SUPPLEMENTAL APPLICATION
DATE: ____________________
STATE OF FLORIDA
FLORIDA DEPARTMENT OF LAW ENFORCEMENT
P.O. BOX 1489
TALLAHASSEE, FL 32302
EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
The following additional documents are required as soon as possible:
All Applicants:
Attach an unmounted, full face
photograph of yourself, not
larger than 2 3/4 x 2 1/2 inches.
Print your name plainly on the
back of the photograph. The
photograph must have been
taken not more than 3 months
prior to the date of this
application.
1.
2.
3.
4.
5.
6.
Copy of Birth Certificate
Copy of Social Security Card.
Copy of Driver License.
Copy of High School Diploma or Certificate and/or certified College Transcript.
Copy of any and all Form DD 214 (applies to previous military personnel only).
Copy of Selective Service Registration Card (males between 18 and 26 years old).
______________________________________________
Position for Which Applying
Forward all materials to: _________________________________
Florida Department of Law Enforcement
Background Investigation Section
P.O. Box 1489
Tallahassee, FL 32302
INSTRUCTIONS
NOTICE: Application must be typewritten or printed legibly in black ink. All questions must be answered; if a question is not
applicable, so state by indicating N/A (not applicable). If space provided is not sufficient for complete answers, or you wish to
furnish additional information, attach sheets of the same size as the application, and number answers to correspond with questions.
Please be specific when completing application to insure all information is complete, true and correct. Omission of facts will be
perceived as falsification and could be grounds for non-employment or dismissal.
I. PERSONAL HISTORY
1.
Full Name
Last Name
2.
Other
Name
Name
Name
* If you have only initials in your name, list them.
* If you have no middle name, enter NMN.
First Name
* If you are a Jr., Sr, II, etc., enter
the abbreviation in the box after your middle name.
Middle Name
Abbv.
* Give other names you used and the period of time you used them, for example: maiden name,
name(s) by a former marriage, former name(s), alias(es), or nickname(s). If the other name is your
maiden name, put nee in front of it.
Month/Year
From
/
Month/Year
From
/
Month/Year
From
/
Page 1
Month/Year
To
/
Month/Year
To
/
Month/Year
To
/
FDLE OEI-32
Revised 07/30/2008
3.
Date & Place of Birth
Date of Birth
City
4.
Other Identifying Information
Height (feet & inches)
Weight (pounds)
County
Hair Color
Eye Color
State
Sex
Race
Country (if not in the United States)
Social Security Number (Optional)
5.
Give the name and address of your personal or family physician, if any:______________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
II. RESIDENCES
1.
Current Address
_______________________________________________
Street Address
Apt. No.
Home Phone:
_______________________________________
Area Code/Number
_______________________________________________
City
County
State
Zip Code
Work Phone:
_______________________________________
Area Code/Number
Cell Phone:
________________________________________
Area Code/Number
A) List all Email Addresses or Instant Messenger Accounts you have utilized in the past:
B) In the event this information becomes invalid, indicate the name and phone number of a relative through whom you may be
reached or who could furnish FDLE with your current address and phone number.
__________________________________________________________________________________________________________
Name
Relationship
Phone Number
2.
List all adult persons other than your spouse and children, who currently reside with you at your current address:
Full Name
Date of Birth
Race & Sex
Relationship
3.
Actual Places of Residence for Past 10 Years
List chronologically all addresses, including residences while at school and in the military, as well as family-owned vacation homes.
For college on-campus residences, give dormitory name, city and state. If residences in military service cannot be shown as street
address, indicate complete military unit designation and location by city and state. If post office box, give location of post office.
From
To
Month/Yr. Month/Yr. Apt. No.
Street Address
City
County
State
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FDLE OEI-32
Revised 07/30/2008
III. EMPLOYMENT HISTORY
1.
List all employments during the past five (5) years including those listed on your state application and any periods of
unemployment. If you had only one (1) employer during the past five (5) years, list your next most recent employer also.
List any employment with a criminal justice agency regardless of when the employment occurred. Describe your work
experience in detail, beginning with your current or most recent job. Use a separate block to describe each position. Include
military service (indicate rank) and volunteer work, if applicable. Indicate number of employees supervised. Provide an
explanation of all gaps in employment. If needed, attach additional sheets, using the same format.
A.
Name of Present or Last Employer: _______________________________________________________________________
Address: ______________________________________________________________________________________________
Your Job Title: ________________________________________________________________________________________
From: ______________ to: _______________
mo/day/yr
mo/day/yr
Annualized Salary: _______________/_______________
starting
ending
Supervisors Name: ____________________________ Title: _____________________ Phone No.: ___________________
May we contact your employer?
Yes
No
Your Name, if different from application: _________________________________________________________________
Duties & Responsibilities: ______________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Reason(s) for Leaving:
B.
