant for employment is final. NO employees of the Sheriff’s Office are required to render an opinion or explanation beyond what is contained in the public record.

I understand that misrepresentation is sufficient cause for rejection of employment or dismissal.

Signature ___________________________________________ Date ________________________

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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). YOU MUST PROVIDE COMPLETE ADDRESSES AND PHONE NUMBERS.

1. Employer: _______________________________________Dates of Employment From: ________________To: _______________Month Year Month Year

Address: _______________________________________________________________________________________________________ Street City State Zip Area Code/Phone Number

Position Held: _________________________________Type of Business: __________________________________________________

Supervisor: ____________________________________________________________________________

Reason for Leaving: ______________________________________________________________________

Description of Duties: _____________________________________________________________________

_______________________________________________________________________________________

2. Employer: ________________________________________Dates of Employment From: ________________To: _______________Month Year Month Year



Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________




Supervisor: ____________________________________________________________________________



_____________________________________________________________________________

SALARY OR EARNINGS

Starting ______Per ______

Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

BCSO-A001




Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________




Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________




Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________




Supervisor: ____________________________________________________________________________


Description of Duties:_______________________________________________________________________________________ ___________________________________________________________________________________________________________

SALARY OR EARNINGS


Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

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BCSO-A001




Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________




Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________

10. Employer: ________________________________________Dates of Employment From: ________________To: _______________

Month Year Month Year



Supervisor: ____________________________________________________________________________



_______________________________________________________________________________________

11. Employer: _______________________________________Dates of Employment From: ________________To: _______________Month Year Month Year



Supervisor: ____________________________________________________________________________



___________________________________________________________________________________________

SALARY OR EARNINGS

Starting ______Per ______ Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

SALARY OR EARNINGS


Ending ________Per ______

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of 25 BCSO-A001

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.

MONTH/YEAR FROM/TO ADDRESS CITY/COUNTY STATE ZIP

BCSO-A001

EDUCATIONAL RECORD

COLLEGE (POST GRADUATE) DATES ATTENDED

COURSE OF STUDY _______________

NAME FROM DEGREE: [ ] Yes [ ] No If NO, How many credits did you complete? MO YR

CITY TO

STATE MO YR

COLLEGE DATES ATTENDED


NAME FROM DEGREE: [ ] Yes [ ] No If NO, How many credits did you complete?

MO YR

CITY TO

STATE MO YR

ACADEMY/TRADE/TECHNICAL/ BUSINESS

DATES ATTENDED /BUSINESSSINESS


NAME FROM Did you graduate? [ ] Yes [ ] No If No, describe the training you received:

MO YR CITY TO

STATE MO YR

OTHER SIGNIFICANT TRAINING DATES ATTENDED


NAME FROM Explain in detail: MO YR

CITY TO STATE MO YR

HIGH SCHOOL (LAST) DATES ATTENDED

DID YOU GRADUATE? [ ] YES [ ] NO

NAME FROM If NO, do you have a general education diploma (G.E.D.) or a high school equivalency? [ ] Yes [ ] No

State: Year:

MO YR

CITY TO

STATE MO YR

HONORS AND AWARDS PROFESSIONAL SOCIETY AFFILIATION

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BCSO-A001

REFERENCES

LIST AT LEAST FOUR (4) REFERENCES, OTHER THAN FAMILY MEMBERS, GIVING COMPLETE INFORMATION ON EACH REFERENCE. REFERENCES SHOULD BE LONG TIME FRIENDS. DO NOT INCLUDE FAMILY MEMBERS, NEIGHBORS, SUPERVISORS OR CO-WORKERS AS REFERENCES.

1. Name: ____________________________________ Relationship: _______________________

Address: _____________________________________________________________________

City: ______________________________________State:____________ Zip: _____________

Home Phone: _______________________________Cell Phone: ________________________


Address: _____________________________________________________________________

City: ______________________________________State:____________ Zip: _____________



Address: _____________________________________________________________________

City: ______________________________________State:____________ Zip: _____________



Address: _____________________________________________________________________

City: ______________________________________State:____________ Zip: _____________


____________________________________________________________________________________

EXPLANATION AND CONTINUATION SHEET (If Needed)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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BCSO-A001

RELEASE OF INFORMATION AUTHORITY

TO WHOM IT MAY CONCERN:

I respectively request and authorize you to furnish the Baker County Sheriff's Office 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 Baker County Sheriff's Office 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 Baker County Sheriff's Office. I further release the Baker County Sheriff's Office 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

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Florida Department of Law Enforcement

AFFIDAVIT OF APPLICANT Incorporated by Reference in Rule 11B-27.002(1)(f), F.A.C.

