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The Clerk of the Circuit Court & Comptroller (Flagler County Clerk of the Circuit Court & Comptroller)

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The Clerk of the Circuit Court & Comptroller
Flagler County, Florida
Employment Application
A separate application must be submitted for each job for which you apply. Copies are acceptable.
POSITION APPLIED FOR (MUST BE COMPLETED)
Date of Application:
Job
Title:
Date
you are available for employment:
Where
did you learn of this vacancy?
INSTRUCTIONS
• Complete this application in its entirety. Type or
print in black or blue ink.
• (Note: A separate application must be submitted
for each vacancy. Photocopies are acceptable.)
• Submit your application in‐person or mail to:
Clerk of the Circuit Court & Comptroller
Kim C. Hammond Justice Center, 2
nd
Floor
1769 East Moody Blvd, Building 1 Bunnell,
FL 32110 – (386) 313‐4445
• Submit your application by email to:
jstachurski@flaglerclerk.com
• Submit your application by facsimile to:
(386) 437‐1091
•
Sign your name in the Certification Section on
page 10. All information you submit is subject
to verification.
Your Name
Your Home Address
City
County State
Zip Code
Your Mailing Address (if different from above)
Home Phone Work, Business, or Cell Phone
Email Address
CITIZENSHIP / AUTHORIZATION TO WORK
The Clerk of the Circuit Court & Comptroller, hereinafter Clerk, hires only Florida U.S. citizens and lawfully authorized alien
workers. If a conditional offer of employment is made, you will be required to provide identification and proof of citizenship or
authorization to work in the United States.
Are you a U.S. citizen or are you legally authorized to work in the U.S.? □ Yes □ No
Have you ever been dismissed or forced to resign from any employment? □ Yes □ No
If yes, please explain:
Have
you filed an application here before? □ Yes □ No If yes, give dates:
Have
you ever been employed here before? □ Yes □ No
If yes, give dates:
Are
you on a layoff? □ Yes □ No Are you subject to recall? □ Yes □ No
Are there any hours, shifts, or days you will not work? □ Yes □ No
If yes, explain: Will you work overtime, if asked? □ Yes □ No
__________________________________________________
Are you now employed?
□
Yes
□
No May we contact your present employer?
□
Yes
□
No
Previous employer?
□ Yes □ No
Please identity any exceptions and reasons for not contacting previous employers:
FRIENDS OR RELATIVES IN THE CLERK'S EMPLOYMENT
To your knowledge, do you have any friends or relatives working for the Clerk's Office?
□ Yes □ No
If yes, name(s): Relationship(s): Dept(s) where employed:
(continue list on another sheet, if necessary)
EDUCATION
Indicate Highest Grade Completed
Grade School (1‐8) □ High School (9‐12) □ GED □ College (1-4) □ Graduate School (1-4) □
HIGH SCHOOL
Name: Location:
Received: □ Diploma □ Certificate of Completion □ GED □ None, highest grade completed:
Your name, if different while attending school:
COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL: (TRANSCRIPTS MAY BE REQUIRED)
# OF CREDIT
TYPE OF
NAME OF SCHOOL
LOCATION
HOURS EARNED
MAJOR/MINOR
DEGREE
QTR SEM
COURSE OF STUDY
EARNED
Your name, if different while attending school:
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 2 of 10
OTHER TRAINING OR COURSE WORK: (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARMED FORCES, ETC.)
NAME OF SCHOOL LOCATION
# OF CREDIT
HOURS EARNED
MAJOR/MINOR
COURSE OF STUDY
DEGREE/
CERTIFICATE
QTR SEM
Your name, if different while attending school:
KNOWLEDGE / SKILLS / ABILITIES (KSAs)
List KSAs and/or certifications you possess and believe relevant to the position you seek, such as operating heavy
equipment, computer skills, fluency in language(s) etc.
CRIMINAL HISTORY INFORMATION
SCREENING WILL BE CONDUCTED ON THE SELECTED APPLICANT. IF YOUR ANSWERS TO THE QUESTIONS BELOW DO NOT
ACCURATELY AND COMPLETELY REFLECT YOUR CRIMINAL HISTORY, YOU WILL BE ELIMINATED FROM FURTHER
CONSIDERATION FOR THE VACANCY.
If you are not sure or do not remember what happened in a criminal case(s), contact the appropriate county, state, or
federal agency so that you can report accurate information on your criminal history.
Answering “yes” to any question(s) will not automatically bar you from employment. The nature, job‐relatedness,
severity and date of the offense(s) in relation to the duties of the position for which you are applying are considered.
1. H
ave you ever been convicted of a felony or a first
‐de
gree misdemeanor?
□ Yes □ No
2. H
ave you ever had the adjudication of guilt withheld or plead nolo contendre for a felony or a first
‐de
gree
misdemeanor?