Name of Next Previous Employer: _______________________________________________________________________
Address: _____________________________________________________________________________________________
Your Job Title: _______________________________________________________________________________________
From: ______________ to: _______________
mo/day/yr
mo/day/yr
Annualized Salary: _______________/_______________
starting
ending
Supervisors Name: _____________________________ Title: ______________________ Phone No: _________________
Your Name, if different from application: _________________________________________________________________
Duties & Responsibilities: ______________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Reason(s) for Leaving:
Page 3
FDLE OEI-32
Revised 07/30/2008
C.
Name of Next Previous Employer: ________________________________________________________________________
Address:______________________________________________________________________________________________
Your Job Title: ________________________________________________________________________________________
From: ______________ to: _______________
mo/day/yr
mo/day/yr
Annualized Salary: _______________/_______________
starting
ending
Supervisors Name: _____________________________ Title: ______________________ Phone No: __________________
Your Name, if different from application: __________________________________________________________________
Duties & Responsibilities: _______________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Reason(s) for Leaving:
D.
Name of Next Previous Employer: _______________________________________________________________________
Address: _____________________________________________________________________________________________
Your Job Title: ________________________________________________________________________________________
From: ______________ to: ______________
mo/day/yr
mo/day/yr
Annualized Salary: _______________/_______________
starting
ending
Supervisors Name: _____________________________ Title: ______________________ Phone No: __________________
Your Name, if different from application: __________________________________________________________________
Duties & Responsibilities: _______________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Reason(s) for Leaving:
2.
Have you ever been dismissed or asked to resign from any employment or position you have held?
If yes, please provide details:
Yes
No
Employers Name: ____________________________________________ Date: _____________________________
Reason:____________________________________________________________________________________________
_______________________________________________________________________
Page 4
FDLE OEI-32
Revised 07/30/2008
3.
Have you ever quit a job after being told you would be fired?
Yes
No If yes, please provide details:
Employers Name: ____________________________________________ Date: ____________________________
Reason:____________________________________________________________________________________________
_______________________________________________________________________
4.
Have you ever left a job by mutual agreement following allegations of misconduct or unsatisfactory job
performance?
Yes
No If yes, please provide details:
Employers Name: ____________________________________________ Date: ____________________________
Reason:____________________________________________________________________________________________
_______________________________________________________________________
5.
Have you ever left a job for other reasons under unfavorable circumstances?
If yes, please provide details:
Yes
No
Employers Name: ____________________________________________ Date: ____________________________
Reason:___________________________________________________________________________________________
______________________________________________________________________
6.
Have you ever had any disciplinary action taken against you by an employer or in any position you have held?
Yes
No If yes, please provide details:
Employers Name: ____________________________________________ Date: ____________________________
Action and Reason: ________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________________
7.
Have you ever applied for employment with any criminal justice agency not listed as an employer?
Yes
No If yes, please provide name of agency and date of application: ____________________________
______________________________________________________________________
8.
Do you own a business, or are you a partner or corporate officer in any business or organization not listed above as
Yes
No If yes, please provide name and address of business,
current or former employer?
corporation or organization and describe your relationship or position: ______________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
IV.
1.
ARREST HISTORY/COURT RECORD
Have you ever been arrested, received a notice or summons to appear, charged, been entered into any pretrial
diversion program resulting in charges being dropped by reason of completion of the program, been convicted, pled
nolo contendere or guilty to any criminal violation, or had your criminal record sealed or expunged?
Yes
No
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FDLE OEI-32
Revised 07/30/2008
2.
Have you ever received a ticket or been charged with a traffic violation (exclude parking tickets)?
Yes
No
If yes to question #1 or #2, list all such matters even if not formally charged, no court appearance, found not guilty,
matter settled by payment of fine or forfeiture of collateral, or pre-trial diversion. (Include your juvenile record and
records of arrests which have been sealed, if any.)
Date
Place & Department
Charge
Court & Place
Disposition
Provide details of all criminal arrests listed above: _______________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
3.
Have you ever been detained by any law enforcement officer for investigative purposes or to your knowledge have
you ever been the subject of or a suspect in any criminal investigation?
Yes
No
If yes, please provide details: _________________________________________________________________________
__________________________________________________________________________________________________
4.
Have you ever committed a crime even if you were not caught or arrested? (Examples of crimes are theft, possession
of illegal drugs, firearms offenses, fraud, passing worthless checks, domestic violence, assault, etc.)
Yes
No If yes, please explain: _______________________________________________________________
__________________________________________________________________________________________________
5.
Have you ever been a plaintiff or defendant in a court action (include any liens, lawsuits, bankruptcy, domestic
violence injunctions, etc.)?
Yes
No If so, give date, place, court, names of parties involved, nature of
action, and final disposition: _________________________________________________________________________
__________________________________________________________________________________________________
6.
