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Please print or type all information. The application must be filled out accurately and completely. If you require assistance due to a disability, please notify our staff. Answer all questions with a red asterisk. If an item does not apply, write not applicable.
Please select the highest grade completed
List the name of the college and/or University attended
List all jobs relevant to the position for which you are applying for the last ten (10) years. Major changes in duties or job titles with the same employer should be listed as separate jobs. Start with your present or most recent position and work back. BE SPECIFIC. All or part of your rating may depend on the information you provide. If you wish to provide additional information, you may submit it as part of your resume. A resume will not be accepted in lieu of completing this section.
NOTE: We may contact previous employers to verify your descriptions of past duties.
Number of hours worked per week
Rate of pay
Explain special term arrangements
Explain special term arrangements for last salary
Provide the date you began and completed position.
Number of persons under your supervision
Detail all tasks, services, or functions that were required for this position
Completion of this survey is voluntary and the information will be maintained separately from your application
This form authorizes the City of Pembroke Pines to verify information provided in the application and supporting documents
List any periods of unemployment and volunteer work relevant to position applying for during the past 10 years.
Detail your activities and volunteer work during this time.
List memberships in professional job related organizations
List certifications and/or licenses that you actively hold (professional, technical, occupational, etc.)
List awards, commendations, outstanding achievement or other recognition received during school, military service, employment or civic duties
Have you ever worked for the City of Pembroke Pines?
Start and End dates of employment with the City of Pembroke Pines
Department/division you worked for?
Any member of your family or household employed by the city?
Please give the person's full name and their relationship to you.
Department/division relative worked in?
A conviction does not automatically mean you cannot be employed by the city. the nature of the offense, how long ago it occurred, relationship to this job, etc. are given consideration
Name, City & State of Court
The court's written decision
Check all that apply
Provide any other relevant information you wish to provide.
In keeping with Florida State Law, honorably discharged wartime veterans, service-connected disabled veterans presently receiving disability benefits, and disabled veterans or MIA person's spouse, who are Florida residents, may be eligible for preference; Veterans who have been employed by the State of Florida or one of its counties, cities, etc. are excluded from this preference. Points will be awarded only if supporting documentation is submitted at the time of application. Acceptable documentation is a copy of a DD-214 and/or proof of receipt of disability benefits dated within six months of the date of application. Materials supplied with the application become property of the City of Pembroke Pines. DO NOT SUBMIT ORIGINALS.
List three (3) personal references who are not relatives or former employers
First and Last Name
Attach/Upload all supplemental documention. (Resume, certificates, DD-214, etc.). Nothing can be added to your application after the announcement period has closed.
I understand that as a condition of employment that statements I have made either verbally or in writing in the course of my seeking employment with the City of Pembroke Pines will be verified through various
sources including but not limited to a Criminal History Records search, Drivers License History, Former and current employers, personal references and consumer credit report. I hereby authorize the City of Pembroke Pines to obtain any information in files pertaining to my employment records including, but not limited to, achievement, attendance, personal history and disciplinary records and credit records. I hereby direct you to release such information upon request of the bearer. This release is executed with full
knowledge and understanding that the information is for the official use only of the City of Pembroke Pines. Consent is further granted for the City of Pembroke Pines to furnish such information as is described above, to third parties in the course of fulfilling its official responsibilities.
I hereby release you, as the custodian of such records, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, sort, or description, which may at any time result to me, my heirs, family, or associates because of
compliance with this authorization and request to release information, or any attempt to comply with it.
Should there be any question as to the validity of this release, you may contact me as indicated below.
Full name(s) used separate by semi-colon (;)
Employment is subject to verification of an applicant's background and conviction record. Persons selected for employment must (1) present a valid social security card, (2) take loyalty Oath, as per Florida Statute, Section 876.05 and (3) subsequent to an offer of
employment, pass a medical examination including testing for current use of drugs and/or controlled substances. If traces of drugs controlled substances are present in a candidate's blood or urine and have NOT been obtained and taken as directed by a valid prescription,
the candidate WILL NOT be given further consideration under the present announcement for this classification. Additionally, the City is required by federal law to verify having seen documents, which the applicant must provide as part of employment processing, that show
the applicant's identity and right to work in the United States.
This field is not part of the form submission.
* indicates a required field