Created 1/1/1992 Original - Agency Copy – FDLE Commission-Approved Revisions: 12/16/2010 Form Effective Date: 3/2013

CJSTC 68

Please type or print in black or blue ink and use capital and small letters for names, titles, and addresses

Social Security Number:

Applicant’s Legal Name: Last First MI

Employing agency:

Use this form to verify your compliance with the employment requirements of Section 943.13, F.S. I fully understand that to qualify for employment as a law enforcement, correctional, or correctional probation officer, I shall comply with the following provisions of Section 943.13, F.S.: • Be at least 19 years of age. • Be a citizen of the United States. • Be a high school graduate or equivalent. • Not have been convicted of any felony or of a misdemeanor involving perjury or false

statement. Any person who, after July 1, 1981, pleads guilty or nolo contendere to or isfound guilty of a felony or of a misdemeanor involving perjury or a false statement

shall not be eligible for employment or appointment as an officer, notwithstanding suspension of a sentence or withholding of adjudication. • Have been fingerprinted by the employing agency. • Have passed a physical examination by a licensed medical specialist approved in Rule

11B-27.002(1)(d), F.A.C.. • Be of good moral character. • Have not received a dishonorable discharge from the U.S. Military.

True False NA In addition, I attest to the following statements: Each statement shall be checked “True” “False” or “NA” 1. I completed my employment application and it is true and correct, and all other information

I furnished in conjunction with my application is true and correct. 2. I provided documentation of proof of my qualifications to the above listed employing agency.

3. I meet the qualifications as specified above.

4. I had a criminal record sealed pursuant to Section 943.059(4)(a), F.S. , or expunged pursuant to Section 943.0585(4)(a), F.S.

5. I am under investigation by a local, state, or federal agency or entity for criminal, civil, or administrative wrongdoing to the best of my knowledge and belief.

6. I separated or resigned from a previous criminal justice employment while under investigation.

7. I am currently serving in good standing in the U.S. Military.

8. I previously served in the U.S. Military.

9. I received a dishonorable discharge from my previous U.S. Military service. 10. I am currently certified as a Florida criminal justice officer in the following area(s): Please check the appropriate box(es).

Law Enforcement Correctional Correctional Probation 11. I authorize the employing agency listed above to apply for my certification. Please check the appropriate box(es).

Law Enforcement Correctional Correctional Probation

NOTICE: This document shall constitute as an official statement within the purview of Section 837.06, F.S., and is subject to verification by the employing agency and the Criminal Justice Standards and Training Commission. Any intentional omission when submitting this application or false execution of this affidavit shall constitute a misdemeanor of the second degree and disqualify the officer for employment as an officer.

PLEASE READ CAREFULLY BEFORE SIGNING. You must complete the remainder of this affidavit in the presence of a notary public. Upon witnessing your signing of this affidavit, a notary public shall complete the notary block by entering the same date the affidavit is signed. I hereby certify that to the best of my knowledge and belief, the information that I’ve entered on this form is true.

12. 13. Applicant’s Signature Date Signed

14. OATH

Pursuant to Section 117.05(13)(a), Florida Statutes

STATE OF COUNTY OF

Sworn to (or affirmed) and subscribed before me this

day of , year , By

Signature of Notary Public – State of Florida

Print, Type, or Stamp Commissioned name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced *NOTE: Private Correctional facilities must submit original and shall forward the completed affidavit stapled to the Registration of Employment, Affidavit of ComplianceForm CJSTC-60 to FDLE, Criminal Justice Professionalism Program, Post Office Box 1489, Tallahassee, Florida 32302-1489, Attention Records Section

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Florida Department of Law Enforcement

AUTHORITY FOR RELEASE OF INFORMATION

(Background Investigation Waiver)

Incorporated by Reference in Rule 11B-27.0022(2)(b), F.A.C.

Effective: 8/9/2001 Pursuant to Original – Employing Agency Revised 8/3/2006 Sections 943.134(2)(a) and (4), F.S.

CJSTC 58

To: Concerned Person or Authorized APPLICANT’S NAME: Representative of Any Organization, Institution or Repository of Records DATE OF BIRTH:

SOCIAL SECURITY NUMBER (Optional):

EMPLOYING AGENCY REQUESTING BACKGROUND INFORMATION: BAKER COUNTY SHERIFF'S OFFICE

I hereby authorize any employee or authorized representative bearing this release, or copy thereof, to obtain any information in your files pertaining to my employment records including, but not limited to, achievement, attendance, personal history, disciplinary records, medical records, credit records, and criminal history records. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for the official use of the requesting agency. Consent is granted for the agency to furnish such information, as is described above, to third parties in the course of fulfilling its official responsibilities. 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 photocopy 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 photocopies from my military personnel and related medical records, including a photocopy of my DD 214, Report of Separation, to:

TCC Criminal Justice Selection Center, 75 College Drive, Suite 203, Havana, FL 32333

Section 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former or current employees states: An employer who discloses information about a former or current employee to a prospective employer of the former or current employee upon request of the prospective employer or of the former or current employee, is immune from civil liability for such disclosure of its consequences, unless it is shown by clear and convincing evidence that the information disclosed by the former or current employer was knowingly false or violated any civil right of the former or current employee protected under chapter 760, Florida Statutes. Pursuant to Sections 943.134(2)(a) and (4), F.S., Chapter 2001-94, Laws of Florida, disclosure of information is required unless contrary to state or federal law. Civil penalties may be available for refusal to disclose non-privileged legally obtainable information.

Applicant’s Signature Date

Applicant’s Address AFFIDAVIT

STATE OF COUNTY OF

Before me personally appeared ________________________________________ who says that he/she executed the above instrument of his or her own free will and accord, with full knowledge of the purpose therefore.

Sworn and subscribed in my presence this ________________ day of ___________________________, 20____________. My Commission

expires on ________________________, 20___________. Personally Known - or -

Produced Identification Notary Public:

Type of identification produced:

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BCSO-A001


1 SHERIFF’S OFFICE DRIVE MACCLENNY, FLORIDA 32063

(904) 259-2231FAX (904) 259-5583

Application Disqualifiers – Sworn Applicants

Driving - 3 moving violations within the past 24 months.- Any driver’s license suspensions / revocations in the last 5 years. (Suspensions for financial

responsibility and failure to pay will be evaluated on a case-by-case basis).Drug Use

- Any illegal drug use in the last 5 year 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).

Criminal Convictions / Arrest - Have been convicted of ANY felony or of a misdemeanor involving perjury or a false statement. Any person

who, after July 1, 1981, pleads guilty or Nolo Contendre to or is found guilty of any felony or of amisdemeanor involving perjury or false statement, regardless of suspension of sentence or withholdingadjudication will not have their application processed. (FSS 943.13 (4)).

- Any convictions for DUI within the last 5 years or any DUI convictions while employed as a law enforcement /or corrections officer (including military police).

- Any domestic violence convictions or pleas pursuant to 18 U.S.C. 922 (g) (9).- Any arrests within the past 5 years.

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.

Statement of Understanding

I, __________________________________, have read the above-listed disqualifiers as a part of the application process with the Baker County Sheriff’s Office. I acknowledge that I am qualified to apply with the Baker County Sheriff's Office. Further, should one of these disqualifiers be disclosed during the background investigation / selection process, I understand that my application process will be terminated immediately.

_____________________________________ _______________________ Signature Date

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darylmobley

Line

BCSO-A001

Law Enforcement Officers Only

Any person who is hired by the Baker County Sheriff’s Office as a Law Enforcement

Officer and does not reside within Baker County at the time of hire, will have 3 (three) months

to establish permanent residency within the boundaries of Baker County. Failure to establish

permanent residency within 3(three) months shall constitute resignation from employment.

If any person who is hired by the Baker County Sheriff’s Office as a Law Enforcement

Officer and does reside within Baker County at the time of hire, but subsequently moves

his/her permanent residence outside the boundaries of Baker County, shall

constitute resignation from employment.

Printed Name of Applicant: ____________________________________

Signature of Applicant: ______________________________________

Date: ______________________________

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