STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO 1940 NORTH MONROE STREET TALLAHASSEE, FLORIDA 32399-1023
SUPPLEMENTAL APPLICATION Equal Opportunity Employer/Affirmative Action Employer The State of Florida does not tolerate violence in the workplace
State Accredited Law Enforcement Agency
LAW ENFORCEMENT INVESTIGATIVE SPECIALIST LAW ENFORCEMENT INTERN
Type or print legibly in ink PERSONAL DATA
First Name:
Middle Name:
Last Name: PHOTOGRAPH Maiden Name:
Former Name(s):
Nickname(s):
Social Security Date of Birth - - Number: / / City State Country Height: Weight: Place of Birth: ’ ” lbs
Yes No Naturalization Certificate Number: Hair Color: Eye Color: Citizen of United States:
BLE-201 (rev. 05/10) State Accredited Law Enforcement Agency Page 1 of 11 GENERAL INFORMATION AND INSTRUCTIONS
A background investigation will be required of all applicants seeking employment as a Law Enforcement Officer, Investigation Specialist or a student seeking to participate in the Internship Program of the Division of Alcoholic Beverages and Tobacco. The information you provide in the State Employment Application and this supplemental application will be used to determine your eligibility and suitability for a law enforcement position with the Division.
Please complete this application accurately and neatly and without errors, omissions or misleading information. Any misrepresentation, falsification, omission or concealment of a material fact may be considered grounds for non-employment or dismissal.
Questions must be answered with a Yes, No or None answer, and all questions must be answered. Applications that are incomplete and/or not typed or printed legibly in ink will not be processed for consideration. If space is insufficient for complete answers, use additional sheets, the same size as the application, and number the answers to correspond with the questions.
RESIDENCE List all places of residence for the past five (5) years. List chronologically all addresses ( from present to past), including residences while in school, in the military and family-owned vacation homes. For on campus, give college/university name, dormitory name and complete address. If military address cannot be shown as a street address, indicate military unit designation, location by city and state and, if post office box, the location of the post office. DATE Apt. Street Address City/County State Zip Month/Year #
/
/
/
/
/
CONTACT INFORMATION Residence Telephone: Work Telephone: Cell Phone: ( ) - ( ) - ( ) -
Yes No If no, state limitati Are you willing to be assigned anywhere in the state of ons in Florida? the space below:
EMPLOYMENT HISTORY Yes No 1. May we contact your present employer?
BLE-201 (rev. 7/10) Page 2 of 12 List all employment during the past ten (10) years; begin with the most recent. If you only had one employer 2. during the last ten (10) years, also list the next most recent job. List all employment with any criminal justice agencies you have ever held, no matter how long ago. Include military service and volunteer work. Name of Employer:
Address:
Your Job Title: Supervisor’s Telephone: ( ) -
Date From: / / To: / / Annual Salary: $
Supervisor’s Name: Title:
Your name, if different from application: Duties and Responsibilities:
Reason(s) for Leaving:
EMPLOYMENT HISTORY (continued) Name of Employer:
Address:
Your Job Title: Supervisor’s Telephone: ( ) -
Date From: / / To: / / Annual Salary: $
Supervisor’s Name: Title:
Your name, if different from application: Duties and Responsibilities:
Reason(s) for Leaving:
Name of Employer:
Address:
Your Job Title: Supervisor’s Telephone: ( ) -
Date From: / / To: / / Annual Salary: $
Supervisor’s Name: Title:
Your name, if different from application:
BLE-201 (rev. 7/10) Page 3 of 12 Duties and Responsibilities:
Reason(s) for Leaving:
Additional PAGE(S)
If additional space is needed for employment history, record information on plain paper and attach sheets to this page. Indicate here the number of additional pages attached:
Provide dates (month and year), a brief explanation and a summary of activities for any gaps in 3. your employment history in the last ten (10) years: Date(s) Explanation / /
/ /
Have you ever submitted an application for law enforcement? If yes, list all agencies Yes No 4A. below. Date Agency Name Status Submitted S
E / / Y / /
Yes No 4B. Have you ever been sponsored to attend any law enforcement academy/program?
Agency Name Begin Date End Date S
E / / / / Y / / / /
Have you ever been dismissed, suspended, asked to resign, demoted, received Yes No 5. an oral or written reprimand or had any disciplinary action taken against you by any employer or supervisor? Details, if yes:
S E Y
Yes No 6. Have you ever had a formal complaint filed against you or been the subject of an internal investigation?
