Office of the Tax Collector
Walton County, Florida
PO Box 510
DeFuniak Springs, FL 32433
Rhonda Skipper,
Tax Collector
Employment Application
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit
#
City
State
ZIP Code
Phone: (Home)
()
E-mail
Address:
Phone: (other)
()
Date Available:
Social
Security No.:
Desired
Salary:
$
Position Applied for:
Full-time:
YES
☐
NO
☐
Part-time:
YES
☐
NO
☐
Referred by:
Have you ever applied with the Tax Collector’s
Office?
YES
☐
NO
☐
If yes, when:
Have you ever worked for this company?
YES
☐
NO
☐
If yes, when?
Are
you a citizen of the United States?
YES
☐
NO
☐
If no, are
you authorized to work in the U.S.?
YES
☐
NO
☐
If
yes, explain:
Are you related to anyone who works in the Tax
Collector’s Office?
YES
☐
NO
☐
State Name:
Please
list all other names you have used including circumstances and time
periods you used them.
(For example: former name(s), alias(es),
or nickname(s).
Name
Circumstances
Dates
from
Dates
to
Education
High School:
Address:
From:
To:
Did
you graduate?
YES
☐
NO
☐
Degree:
College:
Address:
From:
To:
Did
you graduate?
YES
☐
NO
☐
Degree:
Other:
Address:
From:
To:
Did
you graduate?
YES
☐
NO
☐
Degree:
Knowledge, Skills, and Abilities
Please list any foreign languages
you speak, read or write and your level of ability:
Fluent
Good
Fair
Speak
Read
Write
Describe any word processing
or computer skills and list all software used:
Indicate any
special skills you possess and equipment you can use which may be related
to the position applied for:
State approximate
number of words per minute you can type:
List any licenses
or certificates you may have:
References
Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
()
Address:
Full
Name:
Relationship:
Company:
Phone:
()
Address:
Full
Name:
Relationship:
Company:
Phone:
()
Address:
Previous Employment
List sequentially all of your
employers in the last ten (10) years beginning with your current or
most recent employer (use additional pages, if necessary):
Company:
Phone:
()
Address:
Supervisor:
Job
Title:
Starting
Salary:
$
Ending Salary:
$
Responsibilities:
From:
To:
Reason
for Leaving:
May we contact your previous supervisor for a
reference?
YES
☐
NO
☐
Company:
Phone:
()
Address:
Supervisor:
Job
Title:
Starting
Salary:
$
Ending Salary:
$
Responsibilities:
From:
To:
Reason
for Leaving:
May we contact your previous supervisor for a
reference?
YES
☐
NO
☐
Company:
Phone:
()
Address:
Supervisor:
Job Title:
Starting
Salary:
$
Ending Salary:
$
Responsibilities:
From:
To:
Reason
for Leaving:
May we contact your previous supervisor for a
reference?
YES
☐
NO
☐
Company:
Phone:
()
Address:
Supervisor:
Job
Title:
Starting Salary:
$
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May
we contact your previous supervisor for a reference?
YES
☐
NO
☐
Company:
Phone:
()
Address:
Supervisor:
Job
Title:
Starting Salary:
$
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May
we contact your previous supervisor for a reference?
YES
☐
NO
☐
Company:
Phone:
()
Address:
Supervisor:
Job
Title:
Starting Salary:
$
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May
we contact your previous supervisor for a reference?
YES
☐
NO
☐
Company:
Phone:
()
Address:
Supervisor:
Job
Title:
Starting Salary:
$
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May
we contact your previous supervisor for a reference?
YES
☐
NO
☐
Please explain any gaps in
your employment history:
Did
you work for any of these employers under a different name?
YES
☐
NO
☐
If
yes, which employer (s) and under what names:
4. Have you ever received any
written reprimands or disciplinary suspension during any previous employment?
YES
☐
NO
☐
If yes, which employer(s) and under what names:
5.
Have you ever been dismissed or asked to resign from employment you
held?
YES
☐
NO
☐
6.
Have you ever resigned or left a job by mutual agreement following allegations
of misconduct or unsatisfactory job performance?
YES
☐
NO
☐
Residences
List places of residence for the last
three (3) years:
Dates
Street
Address
City
State
County
or Country
From
To
Driving Record
Do you have a valid driver’s
license?