Yes
No
Have you ever been fingerprinted for any reason (arrest, job application, military, etc.)?
If yes, please give date(s) and reasons printed: __________________________________________________________
__________________________________________________________________________________________________
7.
To your knowledge, has your spouse (including future or former spouse), domestic partner, roommate or any
member of your immediate family [father, mother, brother, sister, stepfather, stepmother, half-brother, half-sister,
in-laws or parents of domestic partner or roommate] ever been arrested for any felony offense? (A felony offense is
a criminal violation punishable by imprisonment in excess of one year in a state or federal prison, regardless of
whether the offense occurred in Florida.)
Yes (list below)
No
Persons Name/ Relationship
Date
Place &
Department
Charge
Disposition
For each person listed above, please provide relation to you, social security number (if known), date of birth, race, and brief
details of the arrest: _________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Page 6
FDLE OEI-32
Revised 07/30/2008
1.
2.
Are you a licensed automobile operator?
V. Driving History
Yes
No
License #: _____________________________
Date of Expiration: ______________
State Issued: _______________
Restrictions: ____________
Do you hold or have you ever held a license in any state other than the one listed in question #1?
Yes
No If yes, please provide state(s), name used and approximate dates of license(s) was/were held:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3.
Have you ever been denied issuance of a license or have you ever had a license suspended or revoked?
Yes
No
If yes, please provide complete details: ____________________________________________________
_____________________________________________________________________________________________________
4.
Have you ever had automobile insurance withdrawn or revoked or have you ever been refused automobile insurance?
Yes
No
If yes, please provide complete details: ____________________________________________________
_____________________________________________________________________________________________________
1.
VI. SELECTIVE SERVICE (Male Applicants Only)
Are you registered for Selective Service?
Yes
No
Selective Service #: _______________________ Classification: _________________ Date of Classification: ____________
Address of Local Board: _________________________________________________________________________________
1.
VII. MILITARY HISTORY
Have you ever served on active duty in the Armed Forces of the United States?
Yes
No
Branch of Service: ___________________________________________________________________________________
Highest Rank: ___________________________ Service Number: ____________________________________________
Dates of Duty (mo/day/yr)
2.
From: ______________
To: ______________
From: ______________
To: ______________
Discharge(s); Provide information for any period(s) of service:
Type: __________________ Basis: ________________ Date: ______________ Separation Center: ___________________
Type: __________________ Basis: ________________ Date: ______________ Separation Center: ___________________
3.
Are you now or have you ever been a member of a reserve unit or the National Guard?
Yes
No
Present
Former
Branch of Service: _________________
4.
If you attend drills, provide the name of the unit and location: _________________________________________________
5.
Was any type of disciplinary action taken against you in the service? (Be sure to include nonjudicial punishment[s], if
Yes
No If yes, please provide details: _________________________________________________
applicable.)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Page 7
FDLE OEI-32
Revised 07/30/2008
VIII. ACQUAINTANCES WITH FDLE AND PERSONAL REFERENCES
Relatives, Friends or Acquaintances employed by FDLE (Past or Current):
Name
Location
Length of Acquaintance
Please provide three (3) minimum PERSONAL REFERENCES:
Name
Email Address
Mailing Address & Phone number
IX. MARITAL STATUS
1.
Mark one (1) of the following boxes to show your current marital status. If you were previously married provide the
requested information concerning your former spouse(s). If you are engaged to be married or contemplating marriage
in the near future, complete information must be provided regarding your future spouse. (Use the space provided for
current spouse to record information about your future spouse and clearly indicate that such relationship is a future
one.)
Never married
Married
Engaged
Separated
Legally separated
Divorced
Widowed
Complete the following about your spouse/future spouse:
Spouse
Full Name
Future Spouse
Date of Birth
Place of Birth (include country if outside U.S.)
Race/Sex
Social Security # (optional)
Other Names Used (Specify maiden name, names by other marriages, etc., and show dates used for each name.)
Country of Citizenship
Date Married
Place Married (include country if outside U.S.)
If separated, Date of Separation
If Legally Separated, Court of Record, City (Country)
State
State
(Mo/Day/Yr)
Address of Spouse (Street, city, and country if outside the U.S.)
State
Zip Code
Former Spouse(s) Complete the following about your former spouse(s):
Full Name
Date of Birth
Place of Birth (include country if outside U.S.) Social Security # (optional) Race
Country of Citizenship
Date Married
Place Married (include country if outside U.S.)
State
Check One
Divorced
Widowed
Month/Day/Year
If Divorced, Court of Record, City (Country
State
Page 8
FDLE OEI-32
Revised 07/30/2008
X. FINANCIAL STATUS
1.
Do you have any sources of income other than your salary or the salary of your spouse?
