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Referred / Recruited by: ID#

Collier County Sheriff's Office, Kevin J. Rambosk, Sheriff Employment Application

The Collier County Sheriff's Office is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, national origin, sex, age, physical disability, religion or any other legally protected status. Instructions: Application may be printed, in your own handwriting, legibly in ink or typewritten. This is your application. If additional space is needed, please refer to question number and add information on 8 -1/2 x 11 inch paper. If you are provided a conditional offer of a position, you will be required to complete a questionnaire with detailed background information. Once received by the CCSO, we must retain custody of the application. Portions of the application are subject to disclosure under Florida's Public Records Laws. Please do not staple any documents to any portion of this application.

Position(s) Requested (list in order of preference):

1. Name:

(Last name)

2. Other: List all other names you have used with time periods used (e.g. maiden, former, alias(es)).

3. Education: List highest level attained, year attained, name and address of institution/school, and type of degree (if applicable).

4. Law enforcement or Corrections Officer certification (when and where obtained):

5. Are you willing to work shifts? Nights: Evenings: Weekends:Yes No NoYes NoYes

6. Typing or Keyboarding speed:

Computer programs (software) used in your current or prior position:

7. Military Experience, if applicable. List date(s) of active duty, branch, highest rank obtained and type of discharge.

Do you wish to claim Veteran's Preference? (Call for details) NoYes

8. Have you had any disciplinary action from any employer including military up to & including discharge? If yes, provide details below:

Yes No

(Middle name) (First name)

9. Have you ever been convicted of, or pled guilty to, any criminal violation (including juvenile, expunged, sealed, and/or adjudication withheld)? If yes, provide details below: NoYes

Date: Place: Charge:

Court Location: Disposition:

Social Security Number: xxxxxxxxx format no dashes

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10. List all employment beginning with present employment, including summer and part-time positions while attending school, for the past ten years. If unemployed for a period, set forth date of unemployment.

If more space is needed continue, in above format, on separate sheet of paper.

Social Security Number: xxxxxxxxx format no dashes

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11. Residences: List all residence addresses for the past ten years beginning with current address:

12. The Collier County Sheriff's Office collects your Social Security number which may be used for any of the following purposes: collection of information related to background investigations, to include fingerprints, NCIC/FCIC checks, Credit Bureau reports, verification of employment, local and state records checks, clarification for duplicate names, verification of Military Services. Initial here

13. Driving History: You are not required to complete this question if applying for clerical position or any position that does not require driving a vehicle. State where licensed: License No: List any traffic violation conviction, including adjudication withheld, within the past ten years. Provide date, charge, court location, and disposition:

Social Security Number: xxxxxxxxx format no dashes

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Name:

Confidential Application History

1. Current Address (including street address, city, state, zip):

Mailing address, if different from above:

Residential Phone: Alternate Phone:

2. If a test or examination is required for this position, would you require an accommodation due to a qualifying disability to participate in this test or examination: If yes, explain what accommodation(s) you would need to take the test or examination.

Yes No

3. Aside from any substance abuse for which you have undergone treatment, have you used or experimented with any narcotic or controlled substance such as, but not limited to, marijuana, hashish, cocaine, LSD, amphetamines, heroin, steroids, or any drug of a similar nature? If yes, please explain which drug(s) and the circumstances (where, when, why) of the use. Please indicate frequency and approximate date last used.

Yes No

4. Have you ever supplied or sold any illegal narcotic or controlled substance such as, but not limited to, marijuana, hashish, cocaine, LSD, amphetamines, heroin, steroids, and any drug of a similar nature? If yes, please complete the following:

a. Drug(s):

b. Circumstances (when, where, why):

c. Number of times supplied to others:

d. Date last supplied to others:

e. Number of times sold to others: Date last sold:

f. Was it sold for profit? Yes No

5. Physical description (used to check your criminal history): Height: Weight: Hair Color:

Eye Color: Scars/Marks/Tattoos:

Yes No Yes NoDate, Place, Court:

E-mail Address:

Yes No

Social Security Number: xxxxxxxxx format no dashes

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AUTHORITY FOR RELEASE OF INFORMATION

(Background Investigation Waiver)

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

Florida Department of Law Enforcement

CJSTC 58

To: Concerned Person or Authorized Representative of Any Organization, Institution or Repository of Records

APPLICANT'S NAME:

DATE OF BIRTH:

SOCIAL SECURITY NUMBER (Optional):