BLE-201 (rev. 7/10) Page 4 of 12
BLE-201 (rev. 7/10) (rev. 7/10) BLE-201 10. 2. 1. YES YES 9. YES 8. 7. YES Have you or your spouse ever held a direct or indirect interest in a business a in interest indirect or direct a licensed distribute to sell, alcoholicmanufacture or beveragescigarettes?or held ever spouse your or you Have entity business any in interest ownership indirect or direct other currently or securities bonds, stocks, all List outcome: andincluding Details,location(s) license? Haveyou ever applied anycounty, for state federalor license,excluding driver’s Reason, if yes: Haveyou ever been denied anapplication to carry a concealedweapon? if yes: Details, Haveyou ever applied concealedto carry a weapon? Reason(s): (12) twelve past the during months,thanother planned vacations? work from absent been you have days many How if yes:Details, Company Name Company owned directlyowned indirectlyor by you:
CONFLICT OF INTEREST CONFLICT
Nature ofBusiness Nature
Nature ofInterest Nature Number of Days Number of Yes Yes Yes Yes
Page No No No No 5 : of 12
BLE-201 (rev. 7/10) (rev. 7/10) BLE-201 NOTE: If additional arrest, court or ticket record data is attached, indicate the is arrest, ticketpages:NOTE: recordattached,number additional court of If or indicate data fine offorfeiturecollateral. or a of payment by settled was matter the if or guilty, found not appearance, court no charged, formally not if even space, following the in details give above, questions both or one either to “yes” answered you If RECORDS EXPUNGED AND SEALED
4. 3. 2. 1. 3. / / DATE YES YES YES / / applicants tolist sealed any or record(s),expunged whether adult, juvenile,civilian military. or
beena crime committed if as an adult? have would that act an for court juvenile a before appear to required been ever you Have provide details:If yes, Haveyou ever been onplaced court probation? violation ( Excludingparkingticket(s), youhave ever receiveda ticketbeen or charged with traffic a anycriminal violation? Haveyou ever been arrested, charged receivedaor or notice appear summons for to if yes:Details, cigarettes? or beverages alcoholic sell to licensed anyone by employed been ever you Have if yes:Details,
including speed violations limit LOCATION
ARREST HISTORY/COURT RECORD ARRESTHISTORY/COURT
eto 4.5, Foia Saue, rqie a enforcement law requires Statutes, Florida 943.058, Section : AGENCY )since you have licensed? been
CHARGE/VIOLATION
COURT/PLACE Yes
Yes Yes Yes Yes DISPOSITION
PAGE(S) Page No No No No No 6 of 12
BLE-201 (rev. 7/10) (rev. 7/10) BLE-201 10. YES YES 9. YES 8. YES 7. YES 6. YES 5. YES provide details: If yes, date, disposition. the list yes, If action? court any place, nameof parties involved, of actionin nature (includingdivorce proceedings) and final defendant or plaintiff a been ever you Have provide details:If yes, firearms drugs, illegal of possession offenses, fraud, worthlesspassing checks,etc., if even not you were caught arrested?or theft, as such crime, a committed ever you Have provide details:If yes, alicensepermit? or with conjunction in agency regulatory governmental a by penalized been ever you Have any provide details:If yes, delivered or transported sold, possessed, obtained, weapons, alcoholic beverages,cigarettes or equipment?gambling unlawfully ever you Have in detail: explain If yes, Haveyou ever sold,transported, delivered, possessedor used drugs?any illegal provide details:If yes, Haveyou ever been convicted misdemeanor of a crime domestic violence?or provide details:If yes,
Yes Yes Yes Yes Yes Yes Page No No No No No No 7 of 12 DRIVING HISTORY Yes No 1. Do you have a valid drivers’ license? NOTE: All sworn personnel must possess a valid Florida driver’s license while employed with the Division.
State: License Number: Expiration Date: Restrictions: / /
2. List all states where you have been granted a license to operate a motor vehicle:
City & State: Name: Type & Date: / / / /
Yes No 3. Have you ever been denied issuance of a driver’s license, or have you ever had a driver’s license suspended or revoked?
If yes, provide details:
S E Y
Yes No 4. Have you ever had automobile insurance withdrawn or revoked, or have you ever been refused automobile insurance?
If yes, provide details:
S E Y
Yes No 5. Have you ever been involved in a motor vehicle accident?
If yes, provide details:
S E Y
MILITARY HISTORY Yes No 1. Are you registered for Selective Service?
If yes, Selective Service Number:
Yes No 2. Have you ever served on active duty in the Armed Forces of the United States?