YES
☐
NO
☐
State:
License
Number:
License Class:
Date
of Expiration:
Restrictions:
Have you ever
had your license or driving privileges revoked, suspended, or placed
on probation?
YES
☐
NO
☐
If
yes, please explain (include when, where, what action was taken):
3. How many speeding or other moving
violations have you received in the last three (3) years?
4. List below all traffic violations
(except parking) on your record for the last five (5) years and all
motor vehicle accidents in which you were involved (use additional pages
if necessary):
Date
Location
Description
Result
Arrest History/ Court
Data
Have you ever been convicted
of, or had adjudication withheld after a plea or trial, on a felony?
YES
☐
NO
☐
Have you ever been convicted
of, or had adjudication withheld after a plea or trial, on a first degree
misdemeanor?
YES
☐
NO
☐
Have you ever been detained
by any law enforcement officer for investigations purposes or to your
knowledge have you ever been the subject of or a suspect in any criminal
investigation?
YES
☐
NO
☐
Are you currently, or have
you ever been placed on court-ordered probation?
YES
☐
NO
☐
Have you ever been fingerprinted
for any reason (arrest, job, military, etc.)?
YES
☐
NO
☐
If yes to any of the above
questions, please provide details:
Military Service
Branch:
From:
To:
Rank at Discharge:
Type
of Discharge:
Did you receive any training in the U.S. Armed
Forces that is relevant to this office?
YES
☐
NO
☐
If
other than honorable, explain:
Employment in this office will require a copy
of your DD-214.
Veteran’s Preference
Do you claim veterans’ preference?
YES
☐
NO
☐
(CHAPTER
295, Florida Statutes, exclude non-disabled, retired military person
from veterans’ preference points)
A)
Based on active
duty during wartime or Vietnam era?
YES
☐
B)
As a Veteran
with a compensable service-connected disability?
YES
☐
C)
As the un-remarried
spouse of a veteran who was killed in action or who died of a service-connected
disability?
YES
☐
D)
As the spouse
of a veteran who cannot qualify for employment because of a total and
permanent service-connected disability, or the spouse of a person missing
in action, captured, or forcibly detained by a foreign power?
YES
☐
E)
Have you used
a veteran’s preference at any time?
YES
☐
You
must submit current documentation of your veterans’ preference status.
Please attach a copy of this verification to this application.
Branch
Date of Entry
Date of Honorable
Discharge
Appointment Application Certification
I hereby certify that all of the facts and
information listed on this appointment application are true and complete.
I understand that any false, incomplete or misleading information given
by me on this application is sufficient cause for rejection of this
application. I also understand and agree that any such false, incomplete,
or misleading information discovered on this application at any time
after I am employed may result in dismissal.
I hereby authorize the Tax Collector
to investigate all statements contained in this application, to interview
the references and previous employers listed in this application, and
to obtain a report from a consumer reporting agency to be used for employment
purposes in accordance with the Fair Credit Reporting Act. I authorize
the references and previous employers listed to give the Tax Collector
all facts, opinions and evaluations concerning my previous employers
listed to give the Tax Collector all facts, opinions and evaluations
concerning my previous employment and any other information they may
have, personal or otherwise, and release all such parties from any liability
which may allegedly arise from furnishing such information to the Tax
Collector, including, but not limited to, any liability for defamation
or invasion of privacy.
If I am offered appointment, I understand
that such an offer will be conditioned upon satisfactory results of
a background investigation and/or Tax Collector medical examination
or inquiry, including a drug screen test. If then employed, I understand
that I will be required to serve a ninety (90) day training period.
I further understand that my appointment and compensation can be terminated,
with or without cause or notice, at any time, regardless of the successful
completion of my training period, at the option of either the Tax Collector
or myself. I understand that no supervisor or other representative of
the Tax Collector other than the Tax Collector has any authority to
enter into any agreement for appointment for any specified period of
time, or to make any agreement contrary to the foregoing.
I further understand and voluntarily
agree as a condition of appointment or my continued appointment, that
I may be requested by the Tax Collector to submit to a urinalysis or
other drug screen test and that my failure to take such test(s) when
requested to do so or unsatisfactory test results will disqualify me
from consideration for appointment or may result in my immediate dismissal.