EMPLOYING AGENCY REQUESTING BACKGROUND INFORMATION: Collier 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 the 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 to 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 any 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: Collier County Sheriff's Office - 3319 Tamiami Trail East, Naples, FL 34112-4901 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former employees states: An employer who discloses information about a former employee's job performance to a prospective employer of the former employee upon request of the prospective employer or of the former employee is presumed to be acting in good faith and, unless lack of good faith is shown by clear and convincing evidence, is immune from civil liability for such disclosure of its consequences. For the purposes of this section, the presumption of good faith is rebutted upon showing that the information disclosed by the former employer was knowingly false or deliberately misleading, was rendered with malicious purpose, or violated any civil right of the former employee protected under Chapter 760. Pursuant to Sections 943.134(2)(a) and (4), F.S., Chapter 2001-94, Laws of Florida, disclosure of information 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: ____________________________________________________________________________________________________

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

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APPLICATION PROCESS

1. Application submitted for review. 2. Application information input for automated tracking. 3. Application reviewed for compliance with minimum standards. 4. Candidate is sent a letter to schedule testing, if position requires. 5. Letter sent notifying candidate of eligibility for interview. 6. Candidates ranked based upon interview scores. 7. Written conditional offer of position presented detailing tests / evaluations to follow, not necessarily in the order shown: * Polygraph Exam * Background Investigation * Lab work and Medical Examination * Psychological Evaluation * Physical Agility Evaluation (for certified positions) * Final Review 8. All results compiled to determine suitability for a Collier County Sheriff's Office position. 9. Candidate selected for applicant pool. 10. Notified of date to report to duty or held for available position. 11. The process is lengthy and may take several months. Note: Stated above is the complete application process. The process may be discontinued at any time during the course of testing or evaluations. All procedures are coordinated by the Human Resources Division, per the Sheriff's direction. All final offers are subject to approval by the Sheriff and will be communicated through the Human Resources Division.

REAPPLICATION AND RETESTING:

1. Applicants who are not appointed to probationary status or who fail a portion or portions of the selection process are not necessarily excluded from future consideration. 2. Active applications shall be maintained by the Human Resources Division for a period of one (1) year from date of receipt of the application. a. These applications shall be considered for future vacancies for a period of one (1) year from the date of their original application, unless otherwise disqualified. b. After one (1) year the application shall be deemed inactive and placed in the inactive file. c. Once an application has been placed in the inactive file the application must complete a new application to be considered for future vacancies. 3. Applicants not appointed to probationary status and whose files have been placed in an inactive status may re-apply after one (1) year from their original application, pre-screening interview, or notice of non-appointment, whichever is latest. 4. Applicants not appointed to probationary status for failure to pass skills level test may be retested after review by by the Human Resources Manager or designee and upon request of the affected applicant.

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Additional Space: Please refer to the corresponding question number when adding information below.

If more space is needed, use a 8-1/2 x 11 inch paper and refer to the corresponding question number when added information to that page.

Social Security Number: xxxxxxxxx format no dashes

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Important Reminder Throughout the application process, you will be asked to certify documents and answer questions. Because accurate and truthful reporting of events is an essential function of each and every Collier County Sheriff's Office position, you are strongly urged to complete this information honestly, If you cannot recall exact dates or events, provide as much information as you can recall and note as "approximate". Negative answers or prior experiences may, or may not, cause your application to be rejected; however, failure to disclose such information can, and will, result in immediate disqualification. Attach the following documents: 1. A copy of my birth certificate, required. 2. Proof of high school graduation/GED or highest level of post-secondary education achieved, required. 3. A copy of all DD 214's issued showing character of service, required if applicable. 4. A copy of my official social security card, required. 5. A copy of my driver's license, required. 6. A copy of all name change documents, required if applicable (i.e., marriage certificate, divorce decree, adoption papers, etc). 7. Official college transcript, if applicable. 8. F-BAT / CJBAT results, if available. 9. Copy of certificate issued for basic training in Corrections or Law Enforcement, if applicable. 10. Copy of Florida State Examination results, if applicable. 11. Copy of last two (2) performance appraisals, if available. 12. Copy of naturalization certificate or authorization to work in the U.S., required if applicable. Certification of application: I understand my appointment or employment to a position will be contingent upon the results of a complete background investigation and background application. Any omission, falsification, misstatement or misrepresentation on this application form will be the basis for my disqualification as an applicant or my dismissal from the Sheriff's Office. I authorize any of the persons or organizations referenced in this application to furnish information, personal or otherwise, regarding my ability and fitness for employment or appointment with the Sheriff's Office. I relieve all such parties form any and all liability for any damage that might result from furnishing such information to the Sheriff's Office. I understand and agree to the above conditions and certify that all statements made by me on this application are true, correct and complete, to the best of my knowledge. ______________________________________________ ___________________ Applicant Signature Date ______________________________________________ Witnessed by

ATTENTION If you need a question answered or additional information regarding this application, contact:

Collier County Sheriff's Office

Attn: Human Resources Division 3319 Tamiami Trail East

Naples, Florida 34112-4901 Office: (239) 252-0530

Toll free: 1-877-703-5627 Fax: (239) 252-0979

e-mail: jobs@colliersheriff.org website: http://www.colliersheriff.org

Form #320, Rev. 4/11

Social Security Number: xxxxxxxxx format no dashes

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COLLIER COUNTY SHERIFF'S OFFICE

Notice Regarding Collection of Social Security Numbers

The collection of social security numbers by the Collier County Sheriff's Office (“CCSO”) is either specifically authorized by law or imperative for the performance of CCSO's duties and responsibilities as prescribed by law and the Florida Constitution. The following list identifies the purposes for which social security numbers may be collected, used, or disclosed, the relevant legal authority and whether collection of the social security number for the stated purpose is voluntary or required. This notice is provided to you as your Social Security number has been collected by the CCSO 1. For employment eligibility and reports to IRS and the Social Security Administration, including for W-4's and I-9s [Required by federal statute and regulation 26 U.S.C. 6051 and 26 C.F.R. 31.6011(b)-2, 26 C.F.R. 301.6109-1 and 31.3402(f)(2)-1, and Fla. Stat. §119.071(5) (a) 6] 2. For income tax withholding (including for annuity and sick leave)/payroll deductions on W-2's [Required by 26 U.S.C. 3402, 26 C.F.R. 31.6051-1 and Fla. Stat. §119.071(5) (a) 6] 3. For enrollment/participation in the Florida Retirement System (FRS) and contributions to FRS [Required by Fla. Admin. Code 19-11.010, 19-11.006 and 19- 11.007 and Fla. Stat. §119.071(5) (a) 6 or required by Fla. Stat. §121.051 and 121.071 and Fla. Admin. Code 19-13.003 and Fla. Stat. § 119.071(5) (a) 6] 4. For social security contributions [Required by Fla. Admin. Code 60S-3.010 and Fla. Stat. §119.071(5) (a) 6] 5. For income deduction notices for child support, alimony and child support, and for child support enforcement [Required by Fla. Stat. § 61.1301 (2) (e), 45 C.F.R. 307.11, or Fla. Stat. §§ 61.13, 742.10, 409.2563, 409.256, or 742.031] 6. For unemployment compensation benefits [Required by Fla. Stat. Ch. 443 and Fla. Stat. §119.071(5)(a)6] 7. For reports of worker's compensation injury or death [Required by Fla. Stat. § 440.185, Fla. Admin. Code 69L-3.003 et seq. and Fla. Stat. § 119.071(5) (a) 6]; and worker's compensation petitions for benefits and responses [Authorized by Fla. Admin. Code 60Q-6.103 and Fla. Stat. § 119.071(5) (a) 6] 8. For Vendors/Consultants for whom a federal tax identification number is not available. [Required by 26 C.F.R. § 31.3406-0, 26 C.F.R. § 301.6109-1, and Fla. Stat. §119.071 (5) (a) 6] 9. For tort claims and tort notices of claim against MCSO [Required by Fla. Stat. § 768.28 (6), and Fla. Stat. § 119.071(5) (a)]

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10. For verification of identity, background investigations, criminal history checks, criminal intelligence gathering and criminal investigations [Authorized by Fla.Stat. § 119.071(5) (a) 6] 11. The social security number may be disclosed for the purpose of the administration of health benefits for an MCSO employee or his or her dependents [Required by Fla. Stat. § 119.071(5) (a) 6] 12. The social security number may be disclosed to facilitate the direct deposit of funds by electronic or other medium to a payee's account [Authorized by Fla. Stat. § 119.071(5) (a) 6] 13. The social security number may be disclosed if it is expressly permitted or required by federal or state law, or a court order [Authorized by Fla. Stat. § 119.071(5) (a) 6] 14. The social security number may be disclosed if the individual expressly consents in writing to the disclosure of his or her social security number [Authorized by Fla. Stat. § 119.071(5) (a) 6] 15. The social security number may be disclosed if the disclosure is necessary for the receiving agency or governmental entity to perform its duties and responsibilities [Authorized by Fla. Stat. § 119.071(5) (a) 6] 16. The social security number may be disclosed if the disclosure is made to comply with the USA Patriot Act of 2001, Pub. L. No. 107-56, or Presidential Executive Order 13224. 17. The social security number may be disclosed if the disclosure is made to a commercial entity for the permissible uses set forth in the federal Driver's Privacy Protection Act of 1994, 18 U.S.C. Sec. 2721 et seq.; the Fair Credit Reporting Act, 15 U.S.C. Sec. 1681 et seq.; or the Financial Services Modernization Act of 1999, 15 U.S.C. Sec. 6801 et seq., provided that the authorized commercial entity complies with the requirements of Fla. Stat. § 119.071(5)