Date(s) Branch Highest Rank Serial Number S E
Y / / - / /
BLE-201 (rev. 7/10) Page 8 of 12 Yes No 3. Are you now or have you ever been a member of a reserve unit or the National Guard?
Date(s) Branch Location: / / - / / S E
Y / / - / /
Yes No 4. Have you ever had any type of disciplinary action taken against you in the service?
If yes, provide details:
S E Y
REFERENCES
List five (5) individuals who have known you well for the past five (5) years, excluding relatives and employers:
(1) Name: Occupation: Current Address Apt. No. Telephone Numbers Home Street: ( ) -
Work City: State: Zip: ( ) -
(2) Name: Occupation: Current Address Apt. No. Telephone Numbers Home Street: ( ) -
Work City: State: Zip: ( ) -
(3) Name: Occupation: Current Address Apt. No. Telephone Numbers Home Street: ( ) -
Work City: State: Zip: ( ) -
BLE-201 (rev. 7/10) Page 9 of 12 (4) Name: Occupation: Current Address Apt. No. Telephone Numbers Home Street: ( ) -
Work City: State: Zip: ( ) -
(5) Name: Occupation: Current Address Apt. No. Telephone Numbers Home Street: ( ) -
Work City: State: Zip: ( ) -
FINANCIAL STATUS 1. List all outstanding debts, including credit cards, charge accounts, mortgages, contracts, loans, etc.: Account Creditor/Company City/State Account Number Balance $ . $ . $ . $ . $ . $ . $ . $ .
2. List all current debts which are 30 days past due:
Have you ever had any debts turned over to a collection agency? Yes No 3. If yes, provide details:
S E Y
Have you ever had any goods you purchased repossessed? Yes No 4.
BLE-201 (rev. 7/10) Page 10 of 12
BLE-201 (rev. 7/10) (rev. 7/10) BLE-201
YES 3. YES 2. 1. YES 7. YES 6. YES 5. YES Supervisor: Address: Agency: Haveyou ever participated in criminal a justice internship program? technical university, college, provide details:If yes, school, high in enrolled schoolor trainingcenter? while action you disciplinary of against kind any taken had or expelled suspended, been ever you Have the of Florida State Employment Application: etc., skills, special certifications, licenses, registrations, courses, training all List provide details:If yes, other or lien a had judgment rendered against a youdebt?for lien, tax a to subject been you by controlled company any or spouse your you, Have provide details:If yes, Haveyou,your spouse anycompanyor controlledyou by filed bankruptcy?ever provide details:If yes, Haveyou ever yourhad wagesgarnished? provide details:If yes,
EDUCATION Telephone: City/State: Date(s): (
/
not already listed already not ) ) /
Yes Yes -
Yes Yes Yes -
/
/ Page
No No No No No on 11 of of 12 HONORS, AWARDS AND LEADERSHIP POSITIONS
List any honors and awards you have received and all leadership positions you have held:
SUPPORTING DOCUMENTATION
During the background investigation process, you will be required to provide supporting documentation regarding your age, citizenship, education, licenses, certifications, military service, job evaluations, credit history and any other documentation deemed necessary to verify any information you have provided during the application process.
I, ______, understand that any position offered will be contingent upon the results of a complete background investigation. I am also aware that withholding information or making false statements on this supplemental application will be grounds for non-employment or dismissal from the Division of Alcoholic Beverages and Tobacco. I agree to these conditions and certify that all statements on this supplemental application are true. I understand that I may not lawfully deny arrests or convictions, even if adjudication was withheld or the record was sealed or expunged. I also understand that a misdemeanor arrest or conviction may not necessarily disqualify me for employment.
Signature of Applicant: ______Date: ______
ENCLOSURES: (read carefully – select the applicable paragraph and attach the required forms)
A. LAW ENFORCEMENT APPLICANTS:
FDLE Authority for Release of Information – CJSTC 58 Form must be completed and attached to this supplemental application. An incomplete application and/or Release for Information Form may result in the applicant not being considered for the position.
B. INVESTIGATIVE SPECIALIST APPLICANTS:
Release and Wavier, Form BLE-202 must be completed and attached to this supplemental application. An incomplete application and/or Release for Information Form may result in the applicant not being considered for the position.
C. INTERNSHIP PROGRAM APPLICANTS:
Release and Wavier, Form BLE-202, must be completed and attached to the supplemental application. An incomplete application and/or incomplete Release and Wavier forms may result in the applicant not being considered for the position.
BLE-201 (rev. 7/10) Page 12 of 12