□ Yes □ No
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 3 of 10
3. Have you ever been convicted of a traffic violation?
□
Yes
□
No
If you answered yes to one of the above questions and have a conviction or adjudication of guilt withheld, please
complete the following information regarding each and every felony and/or first degree misdemeanor:
Continue list on another sheet if necessary.
EMPLOYMENT
THIS SECTION MUST BE COMPLETED REGARDLESS OF WHETHER OR NOT A RESUME IS ATTACHED.
Beginning with your PRESENT or most recent employment, list in REVERSE ORDER ALL periods of employment. Each
time you changed jobs or your title changed should be listed as a separate period. Be sure to describe your military
experience, if any. Describe in detail your specific duties beginning with your primary duties.
Attach additional sheets if necessary.
EMPLOYER 1
Employer:
Address:
Your Official Title:
Supervisor’s Name & Title:
Phone Number:
From To Total Months
If part time,
number of
hours per week:
Beginning Salary Ending Salary
Month
Year
Month
Year
$
Per
$
Per
Reason for leaving:
Describe your duties in detail:
Charge
Date of Disposition
County/State
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 4 of 10
EMPLOYER 2
Employer:
Address:
Your Official Title:
Supervisor’s Name & Title:
Phone Number:
From To
Total Months
If part time,
number of
hours per week:
Beginning Salary Ending Salary
Month
Year
Month
Year
$
Per
$
Per
Reason for leaving:
Describe your duties in detail:
EMPLOYER 3
Employer:
Address:
Your Official Title:
Supervisor’s Name & Title:
Phone Number:
From To
Total Months
If part time,
number of
hours per week:
Beginning Salary Ending Salary
Month
Year
Month
Year
$
Per
$
Per
Reason for leaving:
Describe your duties in detail:
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 5 of 10
EMPLOYER 4
Employer:
Address:
Your Official Title:
Supervisor’s Name & Title:
Phone Number:
From To
Total Months
If part time,
number of
hours per week:
Beginning Salary Ending Salary
Month
Year
Month
Year
$
Per
$
Per
Reason for leaving:
Describe your duties in detail:
EMPLOYER 5
Employer:
Address:
Your Official Title:
Supervisor’s Name & Title:
Phone Number:
From To
Total Months
If part time,
number of
hours per week:
Beginning Salary Ending Salary
Month
Year
Month
Year
$
Per
$
Per
Reason for leaving:
Describe your duties in detail:
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 6 of 10
Why do you feel you are qualified for this position?
EXEMPTION FROM PUBLIC RECORDS DISCLOSURE
Are you a current or former law enforcement officer, other covered employee*
or the spouse or child of one, who is exempt from public records disclosure under §119.07, Florida Statutes?
□ Yes □ No
*Other covered jobs include correctional and correctional probation officers, firefighters, certain judges, assistant state attorneys,
state attorneys, assi
stant and statewide prosecutors, personnel of the Department of Revenue or local governments whose
responsibilities include revenue collection and enforcement or child support enforcement and certain investigators in the
Department of Children and Families; human resources, labor relations, or employee relations directors, assistant directors,
managers, or assistant managers and their spouses & children; code enforcement officers and their spouses & children. (See
§119.07, F.S.)
VETERANS’ PREFERENCE CLAIM
I wish to claim Veterans’ Preference in employment in accordance with Chapter 295 of the Florida Statutes. I
qualify
under the following category: (Check one)
A Veteran with an existing compensable service-connected disability who is eligible for or receiving compensation,
disability
retirement or pension under public laws administered by the DVA and the Department of Defense.
The spouse of a Veteran who cannot qualify for employment because of a total and permanent service-connected
disability, or the spouse of a Veteran missing in action, captured in line of duty by a hostile force, or detained or
interned in
line of duty by a foreign government or power.
A Veteran of any war who has served at least one day on active duty during a wartime period as defined in FSS 1.01
(14)
(described below), excluding active
duty for training, and who was discharged under honorable conditions from
the Armed
Forces of the United States of America or who has been awarded a campaign or expeditionary medal.
The unremarried widow or widower of a Veteran who died of a service-connected disability.
The mother, father, legal guardian, or unremarried widow or widower of a service member who died as a result of
military
service under combat-related
conditions as verified by the United States Department of Defense.
A Veteran as defined by FSS 1.01(14), meaning a person who served in the active military, naval, or air service and
who
was discharged or released under
honorable conditions only or who later received an upgraded discharge
under honorable
conditions, notwithstanding any action by the United States Department of Veterans Affairs on
individuals discharged or
released with other than honorable discharges.
A current member of any reserve component of the United States Armed Forces or The Florida National Guard.
