City of Haines City
620 East Main Street
Haines City, FL 33844
Telephone: 863-421-9927
[email protected]The City of Haines City is an equal opportunity employer and will consider all applicants for all positions equally without
regard to their race, sex, age, color, religion, creed, national origin, veteran status or any other legally protected status.
The City of Haines City is a Drug-Free Workplace. Applicants who successfully complete the initial screening process will
be required to do a pre-employment drug screen and physical. Police Department applicants will also be required to
take a Polygraph Examination. In addition, Police Dispatcher applicants will be required to complete a Psychological
Examination.
INSTRUCTIONS: PLEASE PRINT OR TYPE ALL INFORMATION.
The application must be filled out accurately and completely. Do not leave any items blank. If an item does not apply, indicate by N/A
(not applicable). If you need additional space to answer a question fully, you may include additional sheets of paper. Resumes may not
substitute for the complete application. You must attach copies of documents or certificates which support your application for your
application to be considered complete. All materials submitted become the property of the City and will not be returned. All statements
made on the application are subject to verification. A separate application must be completed for each position applied for.
POSITION APPLIED FOR:__________________________ TODAYS DATE:_______________________________________
(MUST BE A CURRENTLY OPEN POSITION)
APPLYING FOR: ____FULL TIME ____PART TIME ____TEMPORARY ____SEASONAL
PREFERRED SALARY: ___________________________
DATE AVAILABLE TO BEGIN WORK: ___________________________
HOW MAY WE CONTACT YOU?
Last Name:______________________________ First Name:_____________________________ Middle Initial: _______
Address:____________________________________________________________________________________________
City:____________________________________
State___________
Zip Code:______________________________
How long at above address? ___________________________________________________________________________
Home Phone Number:___________________
Alternate Phone Number:______________________________________
May we contact you via email? ____Yes ____No
If yes, please provide an email address : _______________________________________________________________
What is the best time to contact you? ____________________
ELIGIBILITY TO WORK
Are you over 18 years of age? ____ Yes ____No
Are you legally authorized to work in the United States? ____Yes ____No
List Alien Registration Number:___________________________ Expiration Date: _________________________________
(You will be required to provide proof of identity and/or authorization to work in the U.S. upon offer of employment.)
DRIVING HISTORY
Do you have a valid drivers license? ____Yes ____No State Issued:___________________ Class:
____________________
Drivers License Number: ___________________________________ Expiration Date: ______________________________
Has you license ever been suspended or revoked? ____Yes ____No
If yes, please provide dates and explain: __________________________________________________________________
ADDITIONAL INFORMATION
Since your 18th birthday, have you ever been convicted of any crime (excluding minor traffic violations)? ____Yes ____No
If yes, briefly describe the circumstances of your conviction, indicating date, nature and disposition of
case?_______________________________________________________________________________________________
___________________________________________________________________________________________________
NOTE: A conviction will not necessarily disqualify you from employment. The nature, job relatedness,
severity and date of the offense are considered.
Have you ever been employed by the City of Haines City? ____Yes ____No
If so, when? ____________ Department? _________________________
Are you related to anyone employed with the City of Haines City? ____Yes ____No
If yes, state name, relationship and department: ___________________________________________________________
Have you ever been fired or forced to resign? ____Yes ____No
If yes, please explain: _________________________________________________________________________________
___________________________________________________________________________________________________
EDUCATION
School
Name and Address of
School
Course of Study
High School
Did you graduate?
Diploma/Degree Earned
x
____Yes
____No
GED Issuing Agency
Jr. College, Technical,
Vocational
____Yes ____No
College
____Yes ____No
Graduate
____Yes ____No
WORK EXPERIENCE
Please complete employment history in detail. A resume may be attached but will not be accepted in place of this
information. Please account for the last 10 years of employment. List names of employers in consecutive order beginning
with your present or last employer. Account for all periods of time including military service and periods of unemployment.
May we contact your present employer regarding your record of employment? ____Yes ____No
Employer:___________________________________
Supervisor:_______________________________
Address:_____________________________________
Phone Number: ___________________________
Your Job Title: ____________________________________________________________________________________
Major Duties:______________________________________________________________________________________
Starting Salary:$__________ Ending Salary:$____________ Dates Employed: From ________ To ______
Reason For Leaving:________________________________________________________________________________
WORK EXPERIENCE
Employer:___________________________________
Supervisor:___________________________
Address:_____________________________________
Phone Number: _______________________
Your Job Title: ___________________________________________________________________________________
Major Duties:____________________________________________________________________________________
_______________________________________________________________________________________________
Starting Salary:$__________ Ending Salary:$____________ Dates Employed: From ________ To ______
Reason For Leaving:________________________________________________________________________________
Employer:___________________________________
Supervisor:___________________________
Address:_____________________________________
Phone Number: _______________________
Your Job Title: ____________________________________________________________________________________
Major Duties:______________________________________________________________________________________
_________________________________________________________________________________________________
Starting Salary:$__________ Ending Salary:$____________ Dates Employed: From ________ To ______
Reason For Leaving:_________________________________________________________________________________
Employer:___________________________________
Supervisor:___________________________
Address:_____________________________________
Phone Number: _______________________
Your Job Title: ___________________________________________________________________________________
Major Duties:_____________________________________________________________________________________
________________________________________________________________________________________________
Starting Salary:$__________ Ending Salary:$____________ Dates Employed: From ________ To ______
Reason For Leaving:___________________________________________________________________________________
SPECIAL SKILLS
Describe any specialized training, apprenticeships, skills and extra-curricular activities:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Have you had any computer or word processing experience or training? ____Yes ____No
List typing speed: _________________ Last Date Tested: ___________________________
Explain in your own words, why you want to work for the City of Haines City. Give any reasons why you feel
you should be considered for the position for which you are applying.