Yes
No
Specify each with an estimated annual amount: ______________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2.
Are you indebted to anyone?
Yes
No List any debt over $500. Be sure to include student loans and
charges accounts. Also, list any debt where payment is past due, regardless of the amount.
Creditor
Address
Amount
Loan or Account Number
3.
Have you, your spouse, or a company controlled by you filed for bankruptcy?
Yes
No
4.
Have you, your spouse, or a company controlled by you been declared bankrupt?
5.
Have you, your spouse, or a company controlled by you been subject to a tax lien or other lien?
6.
Have you, your spouse, or a company effectively controlled by you had legal judgment rendered against you for a debt?
Yes
No
7.
Have you ever been rejected, other than physical or health reasons, for any insurance?
8.
If yes to question #3, #4, #5, #6, #7 above, provide details:_____________________________________________________
Yes
No
Yes
Yes
No
No
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
XI.
1.
QUALIFICATIONS, SKILLS, REGISTRATIONS, LICENSURES & CERTIFICATIONS
List any qualifications, skills, registrations, licensures or certifications which you now hold or have held which are not
listed on your State of Florida Application. (Examples: aircraft pilot, boat captain, business or occupational licenses,
member of bar, CPA, etc.)
License Type
License Number
Date Issued
Expiration Date
Issued By
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Page 9
FDLE OEI-32
Revised 07/30/2008
XII.
PERSONAL DECLARATIONS AND ASSOCIATIONS
1.
Do you now, or have you ever used, experimented with, or tasted, any narcotic or dangerous drug such as, but not
limited to, marijuana, hashish, cocaine, crack, LSD, amphetamines, heroin, GHB, Ecstasy or RAVE club or drugs of a
similar nature?
Yes
No
2.
If your answer is yes to question #1, complete the following items for each drug used:
a.
Drug: _____________________________________ b. How taken: _________________________________________
c.
Circumstances: _____________________________________________________________________________________
d. Number of times used: _______________________________________________________________________________
e.
3.
First time used: _____________________________
f.
Last time used: ______________________________
Do you now, or have you ever abused or illegally obtained any prescription drug?
Yes
No
If yes, provide details including drug, date(s) and circumstances: _______________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4.
Have you ever possessed, supplied or sold any narcotic or dangerous drug?
Yes
No
If yes, provide details including drug, date and circumstances: _______________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
5.
Have you ever been a member, officer or employee of any organization, association or group which: 1) advocates the
overthrow of our government; 2) advocates or approves of committing acts of force or violence to deny others their
constitutional rights; or 3) wants to change our form of government by unconstitutional means?
Yes
No
6.
Have you ever made a financial or other material contribution to any organization of the type described in question #5
above?
Yes
No **If you answer yes to question #5 or #6, answer questions #7, #8, and #9 also.
7.
At the time of your membership, participation or contribution, did you know of any unlawful aims of the organization?
Yes
No
8.
Did you intend to promote any unlawful aims of the organization(s)?
9.
List each organization and provide an explanation of your involvement and activities with each one:
______________________________________________________________________________________________________
Yes
No
______________________________________________________________________________________________________
10. An investigation will be conducted of all information listed on this application. Because of this, are you aware of any
information about yourself or any person with whom you are or have been closely associated (including relatives and
roommates) which might tend to reflect unfavorably on your reputation, morals, character, ability, or loyalty?
Yes
No If yes, provide your version of this/these incident(s): ____________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Page 10
FDLE OEI-32
Revised 07/30/2008
I understand that any appointment tendered me will be contingent upon the results of a complete background
investigation, and I am aware that withholding information or making false statements on this application may be the
basis for non-employment or dismissal from the Florida Department of Law Enforcement. I agree to these conditions
and I hereby certify that all statements made by me on this application are true and complete. I understand that I may
be required to submit to the department a copy of my Income Tax Return for the year prior to employment and may be
required to submit a copy of my Income Tax Return each year thereafter while employed by the department. I further
fully understand and consent to a polygraph examination concerning the veracity of my responses to the information
requested on this application. I also understand an employee of the Florida Department of Law Enforcement is exempt
from appeal rights to the Public Employees Relations Commission under Florida Statutes as it applies to transfers.
I authorize any of the persons or organizations referenced in this application to give you any and all information
concerning my previous or current employment, education, or any other information they might have, personal or
otherwise, and release all such parties from liability for any damage that may result from furnishing such information to
you.
I agree to conform to the rules and regulations of the department and acknowledge that these rules and regulations may
be changed, interpreted, withdrawn, or added to by the department at any time, at the departments sole option, and
without any prior notice to me.
__________________________________________________
Signature of the applicant as usually written
(DO NOT USE NICKNAMES)
_____________________
Date
___________________________________________________
Print Legal Name
Page 11
FDLE OEI-32
Revised 07/30/2008
