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Conviction of a crime or adjudication alone typically will not disqualify you from being considered for employment unless it is related to the position sought. Failure to submit or giving inaccurate information on the Criminal History Disclosure Form may cause candidates to be disqualified or dismissed.

Include military service assignments and volunteer activities. (Exclude groups which indicate race, color, religion, sex or national origin). Are there any employers listed below you WOULD NOT like contacted for employment reference checks? Please indicate by placing a check in the box by employer’s name

Please Read Carefully Before Signing Statement of Application: I understand that previous employers will be contacted for references. I hereby authorize former employers to furnish any and all records of my service with them. I also release my former employers from any liability for any damage in providing this information. I also authorize educational institutions to furnish any records of education-related information they may have concerning me. Status: I understand that positions regarded as part-time and/or temporary are paid for actual hours worked and are not entitled to benefits offered to full time positions, with the exception of FICA and Worker’s Compensation. Probation Period: I understand that if hired, my position with the City of New Smyrna Beach is temporary during the established initial probationary period. My employment may be ended before the expiration of that period for any reason, without recourse. Physical Examination/Drug/Alcohol Testing: I am aware that the City of New Smyrna Beach is a “Drug-free Workplace”. I understand that I may be required to take and pass a physical examination after an offer of employment is made and employment is contingent on the results of that examination in accordance with the Americans With Disabilities Act (ADA). I also understand that the post-offer physical, I will receive a copy of the City’s Drug-free Workplace Program. Any illegal or controlled substance that shows in my test results will cause my immediate disqualification for employment with the City of New Smyrna Beach. Public Records: Pursuant to Florida Statute 119, the Public Records Act, documents made or received by the City of New Smyrna Beach may be public record and open for inspection by the public. Some records, such as social security numbers, examination questions and answers and medical documentation are not public records and may not be disclosed. Certification: I understand that this application must be completed in full. Incomplete applications may be rejected. I agree that any false or misleading information provided by me will be cause for canceling the application process. If hired by the City of New Smyrna Beach, after my hire date, it may cause my dismissal from City service. I have answered all the questions on this form completely and truthfully. I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. If hired, I agree to accept conditions of employment and abide by rules, procedures and policies of the City of New Smyrna Beach. Release of Information: I hereby release from liability and promise to hold harmless under any and all possible claims or causes of action (i) any and all persons or entities who shall furnish such information to the City, its officers, agents or employees, and (ii) the City, its officers, agents or employees for any statements, acts or omissions in the course of obtaining said information. Furthermore, I understand that this release is signed, free from duress, and with the full knowledge and understanding that any information obtained will be used in assessing my relative fitness for employment with the City of New Smyrna Beach. By signing below you hereby acknowledge I will be required to complete a Criminal History Disclosure Form for the City of New Smyrna Beach when requested.

World War II: December 7, 1941 to December 31, 1946 Korean Conflict: June 27, 1950 to January 31, 1955 Vietnam Era: February 28, 1961 to May 7, 1975 Persian Gulf War: August 2, 1990 to January 2, 1992 Operation Enduring Freedom: October 7, 2001 to TBD Operation Iraqi Freedom: March 19, 2003 to TBD Operation New Dawn: September 1, 2010 to TBD Applicants claiming preference is responsible for providing the required documentation (DD214) at the time of making an application for a vacant position. AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER AND DRUG FREE WORKPLACE Vetereans Preference 1/1