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 7 of 10
Wartime Periods:
World War II: December 7, 1941 to December 31, 1946 Persian Gulf War: August 2, 1990 to January 2, 1992
Korean Conflict: June 27, 1950 to January 31, 1955 Operation Enduring Freedom: October 7, 2001 to TBD
Vietnam Era: February 28, 1961 to May 7, 1975 Operation Iraqi Freedom: March 19, 2003 to TBD
Operation New Dawn: September 1, 2010 to TBD
Character of Discharge: (Check one)
Honorable
General Dishonorable Other (explain)
Documents that must be submitted at time of application in order to claim preference:
Veterans, disabled Veterans, spouses of disabled Veterans and family members shall furnish a DD-214 or equivalent certification listing military
status, dates of service and Character of Discharge. Disabled Veterans shall also furnish a document from the Department of Defense, the
DVA, or the Florida Department of Veterans’ Affairs certifying that the Veteran has a service-connected disability.
Spouses of disabled Veterans shall also furnish either a certification from the Department of Defense or the DVA that the Veteran is totally and
permanently disabled or an identification card issued by the Department; spouses shall also furnish evidence of marriage to the Veteran and a
statement that the spouse is still married to the Veteran at the time of the application for employment; the spouse shall also submit proof that
the disabled Veteran cannot qualify for employment because of the service-connected disability.
Spouses of persons on active duty shall furnish a document from the Department of Defense or the DVA certifying that the person on active
duty is listed as missing in action, captured in line of duty, or forcibly detained or interned in line of duty by a foreign government or power; such
spouses shall also furnish evidence of marriage and a statement that the spouse is married to the person on active duty at the time of that
application for employment.
The mother, father, legal guardian, or unremarried widow or widower of a deceased Veteran shall furnish a document from the Department of
Defense showing the death of service member while on duty status under combat-related conditions or the DVA certifying the service-
connected death of the Veteran, and shall further furnish evidence of marriage or other relationship. The legal guardian shall show the proper
court documents establishing the legal authority for the Guardian.
Current reserve and National Guard members provide a letter from their Commanding Officer stating the dates of their military service.
An applicant eligible for Veteran’s Preference who believes he or she was not afforded employment preference in accordance with
Florida law may file a complaint requesting an investigation with the Department of Veterans’ Affairs, 11351 Ulmerton Road,
Room
311-K, Largo, Florida, 33778. A complaint must be filed within 21 calendar days from the date that the notice of hiring
d
ecision is
received by the applicant or within three calendar months of the date the application is filed with the employer. If no
notice is given, it
is the responsibility of the preferred applicant to maintain contact with the employer to determine if the position
has been filled.
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 8 of 10
REFERENCES
Please list three professional references.
REFERENCE 1
Full Name: Relationship:
Company: Phone:
Address:
REFERENCE 2
Full Name: Relationship:
Company: Phone:
Address:
REFERENCE 3
Full Name:
Relationship:
Company:
Phone:
Address:
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 9 of 10
CERTIFICATION
I understand that any omissions, falsifications, misstatements, or misrepresentations of the information provided by me 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 I provide may be investigated as allowed by law. I consent to the release of information and release this employer
from any liability as a result of such contact 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 Clerk government for employment purposes. This consent shall continue to be effective during my employment if
I am hired. I understand that applications submitted for the Clerk employment are public records except as noted on page 7. I
certify that to the best of my knowledge and belief that all of the statements contained herein and on any attachments are true,
correct, complete, and made in good faith. I further understand that if I am selected to fill an open safety or security sensitive
position, prior to appointment I may be required to successfully pass a pre‐employment drug test.
Applicants accepted for employment should clearly understand that while we make every effort to provide steady, continuous work,
we have no employment contracts, and we cannot guarantee the permanence of any position. Job tenure can be affected by many
factors including business/economic conditions, changes in laws or employee policies, conformity to our work rules, job performance,
etc. And of course, employees may elect to leave on their own accord to seek other jobs.
I understand that any employment with the Employer is for no term and may be terminated by me or the Employer with or without
notice or cause at any time. I further understand that no oral promise, Employer Policy, custom, business practice or other
procedure (including the Employer's Personnel Handbook or any personnel manuals) constitutes an employment contract or
modification of the “at-will” employment relationship between me and the Employer.
The contents of any employee handbook or personnel manuals, as well as other Employer policies and practices, are subject to
change or modification by the Employer, solely at its discretion, without notice. I also understand that no supervisor or other official
of the Employer (except its Clerk, in writing) has the authority to enter into any agreement with me or to make any agreement
contrary to the foregoing.
This application will remain active for up to six (6) months. Any applicant wishing to be considered for employment beyond six (6)
months should reapply.
SIGNATURE: DATE:
This Employer is an equal employment opportunity employer, and maintains a drug‐free workplace. We adhere to a policy of
making employment decisions without regard to race, color, age, sex, religion, national origin, handicap or marital status. We
assure you that your opportunity for employment with this Employer depends solely upon your qualifications.
Revised 12/14 Clerk of the Circuit Court & Comptroller – Employment Application 10 of 10
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Completed 22 July 2021

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