CERTIFICATION
I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for
employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any
information that I give may be investigated as allowed by law through various sources including but not limited to a Criminal
History records search, Drivers License history, credit check, former and current employers, and personal references (Police
Department applicants). I consent to the release of information about my ability, employment history, and fitness for
employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators,
personnel staff, and other authorized employees of the City of Haines City. This consent shall continue to be effective during
my employment if I am hired. I understand that applications submitted for City employment are public records. I certify that
to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct,
complete, and made in good faith.
If employed, I agree to conform to the rules and regulations of the City of Haines City. I understand that if hired my
employment is at-will, either party may terminate the employment relationship with or without cause or notice. I understand
that no representative of the City of Haines City, other than the City Manager has the authority to enter into any agreement
for employment for any specified period of time or make any agreement contrary to the foregoing.
Signature:__________________________________________________________________________________________
LICENSES & CERTIFICATIONS
Examples: Teacher Certification, RN, LPN, PE, CPA, PHR etc.
Licensure, Certification
Number
Date Received
Expiration date
Agency
Explain in your own words, why you want to work for the City of Haines City. Give any reasons why you feel
you should be considered for the position for which you are applying.
CERTIFICATION
I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for
employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any
information that I give may be investigated as allowed by law through various sources including but not limited to a
Criminal History records search, Drivers License history, credit check, former and current employers, and personal
references (Police Department applicants). I consent to the release of information about my ability, employment history,
and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to
investigators, personnel staff, and other authorized employees of the City of Haines City. This consent shall continue to be
effective during my employment if I am hired. I understand that applications submitted for City employment are public
records. I certify that to the best of my knowledge and belief all of the statements contained herein and on any
attachments are true, correct, complete, and made in good faith.
If employed, I agree to conform to the rules and regulations of the City of Haines City. I understand that if hired my
employment is at-will, either party may terminate the employment relationship with or without cause or notice. I
understand that no representative of the City of Haines City, other than the City Manager has the authority to enter into
any agreement for employment for any specified period of time or make any agreement contrary to the foregoing.
Signature:__________________________________________________________________________________________
Date:______________________________________________________________________________________________
VETERANS PREFERENCE INFORMATION
Completion of the Veterans Preference section is made on a VOLUNTARY basis and kept confidential in accordance with
the Americans with Disabilities Act. Complete ONLY if claiming veterans preference.
Are you presently or have you ever been a member of the U.S. military? ____Yes ____No
If yes, Branch of
Service:________________________________________________________________________________
Date Entered: _____________________ Date Separated: ______________________
Rank: ___________________________ Specialty:_____________________________
Type of Discharge: ______________________________ % of Disability Rating if any: ____________________________
Check appropriate item to claim Veterans Preference. A DD214 or comparable document which serves as a certificate of
release or discharge claim must be furnished at the time of application.
_____1. Are you a veteran entitled to disability compensation under the laws administered by the U.S. Veterans
Administration for a disability of 30% or more; or who is receiving compensation, disability retirement benefits, or pension
by reason of public laws administered by the Veterans Administration and the Department of Defense?
_____2. Are you the spouse of a veteran who cannot qualify for employment because of a total and permanent disability,
or the spouse of a veteran missing in action, captured or forcibly detained by a foreign power?
_____3. Are you a veteran of any war who has served on active duty for at least one (1) day during a wartime period,
excluding active duty training, and who was discharged under honorable conditions from the Armed Forces of the United
States of America?
____4. Are you the un-remarried widow or widower of a veteran who died of a serviceconnected disability?
Have you claimed and been employed through veterans preference since 10/1/1987? ____Yes ____No
If yes, give name of employer: _________________________________________________________________________
Have you ever been employed by any governmental entity within the State of Florida? ____Yes ____No
Are you a resident of the State of Florida? ____Yes ____No (Veterans Preference is only available to Florida residents.)
