Utilities Commission

City of New Smyrna Beach, Florida
200 Canal Street
New Smyrna Beach, Florida 32168

APPLICATION FOR EMPLOYMENT

Notice to Applicant:
I understand and agree that qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a disability that does not prevent the applicant from performing the essential functions of the positions(s) sought. I also understand and agree that unlawful harassment whether on the basis of sex, race, national origin, age, religion, disabilities, etc. will not be tolerated and can lead to immediate discharge. All employment applications are subject to public disclosure under Chapter 119, Florida Statues.

 

Position(s) applied for:

Referral Source:

First Name: Last Name:

Middle:

Street Address:

City: State: ZipCode:

Phone Number: Cell Phone Number:

Have you filed an application here before? Yes No If Yes, what date?

Have you ever been employed here before? Yes No If Yes, what date?

Are you a citizen of the United States? Yes No
If not, Alien Registration Number:

Are you available to work: Full Time Part Time Shift Work

Are you on lay-off from another employer where you have the right to be recalled?
Yes No


If yes, when do your recall rights expire?

Do any of your relatives work here? Yes No
If Yes, list name(s) and relationship:

Have you ever been convicted of a felony? Yes No

Have you ever been accused of unlawful discrimination, including sexual harassment?
Yes No

If yes, explain:

 

EMPLOYMENT EXPERIENCE

List each job held. Start with your present or last job.
Include military service assignments and volunteer activities.
(Exclude groups which indicate race, color, religion, sex or national origin.)

Present or last employer
 Phone No. Position Held & Nature
Street Address Supervisor’s Name
City Hourly Rate Start End:
State Zip Code: Dates Employed From: To
Reason for Leaving:


Present or last employer
 Phone No. Position Held & Nature
Street Address Supervisor’s Name
City Hourly Rate Start End:
State Zip Code: Dates Employed From: To
Reason for Leaving:


Present or last employer
 Phone No. Position Held & Nature
Street Address Supervisor’s Name
City Hourly Rate Start End:
State Zip Code: Dates Employed From: To
Reason for Leaving:


Present or last employer
 Phone No. Position Held & Nature
Street Address Supervisor’s Name
City Hourly Rate Start End:
State Zip Code: Dates Employed From: To
Reason for Leaving:


Present or last employer
 Phone No. Position Held & Nature
Street Address Supervisor’s Name
City Hourly Rate Start End:
State Zip Code: Dates Employed From: To
Reason for Leaving:

Please indicate which of these employers you do not wish us to contact.

 

EDUCATION

School
Name/Location of School
Course of Study
Years Completed
Degree or Diploma
High School
College
Business/
Trade/
Technical
Graduate
School


Summarize special skills and qualifications acquired from employment, education or other experience.
(Include professional certifications, apprenticeships, etc.)

List professional, trade, business or civic activities and offices held.
(Exclude groups which indicate race, color, religion, sex or national origin or disability.)

 

MILITARY SERVICE RECORD

Were you in U.S. Armed Forces? Yes No If yes, what branch?

Dates of duty: From to

Rank at discharge

List duties in the service including special training:

Reserve status rank & branch Active

Other

 

PROFESSIONAL REFERENCES

Name and Occupation Address Phone #


State any additional information you feel may be helpful to us in considering your application.

 

Veteran’s Preference: Documentation substantiating your claim (e.g. DD-214 and/or letter establishing eligibility to receive disability compensation from the Department of Defense or equivalent certification) must be furnished at the time of application.

  • A veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement, or pension under public laws administered by the U.S. Veteran’s Administration and Department of Defense; or

  • 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; or

  • A veteran who has served on active duty for one (1) day or more and who was honorably discharged from the Armed Forces of the United States of America, if such active duty was performed during a wartime era, excluding active duty for training; or

  • The unremarried widow or widower of a veteran who died of a service-connected disability.

Branch of Service:

Date of Entry: Date of Discharge:

Type:

Have you ever been employed in any State or government subdivision using Veteran’s Preference?
Yes No
If yes, Name of Employer:

Date Employed:

Note: Under Florida law, preference in appointment shall be given to those persons included in (1) and (2) above and second to those persons included in (3) and (4) above. If the applicant claiming veteran’s preference for a vacant position is not selected for the vacant position, he/she may file a complaint with the Department of Veteran’s Affair, PO Box 31003, St. Petersburg, Florida 33731. A complaint must be filled within 21 days of the applicant receiving notice of the hiring decision made by the employing agency. If not notified, the complaint must be filed within three (3) calendar months from the date application is received by the Personnel Department.

AGREEMENT - PLEASE READ CAREFULLY BEFORE SIGNING

I certify that answers given herein are true and complete to the best of my knowledge. I understand that any incorrect, incomplete, or false statements or information furnished by me may subject me to disqualification or to discharge at any time. If employed by the Utilities Commission, I agree to comply with all its orders, rules and regulations which are now in effect or become effective during my employment. I authorize release of all the information contained herein and hereby release the Utilities Commission, its employees, my references, my former employers, schools and all individuals connected therewith, from all liability for any damages or injury whatsoever related to the taking of pre-employment examinations and the and the furnishing or use of this or related information. I am aware that this application is subject to the provision of FS119 and as a “Public Record” may be open for personal inspection by any person. I understand that any offer of employment is conditional upon my taking and passing a pre-employment physical examination which includes a drug screening test and I hereby authorize the Utilities Commission to do a criminal background check on me. I further understand and agree that if I am employed by the Utilities Commission, that my employment will be “at will” unless otherwise stipulated by contract. That is, either I or the Utilities Commission may end the employment relationship at any time, for any reason, or for no reason. I understand that I have an affirmative obligation to report any unlawful harassment, and that I will not be disciplined for reporting any incident. I understand that I am expected to report to work on time and that 6 or more occurrences of absenteeism will lead to my discharge.

Applicant’s Initials:
"By digitally signing this form, you are verifying that all the information you have provided is true, correct, and complete."