Note: In the event that an applicant
is selected for employment, the Social Security number you provide on
this document will be used for purposes of: Employment Eligibility,
Authorization for Drug/Alcohol Testing, Criminal History Check, Federal
requirements, Financial requirements, Retirement, Insurance, Worker’s
Compensation, Sick Leave Pool and Educational Assistance by the Walton
County Tax Collector’s Office. All documents will be placed
into an individual Personnel File and upon any review by a public entity
all Social Security numbers shall be redacted.
I certify that my answers are true and
complete to the best of my knowledge.
If this application leads to employment,
I understand that false or misleading information in my application
or interview may result in my release.
Signature:
Date:
You may mail or fax your application
to:
Walton County Tax Collector’s Office
Attention: Human Resources
PO Box 510
DeFuniak Springs, FL 32435
Phone: (850) 892-8121
Facsimile: (850) 892-8693
Resumes may be emailed to: woodebra@co.walton.fl.us
.
We encourage you to log onto our webpage
at www.waltontaxcollector.com
for future vacancy announcements.
Confidential Employee History
Name:
Social
Security No:
The information contained
herein is confidential and will not be made available for public inspection.
1. Are you now able to perform the duties
set forth in the job description or task analysis related to the position
for which you have applied, with or without accommodation?
YES
☐
NO
☐
2.
If a test or examination is required for this position, would you be
able to take this text or examination with or without accommodations?
YES
☐
NO
☐
Explain what accommodation(s)
you would need to perform these tasks or take the test or examination:
4. Do you now, or have you possessed, supplied,
or sold any narcotic or controlled substance such as, but
not limited to, marijuana, hashish, cocaine, LSD, amphetamines, heroin,
steroids or any drug of a similar nature?
YES
☐
NO
☐
If yes, please complete the
following?
a. Drug(s):
b. Circumstances:
c. Number of times possessed/supplied/sold:
d. First time possessed/supplied/sold:
e. Last time possessed/supplied/sold:
5. Do you currently use any narcotic or controlled substances, such
as those listed in question 4 or have you used such a narcotic or controlled
substances within the last year?
YES
☐
NO
☐
6. Please provide name and address of next of kin or other person to
be contacted in case of an emergency.
Name:
Relationship:
Address:
City:
State:
Zip:
Home Phone:
Business or other phone:
7. Please
provide the name and address of your personal or family physicians to
be contacted in case of an emergency.
Name:
Address:
City:
State:
Zip:
Business phone:
Walton County Tax Collector’s Office
Human Resources
PO Box 510
DeFuniak Springs, FL 32435
850.892.8121
Dear Applicant:
In order for the Walton County Tax Collector’s
Office to comply with the Equal Opportunity and Affirmative Action regulations,
we are required to compile summary data on the sex, ethnicity, and veteran
status of all applicants. The information solicited is collected for
the sole purpose of providing data to be used for statistical analysis;
therefore, you should not identify yourself on this form. You have the
option of supplying or not supplying the information requested. This
information, if provided, will neither enhance nor detract from you
opportunity for employment with the Tax Collector’s Office. The information
provided on this form will not be made available to those making employment
decisions.
Ethnic Background (please check the appropriate
box)
☐ American Indian/ Alaskan Native
☐ Hispanic
☐ Asian/ Pacific Islander
☐ White
☐ Black
☐ Other
Sex:
☐
Male
☐
Female
Date of birth:
Dates of application:
What related accommodations would be
necessary in order that all advertised duties and responsibilities could
be performed?
** IMPORTANT- PLEASE READ **
The immigration Reform and Control Act
of 1986 makes it illegal for employers to knowingly hire any unauthorized
or illegal alien. Therefore, employers must verify the employment eligibility
of all applicants hired. Applicants selected for hire must show an employer
documentation to establish United States citizenship or that the individual
is a legal permanent resident alien or an alien authorized to be employed
in the United States. This documentation is required on the date of
hire.
If you have any questions regarding what
documentation will be required to meet this federal requirement, please
check with the Human Resources Office.
The Walton County Tax Collector’s Office
is an equal opportunity employer. All applicants are considered without
regard to race, color, sex, national origin, religion, age, marital
or veteran status, or the presence of a non-job related medical condition
or handicap.