Are you claiming Veterans Preference points? ____Yes ____No
NOTE: Under Florida Law, preference in appointment and employment shall be given, by state and its political
subdivisions, first to those persons included in items 1 & 2 above; and second to those persons included under items 3 & 4
above. If any applicant claiming veterans preference for a vacant position is not selected for the position they may file a
complaint with the Department of Veterans Affairs, P.O. Box 1437, St. Petersburg, Fl 33731. A complaint shall be filed
within 21 days after notice of a hiring decision. If a notice of hiring decision is not given, a complaint may be filed at any
time.
EEO SURVEY
PLEASE NOTE: COMPLETION OF THIS FORM IS STRICTLY VOLUNTARY.
Applicants are assessed for those qualifications directly related to the job applied for without regard to race, color, religion,
sex, national origin, age, marital status, medical condition or disability. However, this information is required by the Federal
Government and is gathered for statistical purposes only. This form will be detached from your application and will be kept
separate and confidential. This form is not used in the employment selection process.
Position Applied For:___________________________________________ Date:__________________________________
Name:______________________________________________________
Address:___________________________________ City: _____________________ State:_________ Zip
Code:_________
Date of Birth:_______________________________ Gender: _______Male _________Female
Race: (Check Only One)
White
Black or African-American
American Indian/Alaskan Native
Asian /Pacific Islander
Hispanic
Other (Please Specify) ______________________________
HOW DID YOU HEAR ABOUT US?
Walk-in/City Bulletin Board
City Employee ________________________________
City of Haines City Website
Professional Publication ________________________
Lakeland Ledger
School Placement
Orlando Sentinel
Other _______________________________________
POLYGRAPH EXAMINATION
(Police Department Applicants Only)
Prior to final approval for hiring, as a police department applicant you will be required to undergo a polygraph examination
regarding your background and other aspects of your character.
The following is a list of subject areas from which polygraph questions will be drawn:
FINANCIAL STATUS
WORK RECORD
HONESTY
USE OF ALCOHOL
DRIVING RECORD
ARRESTS AND CONVICTIONS
DRUGS, NARCOTICS, AND MARIJUANA
GAMBLING
BLACKMAIL
FRIENDS, RELATIVES AND ASSOCIATES
LOYALTY TO THE UNITED STATES
APPLICATION CHECKLIST
Thank you for your interest in career opportunities with the City of Haines City. Before submitting
your application to Human Resources, please be sure to read the instructions below. Incomplete
applications will be automatically disqualified during the eligibility process. Please attach a legible
copy of the following to your completed City of Haines City application; please do not submit
original documents:
Copy of licenses and certifications
Copy of DD214 (if claiming Veterans Preference)
Copy of Valid Florida Drivers license
We appreciate your adherence to these guidelines and look forward to processing your application.
If you have any questions, please call 863-421-9929 or email your application to us at
[email protected]
DURATION OF SELECTION PROCESS
(Police Department Applicants Only)
It is impossible to state all relevant and material factors for a complete background investigation. In
each case, the City of Haines City Police Department will consider whether the applicant's
background makes him/her the best qualified candidate for employment. It is estimated that
processing the application will normally take up to (5) five weeks, depending on how soon
background information is received. Waiting on responses regarding personal references can
sometimes delay the process for up to (12) weeks. Please notify personal references, acquaintances,
as well as past and present employers, that they will be contacted by our background investigator.
This will expedite the application process.
REAPPLICATION POLICY
(Police Department Applicants Only)
Applicants applying for a City of Haines City Police Department position who are not selected must
wait six (6) months before reapplication to the same position.
There is no waiting period for applicants applying for a City of Haines City Police Department
position who are not selected, and who desire to apply for a different position within the City of
Haines City.
7
PERSONAL REFERENCES & ACQUAINTANCES
(Required for ALL Police Department Applicants Only)
Personal References: Give three (3) references (not relatives, former or present employers, or school
teachers) who are responsible adults of reputable standing in their communities, such as property owners,
business or professional men or women, who have known you well for the past five (5) years.
Complete Name:
__________________________________________
(Last Name, First, Middle)
Home Address:
__________________________________________
City & State including zip code:
__________________________________________
Years Acquainted
Occupation
_______________________________
____
Home Phone:
_______________________
Business Address:
________________________________
___
City & State:
______________________________
_____
Business Phone:
Complete Name:
Home Address:
__________________________________________
(Last Name, First, Middle)
__________________________________________
Years Acquainted
Occupation
Complete Name:
City & State including zip code:
____________________________________________
Home Phone:
________
_______________________
Business Address:
______________________________
_____
City & State including zip code:
____________________________________________
Business Phone:
_____
Home Address:
__________________________________________
(Last Name, First, Middle)
__________________________________________
Years Acquainted
_________________________________________
Occupation
_________________________________________
City & State including zip code:
_____________________________________________
______
Home Phone:
_________________________________
Business Address:
___________________________________________
City & State:
________________________________________
________
___________
Business Phone:
