FLORIDA HIGHWAY PATROL STATE TROOPER APPLICANT SPECIAL INSTRUCTIONS … · FLORIDA HIGHWAY PATROL STATE TROOPER APPLICANT SPECIAL INSTRUCTIONS ... E. Answer all questions accurately

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FLORIDA HIGHWAY PATROL

STATE TROOPER APPLICANT

SPECIAL INSTRUCTIONS

**Carefully read and follow ALL below instructions**

This packet of information is part of the selection process for a position as a State Trooper with the Florida Highway

Patrol. Your failure to follow any of these instructions or provide the required information will result in your file being

placed in an inactive status. This affidavit is part of the applicant screening process and is used to determine your ability to

follow instructions.

Step 1: Print out this ENTIRE packet (print only one-sided copies and do NOT staple).

Step 2: Legibly complete ALL pages of this packet and ensure you have all forms requiring a notary’s signature

signed and notarized (we will NOT notarize any of the forms for you). Also, ensure you have ALL

requested forms and documents along with this packet. Failure to have all forms and notarizations will

result in your application being placed in an inactive status.

Step 3: Make a copy of your completed packet and bring it with you to Physical Abilities Testing (PAT) on your

scheduled PAT date (we will NOT make copies for you). DO NOT MAIL THIS PACKET.

Step 4: Prior to attending your scheduled PAT Testing, you MUST visit your physician (Medical Doctor) and have

the Florida Highway Patrol Medical Release Form (page 8 of this packet) completed by your physician.

A Licensed Practical Nurse, or equivalent, completing this form will NOT satisfy the requirement of

your clearance by a Medical Doctor.

Step 5: You will need to take and pass the Criminal Justice Basic Abilities Test (CJBAT) for Law Enforcement

Officer and bring WRITTEN proof of a passing score to PAT testing. The Florida Highway Patrol does

NOT administer this test. The CJBAT must be scheduled by you and paid-for AT YOUR OWN

EXPENSE. Your application will NOT be processed without proof of a passing score on this test. If you

have taken and passed the CJBAT for Law Enforcement Officer within the last four years, you will not

need to retake the CJBAT. However, you WILL need to bring written proof of a passing score to PAT

Testing. More information about this test, study materials, and where the test is administered can be found

at the following website:

Step 6: The conditions of employment are based upon your successful completion of the Physical Abilities Test.

Arrangements should be made for you to be at the testing facility for the entire day.

Step 7: If you have any tattoos, you will need to ensure they comply with FHP Academy policy (see page 51 of

this packet for more information).

Step 8: DO NOT ARRIVE LATE. Applicant orientation begins promptly at 6:00 a.m. EST and late arrivals will

NOT be admitted. PAT Testing will occur immediately after orientation. Bring pens with you to orientation.

Your invitation to the FHP PAT Test listed three testing sites (Tallahassee, Orlando, and Miami). You MUST notify

us which PAT Testing session you will be attending by emailing us at [email protected] PRIOR to the scheduled

testing date. If you fail to notify us of the date and location where you will be participating in PAT Testing, you WILL

NOT BE ADMITTED INTO TESTING and YOUR APPLICATION WILL BE PLACED IN AN INACTIVE

STATUS. If you fail to appear at your scheduled PAT Testing, you will be considered no longer interested in a position as

a State Trooper. Please allow 3 weeks after PAT Testing before calling 850-617-2315 regarding the status of your

application.

initiator:[email protected];wfState:distributed;wfType:email;workflowId:c17ebef7aaed33419b44946ffafb4bbe

http://www.fdle.state.fl.us/CJSTC/Officer-Requirements/Basic-Abilities-Test.aspx

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INSTRUCTIONS FOR COMPLETING THE APPLICATION

Notice: Read and follow these instructions exactly. Any unanswered, incomplete, or omitted information may result in

rejection of your application. Any falsification WILL result in disqualification of your application and potential

disqualification from future employment consideration with FHP. The information in this packet WILL be used in all

stages of the background process to include POLYGRAPH so ensure you are completely TRUTHFUL! This document,

when completed, along with its attachments, will be used by the Florida Highway Patrol as an investigative aid. Retention

of this personal data will remain in the files of the Personnel Office and Background Investigations Office.

A. TYPE OR PRINT in black ink only. If printing, make sure it is completely legible.

B. Answer all questions. If one does not apply to you, write N/A in the corresponding area. Do not leave any section

blank.

C. If the space provided is insufficient, use a separate sheet of 8 1/2 x 11 paper to continue answering the question(s)

and precede each answer with the number of the section to which it refers. Attach that sheet and any others to the

back of this packet.

D. Do not misstate or omit any material fact in this application. The information you provide WILL BE VERIFIED

to determine your qualifications for employment.

E. Answer all questions accurately and completely. Do not make exaggerated, false or misleading statements, or

otherwise falsify information as it may cause rejection of your application. If you are chosen for employment and

it is discovered that you falsified any information in this packet, it may be grounds for dismissal.

F. Each and every question has a purpose for being asked; answer each question completely and accurately,

even if you think it is not important.

G. The following items MUST accompany this application (Do NOT bring original copies unless otherwise noted):

1. Photocopy of your high school diploma or high school transcript

2. Official college transcripts in envelopes sealed by the issuing institution (“issued to student” or photocopied

transcripts are not acceptable)

3. Photocopy of GED diploma (GED test scores are required if obtained outside of the State of Florida)

4. Photocopy of DD214 Form(s) member four (4) copy for all periods of service (applies to previous military

personnel only)

5. Photocopy of birth certificate (U.S. or U.S. Territories only) or

Original certificate of naturalization, if applicable. Bring the ORIGINAL certificate along with a

photocopy of it with you to PAT Testing. The original will be returned to you at PAT Testing.

6. Photocopy of marriage certificate, divorce decree, adoption or legal name change paperwork (if name on

birth certificate is different from your name on the application)

7. A current individual passport style color photograph (uncovered with no hat or sunglasses)

8. Proof of registration with the U.S. Selective Service System (see below website for more information)

https://www.sss.gov/Registration-Info/Who-Registration

9. All out-of-state driving records (must be ORIGINAL CERTIFIED copies from the State DMV).

10. State of Florida Law Enforcement Standards Certification/Test Scores (Florida Certified Law Enforcement

Officers only)

11. Photocopy of Social Security Card

12. Photocopy of current Driver License with photograph

https://www.sss.gov/Registration-Info/Who-Registration

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MINIMUM EMPLOYMENT REQUIREMENTS

H. You MUST be a United States citizen. Naturalized citizens must provide an ORIGINAL “Certificate of Naturalization.” (As previously indicated, it will be returned to you at PAT Testing.)

I. You must be at least 19 years of age.

J. MINIMUM VISION REQUIREMENTS: You must have minimum correctable vision of 20/30 in each eye, normal color-distinguishing capability and a 140-degree field of vision.

K. If you are hired, you must complete a period of training and serve in a probationary status for twelve months (Section

§321.04(2), Florida Statutes).

L. You must be willing to accept a duty assignment ANYWHERE in the State of Florida.

M. A thorough background investigation, including information as to your character, general reputation, personal characteristics and lifestyle will be part of the screening process. This information is solely for the purpose of evaluating your qualifications for employment with the Florida Highway Patrol and shall remain the property of the Division. Any willful falsification or misrepresentation of information on this or any application will be reason for disqualification. By submitting this application, you are authorizing the Florida Highway Patrol to contact any and all available sources for the purpose of obtaining information as to your qualifications for employment as a State Trooper with the Florida Highway Patrol.

N. You must possess a VALID driver license.

HAVE YOU READ AND DO YOU UNDERSTAND ALL OF THE ABOVE INFORMATION? YES NO

________________________________________ _________________________________ (MMDDYY)

Applicant’s Signature Date

______________________________________

Printed Name

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Official (FHP) Use Only:

BRC_______ TRC_______ Applicant Information Survey

(Print or Type Clearly)

Position for which you are applying (Check One): State Trooper Auxiliary Officer

PAT Testing Location (Check One): Tallahassee Orlando Miami Other: _________________

Driver License Number: ______________________ State: ___________ Race: _____________ Sex: ________

Social Security Number: _____-______-_________ Date of Birth: _____________________ (MM/DD/YY)

First Name: ___________________ Middle Name: ________________ Last Name: _______________________

Maiden Name (If applicable):___________________________________

Mailing Address: ____________________________________________________________________________ Street Address City County State Zip Code

Home Phone: (_____)___________________ Work Phone: (_____)_________________________

Cell Phone: (_____)__________________ Personal Email:___________________________@_______________

Is the above address different from your original State of Florida application? Yes No

Education Level: BS / BA Degree or Higher: AS / AA Degree:

120+ Credit Hours: 60+ Credit Hours: 90+ Quarter Credit Hours:

Military Experience: Yes No Honorable Discharge: Yes No

Are you an active/current Law Enforcement Officer? Yes No

Are you currently employed as a Florida Law Enforcement Officer? Yes No If yes, name of agency: _____________________________________________

Have you been previously employed as a Florida Law Enforcement Officer? Yes No If yes, name of agency(s): ______________________________________________________________________

___________________________________________________________________________________________

Are you willing to relocate ANYWHERE in the State of Florida? Yes No

How did you hear about employment with the Florida Highway Patrol? (Check all that apply)

FHP Employee ____________________________ FHP Recruiter ______________________________ Name Name

BeATrooper.com Facebook Instagram Other Social Media (Specify) __________________

DHSMV Employee ___________________________ Other Law Enforcement Agency Referral Name

College/Vo-Tech Referral _______________ Job Fair _______________ Radio ___________ Location Location Location

Billboard U.S. Military Referral FHP Station Open House Self-Initiated

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Applicant Name: Social Security Number: _______-______-________

Check One: Male Female

Official (FHP) Use Only: Weight: Height: Tattoo DQ:

MALE FEMALE

HEIGHT MAXIMUM HEIGHT MAXIMUM

4'5" 133 4'5" 134

4'6" 137 4'6" 138

4’7” 142 4’7” 141

4’8” 147 4’8” 144

4’9” 151 4’9” 148

4’10” 156 4’10” 151

4’11” 140 4’11” 154

5’0” 165 5’0” 158

5’1” 170 5’1” 161

5’2” 175 5’2” 164

5’3” 178 5’3” 169

5’4” 183 5’4” 172

5’5” 187 5’5” 176

5’6” 193 5’6” 181

5’7” 198 5’7” 185

5’8” 203 5’8” 189

5’9” 207 5’9” 194

5’10” 213 5’10” 199

5’11” 218 5’11” 205

6’0” 224 6’0” 210

6’1” 229 6’1” 215

6’2” 235 6’2” 221

6’3” 240 6’3” 227

6’4” 251 6’4” 233

6’5” 258 6’5” 239

6’6” 265 6’6” 246

6’7” 272 6’7” 253

6’8” 280 6’8” 260

6’9” 289 6’9” 267

6’10” 297 6’10” 274

6’11” 305 6’11” 282

7’0” 314 7’0” 290

________ PAT Time: __________(Max 6:04 to Pass)

Pass:DQ:

______________ PAT Date

______________FHP Staff Initials

MartinR2

Typewritten Text

Date of Birth: ________ / ________ / ____________ (MM/DD/YYYY)

January 21, 2018

TO: Certified Physicians, Certified Advanced Registered Nurses, Physician’s

Assistant’s and State Trooper Applicants

FROM: Major Nancy D. Rasmussen

FHP Training Academy Director

SUBJECT: Physical Fitness Assessment/Physical Fitness Conditioning Program

It is a requirement for any basic recruit enrolled or employed in a basic recruit training

program to participate in a physical fitness evaluation and training program. The Florida Highway Patrol

(FHP) Training Academy has a physical fitness program that covers the entire course of basic recruit

training. Recruits are involved in physical fitness every day, Monday through Friday, for 45 to 50 minutesfor each battery of exercise.

Mondays, Wednesdays, and Fridays are run days. The training session begins with “static”

stretching. Once the recruits are stretched, they run together as a group. An FHP Training Academy Staff

member, who is a Criminal Justice Standards and Training Commission (CJSTC) certified instructor, leads

the run. Distances of the group run range from 1.5 miles to 6 miles during each battery of exercise. At the

completion of the run, there is a brief “cool-down” by marching, followed by more “static” stretching.

Running does not occur on days when the temperatures are below freezing, when the heat index is unsafe,

or when other inclement weather is present.

Tuesdays and Thursdays are gym days. These training sessions take place in a climate-

controlled gym with padded floors. Gym days consist of “static” stretching, calisthenics (including but not

limited to push-ups, sit-ups, jumping jacks, windmills, mountain climbers, etc.), followed by “static”

stretching and a “cool-down” session. An FHP Training Academy Staff member, who is a CJSTC certified

instructor, leads the gym session.

Most of the FHP Training Academy Staff are certified first responders and instructors.

Automated External Defibrillators (AED’s) are located throughout the facility for emergency use, if needed.

Recruits who become injured in any way are referred to a physician for treatment, and if so ordered, are

excluded from fitness training until cleared by the physician or dismissed from the Training Academy.

The FHP Training Academy takes great pride in its physical fitness and wellness program

and has taken every necessary step to provide a safe fitness training environment for its recruits.

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WAIVER OF LIABILITY

I (print name) ____________________________________________ attest that I am in good physical condition. I understand that as an applicant to the Florida Highway Patrol, I will submit to a physical assessment of my ability to perform the essential functions of a law enforcement officer. I understand and acknowledge this involves strenuous and exhaustive physical activities. I received a description of the activities I am requested to perform in advance of these activities.

I understand that employment is based upon successful completion of the following: Criminal Justice Basic Abilities Test, Physical Abilities Test, polygraph examination, psychological screening, background investigation, physical examination, vision examination, and drug screening. I understand the Florida Highway Patrol will continue to consider me for employment as long as I pass the aforementioned examinations. THIS IS NOT A GUARANTEED JOB OFFER.

I hereby release the State of Florida, the Department of Highway Safety & Motor Vehicles, the Division of Florida Highway Patrol, its employees, agents, representatives and assignees from liability for any injury I may sustain while involved in, or as a result of the Physical Abilities Test (PAT).

_________________________________________________ ___________________ (MM/DD/YYYY) Applicant’s Signature Date

_____________________________________________________________________________________ Street Address City County State Zip Code

AFFIDAVIT

STATE OF __________________________ COUNTY OF __________________________

Before me personally appeared the said _______________________________________ who says that the execution of the above instrument is by free will and accord, with full knowledge of the purpose therefore.

Sworn to and subscribed before me on this ______________________ day of __________________________, 20 _____.

_______________________________________________________ My Commission expires __________, 20______. Notary Public

Personally-Known ____ OR Produced Identification ____. Type of Identification Produced ________________________

_____________________________________________ Notary Seal

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MEDICAL RELEASE FORM

THIS FORM IS TO BE COMPLETED AND THE DOCTOR’S APPROVAL MUST APPEAR ON THIS FORM IN ORDER TO PARTICIPATE IN THE PHYSICAL ABILITIES TEST.

Name of Participant: _______________________________________ ________-_______-__________ Print Name Social Security Number

Dear Physician,

The above-named individual intends to participate in the Florida Highway Patrol pre-employment physical abilities test. We are aware of the fact that strenuous physical activity may be inadvisable for some individuals. Therefore, we request that you indicate whether the above-named participant has any medical condition or disorder that would preclude participation. It’s emphasized that we are not asking you to assume responsibility for the participant while participating in this test. Rather, we want to have as much information as possible when making decisions concerning applicability of testing.

The testing program will consist of a series of physical abilities tests conducted at our training site. The battery of job-related field tests are intended to be completed in the fastest possible time and will require maximum effort by the participant. Tests are designed to measure balance, muscular endurance and strength, flexibility, anaerobic power and capacity, fine motor skills and aerobic power. Tests will include two 220 yard runs, dragging a 150-pound object 100 feet, jumping over obstacles (12-24 inches high), climbing over a wall (40 inches high), two 50-foot sprints and movement around a series of pylons. The primary goal of this testing is to determine whether the participant is capable of performing minimum standards appropriate to law enforcement, corrections or correctional probation.

I have examined this participant and his/her medical history, and based upon my evaluation I recommend that:

Within a reasonable degree of probability, no medical condition or disorder exists which precludes this participant from

participation in the physical abilities tests as described.

Participation is NOT advisable at the present time.

(If you advise against participation, please do not disclose the participant’s medical condition on this form.)

____________________________________________ _________________________________ Signature of Physician Date Physician Signed

____________________________________________ Printed Name of Physician

___________________________________________________________________ Name and address of Facility, Clinic, or Physician’s Office

**This form only valid for 90 DAYS from the above date**

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The following three (3) pages are Injury and Damage Releases for the three main locations where the Physical Abilities Test (PAT) is

administered by the Florida Highway Patrol.

You will ONLY NEED ONE INJURY AND DAMAGE RELEASE completed for participation in PAT Testing. The location in which you

will be attending the testing will determine which release you will complete. Below is a list of PAT Testing locations which will help you to determine which release to complete. Without a release completed, you

will NOT be permitted to participate in PAT Testing.

Tallahassee (Havana) Florida Highway Patrol Academy / Florida Public Safety Institute

(use this form if you are completing your PAT test in Tallahassee, Havana, or any other location OTHER THAN Valencia Community College or Florida International University)

Orlando Valencia Community College

(use this form if you are completing your PAT test in Orlando, Florida at Valencia Community College)

Miami Florida International University

(use this form if you are completing your PAT test in Miami, Florida at Florida International University)

Whichever form does NOT apply to your PAT Testing location, draw an “X” over the page and include it with the packet and submit it at PAT

Testing.

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Florida Highway Patrol Academy / Florida Public Safety Institute INJURY AND DAMAGE RELEASE

Whereas, the below named individual, for his/her own benefit, desires to participate in a Physical Abilities Test (PAT) of their ability to perform the essential functions of a State Trooper, administered by the Florida Highway Patrol.

Whereas, the individual realizes that participation in such assessment is subject to inherent risk, and the individual hereby releases and holds harmless the State of Florida, the Department of Highway Safety and Motor Vehicles, the Florida Highway Patrol, and the Florida Public Safety Institute, their agents and employees, co-sponsors and their agents and employees, and fellow candidates, in connection with bodily injury, death or property damage incurred by the below named individual in any way related to or arising out of this physical assessment activity, whether such injury or death arises or is alleged to have arisen from negligence of the individual, the State of Florida, the Department of Highway Safety and Motor Vehicles, the Florida Highway Patrol, or the Florida Public Safety Institute, their agents or employees, co-sponsors, their agents or employees, or fellow candidates, or the contributory negligence of any of the aforementioned.

Signed this __________________________ Day of ____________________________, 20____________

Print Name: ___________________________________________________________________________

Signature: ____________________________________________________________________________

AFFIDAVIT






_____________________________________________ Notary Seal

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Valencia Community College Criminal Justice Center INJURY AND DAMAGE RELEASE

Whereas, the below named individual, for his/her own benefit, desires to participate in a Physical Abilities Test (PAT) of their ability to perform the essential functions of a State Trooper, administered by the Florida Highway Patrol.

Whereas, the individual realizes that participation in such assessment is subject to inherent risk, and the individual hereby releases and holds harmless the State of Florida, Board of Regents, Valencia Community College, its agents and employees, co-sponsors and their agents and employees, and fellow candidates, in connection with bodily injury, death or property damage incurred by the below named individual in any way related to or arising out of this physical assessment activity, whether such injury or death arises or is alleged to have arisen from negligence of the individual, the State of Florida, Board of Regents, Valencia Community College, its agents or employees, co-sponsors, their agents or employees, or fellow candidates, or the contributory negligence of any of the aforementioned.


Print Name: ___________________________________________________________________________

Signature: ____________________________________________________________________________

AFFIDAVIT






_____________________________________________ Notary Seal

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Florida International University INJURY AND DAMAGE RELEASE

Whereas, the below named individual, for his/her own benefit, desires to participate in the Florida Highway Patrol Physical Abilities Test (PAT) at the Florida International University.

Whereas, the individual realizes that participation in such assessment is subject to inherent risk, and the individual hereby releases and holds harmless the State of Florida, Florida International University, its agents and employees, co-sponsors and their agents and employees, and fellow attendees, in connection with bodily injury, death or property damage incurred by the below named individual in any way related to or arising out of this physical assessment activity, whether such injury or death arises or is alleged to have arisen from negligence of the individual, the State of Florida, Florida International University, its agents or employees, co-sponsors, their agents or employees, or fellow attendees, or the contributory negligence of any of the aforementioned.


Print Name: ____________________________________________________________

Applicant’s Signature: ________________________________________________

AFFIDAVIT






_____________________________________________ Notary Seal

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State of Florida

Department of Highway Safety and Motor Vehicles

Division of Florida Highway Patrol

Supplemental Application for State Trooper

An Equal Opportunity Employer/Affirmative Action Employer

Florida Highway Patrol Background, Recruitment & Selection Neil Kirkman Building

2900 Apalachee Parkway, Mail Stop 49 Tallahassee, FL 32399-0525

Print or type in black ink only

Applicant: ________________________________________________________________________________________ First Name Middle Name Last Name (Maiden)

Mailing Address: ___________________________________________________________________________________ Street Address City County State Zip Code

Residence: ________________________________________________________________________________________ Street Address City County State Zip Code

Home Phone: (______) ____________________________ Work Phone: (______) _____________________________

Cell Phone: (______) _______________________ Personal Email: ________________________@________________

Social Security Number: ______-_____-_________ Date of Birth: ____/_____/_______ (MM/DD/YR)

Driver License Number: ________________________ State: _______________ Sex: Male Female

(Check only one) Race / Ethnicity: White Black Hispanic Other ________________________________________

Height: _____________ Weight: ____________ Color of Eyes (Natural): _________________ Feet / Inches Pounds

U.S. Citizen: Yes No By Birth: Yes No By Naturalization: Yes No

Place of Birth: _____________________________________________________________________________________ City State Country

For Official (FHP) Use Only: Basic Recruit Class (BRC) Transitional Recruit Class (TRC)

HSMV 91029 (Rev 02/28/2018)

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APPLICANT INFORMATION

1. _______________________________________________________________________________________First Name Middle Name Last Name Maiden

2. _______-__________-________ 3. ______________________________ Social Security Number Nick Name (If applicable)

4. List any-and-all other names you have used, dates of use, and the circumstances surrounding their use. ProvideALL documentation of ANY name changes.

a) Name: ______________________________________________ Dates: ___________________ (From/To)

Reason: _____________________________________________

b) Name: ______________________________________________ Dates: ___________________ (From/To)

Reason: _____________________________________________

c) Name: ______________________________________________ Dates: ___________________ (From/To)

Reason: _____________________________________________

5. Have you ever worked for the Florida Highway Patrol as a State Trooper? Yes No

If yes, give dates and years of service and reason(s) for leaving: _______________________________

__________________________________________________________________________________

6. Have you previously applied for a position as a Florida Highway Patrol State Trooper? Yes No

If yes, provide date(s) of previous application(s) and reason(s) for not completing the hiring process:

__________________________________________________________________________________

__________________________________________________________________________________

7. Have you previously applied for a position as a Florida Highway Patrol Duty Officer? Yes No


__________________________________________________________________________________

__________________________________________________________________________________

8. Have you previously applied for a position as a Florida Highway Patrol Auxiliary Officer? Yes No


__________________________________________________________________________________

__________________________________________________________________________________

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9. Have you ever been denied employment with the Florida Highway Patrol? Yes No

If yes, provide date(s) of previous denial(s) and reason(s) given for the denial(s):

__________________________________________________________________________________

__________________________________________________________________________________

10. Marital Status: Single Married (check one)

(If married or divorced, submit copy(s) of marriage certificate or divorce decree)

11. Current Spouse Information: ____________________________________________________________________First Name Middle Name Last Name Maiden

12. Current Spouse Address: _______________________________________________________________________Number and Street City State Zip Code

13. Previous Spouse Information: ___________________________________________________________________First Name Middle Name Last Name Maiden

Previous Spouse Address: ______________________________________________________________________ Number and Street City State Zip Code









(If you have had more than five previous spouses, attach a separate sheet listing the above information andattach it to the back of this packet.)

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EDUCATION

18. List all high schools attended. (Attach a copy of your high school diploma/GED to back of this packet.Photocopies of high school transcripts are acceptable. Photocopy of GED Test Scores are required if GED wasissued outside of the State of Florida)

School: _____________________________________ Dates Attended (From/To): _________________________

Address: ____________________________________________________________________________________Number and Street City State Zip Code

Diploma GED (Check one) Graduated? Yes No


Address: ____________________________________________________________________________________ Number and Street City State Zip Code














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HIGHER EDUCATION

19. List all colleges/universities/trade schools attended. Attach OFFICIAL transcripts SEALED by each institution.


Address: ____________________________________________________________________________________Number and Street City State Zip Code

Graduated? Yes No Number of Credit Hours Earned: _______ Degree Earned: __________________









Graduated? Yes No Number of Credit Hours Earned: _______ Degree Earned: ___________________







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20. Have you ever been expelled or suspended for cheating, fighting or any criminal act in high school or college?

Yes No If yes, explain in detail: ________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

(INTENTIONALLY LEFT BLANK)

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MILITARY INFORMATION

21. Are you currently on active duty in the United States Military? Yes No

If yes, when will you be released? ________________ (MM/DD/YY)

22. Have you ever served in a military organization of the United States? Yes No

(If yes, attach a photocopy of your DD 214 Form(s) member four (4) copy for each period of service)

Branch(s) of Service: __________________________ Service Number: ________________________________

If currently still enlisted, please attach a letter from your Company Commander stating your estimated time of

separation date and type of discharge expected. Once your DD 214 has been received, forward only your member

4 copy.

23. Provide dates of all periods of active military service along with branch information: _______________________

___________________________________________________________________________________________

___________________________________________________________________________________________

24. Type of Discharge? Honorable Medical General Dishonorable

Under Honorable Conditions Less Than Under Honorable Conditions

25. If other than “Honorable Discharge,” explain circumstances surrounding separation: _______________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

26. Were you ever court martialed, tried on charges, or the subject of a summary court, deck court, captain’s mast,

company punishment, Article 15 UCMJ, or any other disciplinary action while a member of the armed forces?

Yes No

If yes, explain below and attach copies of written documentation to back of application. If documentation is

not available, an original letter from the official agency records office must be provided stating that a record

search was performed and no records were found. Attach additional sheets to the back of this packet, if necessary.

___________________________________________________________________________________________

___________________________________________________________________________________________

SELECTIVE SERVICE INFORMATION

27. If you are a male and have never served in the U.S. Armed Forces, have you registered with the U.S. Selective

Service System? (Males MUST check either Yes or No) Yes No N/A (females only)

If yes, provide registration number: ___________________

Is proof of registration attached? Yes No

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EMPLOYMENT HISTORY

28. Have you been discharged from ANY employment for reasons OTHER THAN MEDICAL?

Yes No

29. Have you ever resigned when anticipating your employer intended to dismiss (fire) you for any reason?

Yes No

30. Have you ever resigned when anticipating your employer intended to take any form of disciplinary action againstyou?

Yes No

31. Have you had any extended absences from work for reasons other than medical or approved vacations?

Yes No

*If you answered “Yes” to any of questions 28 through 31, explain in full detail below (include employer names).

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

32. List ALL work and public contact experience, including military service, beginning with the most recent job andwork backward. Include ALL full-time, part-time, seasonal and summer jobs back to age 16. Include militaryservice and jobs in proper sequence. Do not omit any period of employment. Use additonal sheets, if necessary.(See "Gap" Section on page 25 to list periods of unemployment.)

Employer: ______________________________________________ Work Number: _________________________

Street Address: ________________________________ City: ____________________State: ________ Zip: _______

Supervisor: _______________________________________ Full Time Part Time Hours Per Week: ________

Position Held: ________________________________________ Salary per month: __________________________

Is this employer still in business? Yes No If no, explain: ___________________________________________

Employment Dates: From: ___________/__________/__________ To: __________/__________/__________ Month Day Year Month Day Year

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Job duties: ________________________________________________________________________________________

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_________________________________________________________________________________________________

_________________________________________________________________________________________________

Reason(s) for Leaving: ______________________________________________________________________________







Job duties: ________________________________________________________________________________________

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Job duties: ________________________________________________________________________________________

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Job duties: ________________________________________________________________________________________

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Job duties: ________________________________________________________________________________________

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Job duties: ________________________________________________________________________________________

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Job duties: ________________________________________________________________________________________

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_________________________________________________________________________________________________








Job duties: ________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________








Job duties: ________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________




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Job duties: ________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


Gaps in Employment

If there are ANY gaps in employment above (periods of time in which you were unemployed), including gaps in military service, list them below in order to provide an unbroken timeline for employment/unemployment history. Use additional sheets, if necessary:

Dates: _______________________ (MM/YYYY) Reason(s) for gap: __________________________________From / To











/

/

/

/

/

/

/

/

/

/

/

26 of 62

Law Enforcement Information

33. Have you EVER submitted an application to ANY other Law Enforcement Agency? Yes No

If yes, list below (use additional sheets if necessary). (This includes city, county, state and federal agencies.)

Agency Date Applied

Status or Reason for Not Being Hired

34. Have you ever taken a polygraph examination, voice stress analysis test or psychological screening with any otherLaw Enforcement Agency? Yes No If yes, list below (use additional sheets if necessary).

Agency Date Type of Test Status or Result

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35. Have you had Law Enforcement training of any kind? Yes No If yes, list type of training, providers and dates of training: ________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

36. Are you currently certified as a Law Enforcement Officer in the State of Florida? Yes No

37. Are you currently certified as a Correctional Officer in the State of Florida? Yes No

38. Have you EVER received any disciplinary action as a Law Enforcement Officer and/or Correctional Officer?Yes No If yes, list below and attach copies of written documentation of disciplinary action.

Agency Date Complaint Status or Result

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General Information

39. Do you possess a valid driver license? Yes No If yes, in which state are you licensed? _____________

Driver License Number ____________________________

40. List ALL states in which you have previously been licensed to drive.

(Attach certified copies of all out-of-state driving records to the back of this packet).

State Dates in which you were licensed (To/From)

Certified Copy of Record Attached?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

41. List ALL traffic citations, excluding parking tickets, you have received in your lifetime. (Use additional sheets, ifnecessary.)

Reason/Violation City/State of Issuance Date (MM/YYYY)

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Traffic Crash History

42. Have you EVER been involved in a traffic crash (including a patrol car crash if you are a current or former lawenforcement or corrections officer)? Yes No

If yes, list ALL traffic crashes in which you have been involved as a DRIVER, not as a passenger. Include trafficcrashes where law enforcement was NOT notified and/or those where a traffic crash report was not completed.Use additional sheets, if necessary:

Country/State/County in which traffic crash occurred

Date of traffic crash (MM/YYYY)

Were you determined to be at-fault?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

43. Have you ever been charged with Driving Under the Influence, Driving While Intoxicated or Driving withand Unlawful Blood Alcohol Level, whether convicted or not? Yes No

Have you ever been charged with Operating Under the Influence, Operating While Intoxicated or BoatingUnder the Influence of Alcohol, whether convicted or not? Yes No

Have you ever been charged with Reckless Driving or Fleeing and Eluding a Police Officer, whetherconvicted not?or Yes No

44. For ANY reason, has your driving privilege EVER been:

Canceled? Yes No Suspended? Yes No Revoked? Yes No

If yes, explain fully in COMPLETE DETAIL below: _______________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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General Information

45. Excluding non-criminal traffic citations or infractions, have you EVER been arrested, taken into custody,detained for investigation or charged with a crime by any Law Enforcement Agency or State/FederalAttorney’s Office (include expungements, indictments, criminal summons’, criminal informations, sealedrecords, injunctions, pre-trial diversions, pardons, nolle prosequi, etc.) as an adult or juvenile? Yes No

If yes, explain in COMPLETE DETAIL: ________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

46. List any and ALL arrests. Attach copies of Arrest Reports or Offense Incident Reports from the arresting orinvestigating agency for each incident. Attach copies of the Final Court Disposition for each arrest from thecourt that had jurisdiction over each incident. Legible copies are required. If documentation is not available,an original letter from the official agency records office must be provided stating that a records search wasperformed and no record(s) found for each incident. Use additional sheets if necessary.

Date City/State Agency Charge Final

Disposition Arrest Report

Attached? Court Report

Attached?

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

:

31 of 62

47. Have you EVER used, experimented, possessed, injected, inhaled, swallowed or ingested ANY illegal drug?Yes No(This includes prescription drugs not prescribed to you for your use, anabolic steroids, and Designer Drugs.)

If yes, (for each drug) list the type of drug, number of times used, and dates of use. Use additional sheets,if necessary.

Drug Type (Be Specific) Number of times used (Provide a numeric response)

Date(s) used (MM/YY)

48. Have you ever sold, given, or exchanged any goods or services for any illegal drug? Yes NoIf yes, explain in detail with dates, number of occurrences, goods or services sold/given/exchanged, and for

which drug(s): ______________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

49. Have you ever been present while an illegal drug was used. sold, given, exchanged, or transported? Yes NoIf yes, explain in detail with dates, number of occurrences, and circumstances surrounding your presence

when an illegal drug was used, sold, given, exchanged or transported: _______________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

50. Are you now or have you ever been a member, or supported the views or beliefs, of any foreign or domesticorganization, association, movement, group, or combination of persons which is totalitarian, fascist, communist, orsubversive, or which has adopted, or shows a policy of advocating or approving the commission of acts of force orviolence to deny other persons their rights under the Constitution of the United States, or which seeks to alter theform of Government of the United States by unconstitutional means? Yes NoIf yes, explain in detail with dates, name of organization, association, movement, or combination of

persons, and the circumstances surrounding your membership in, support of, or belief in such: __________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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Character References

51. List FOUR character references who have definite knowledge of your qualifications and fitness for the position

of State Trooper and who are able to speak confidently about you and your reputation. All persons you list may be

asked to appraise your character, ability, personality, and other qualities. DO NOT include relatives, former

employers, former supervisors, or individuals living outside of the United States.

a) Name: _______________________________________________ Home Phone: (_____)__________________

Home Address: ___________________________________________________________________________

Street Address City State Zip Code

Business, Occupation, or Profession: __________________________________________________________

Years Known: ____________ Name of Business: ________________________________________________

Business Address: _________________________________________________________________________


Business Phone: (_____)________________Ext: ___________ Cell Phone: (_____)_____________________

b) Name: _______________________________________________ Home Phone: (_____)__________________

Home Address: ___________________________________________________________________________







c) Name: _______________________________________________ Home Phone: (_____)__________________

Home Address: ___________________________________________________________________________







d) Name: _______________________________________________ Home Phone: (_____)__________________

Home Address: ___________________________________________________________________________







34 of 62

Credit History

52. Has your credit record (including your spouse’s credit record) EVER been considered unsatisfactory, or have youEVER been refused credit (this includes credit cards, loans, or any other forms of credit)? Yes NoIf yes, explain in detail with dates, places, names of creditors and circumstances surrounding the

unsatisfactory or refusal of credit: ______________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

53. Have you EVER filed for bankruptcy? Yes No If yes, explain in detail and include dates and thecourt in which the bankruptcy was filed. Attach copies of bankruptcy documents including a copy of theSchedule F (Chapter 7, 11 or 13).___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

54. Have you EVER been the subject of a court-ordered Judgment or Lien? Yes No

If yes, explain in detail: ________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

55. List ALL debts that are, or have been, more than 60 days past-due, delinquent and/or subject to collection. Useadditional sheets, if necessary:

Name of Creditor: _____________________________________ Account #: _____________________________

Mailing Address: ____________________________________________________________________________Street Address City State Zip Code

Number of Payments Past Due: ________ Total Amount Due: ___________ Last Payment Date: _________


Mailing Address: ____________________________________________________________________________ Street Address City State Zip Code











36 of 62

56. Are you currently paying child support? Yes No Are you currently paying alimony? Yes No

57. If you are paying child support or alimony of any kind, have you EVER been delinquent in your payments?Yes No N/A

If you answered yes to Question #57, explain in detail: _______________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

58. Have you EVER sued, or been sued by, ANY person, business, entity, or employer? Yes No

If you answered yes to Question #58, explain in detail: _______________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

37 of 62

Residence History

59. Chronologically, beginning with your CURRENT residential address and working BACKWARD, list ALLprevious places of residence for the LAST 10 YEARS. There shall be NO GAPS in dates in which you lived at aresidence. If you have lived at your current address for 10 years or more, list the THREE previous addresses whereyou resided prior to your current residential address. DO NOT OMIT ANY ADDRESSES. If you have lived at yourcurrent residential address for your lifetime, only your current residential address will need to be listed and indicatedon the page. Use additional sheets, if necessary.

Residential Address: __________________________________________________________________________ Street Address City State Zip Code

Dates lived at this residential address: From _________________ (MM/YY) To _________________ (MM/YY)

Have you resided at this address your entire lifetime? Yes No If no, continue listing addresses below.













38 of 62

EQUAL EMPLOYMENT OPPORTUNITY SURVEY

60. Notice to All Applicants: The following information is requested to aid the Florida Highway Patrol in itscommitment to Equal Employment Opportunity. Your application will NOT be rejected because of your race,color, sex, religion, creed, handicap, national origin, political beliefs, or age, except as provided by law.

Social Security Number: ______-_____-_______ Date of Birth: ____________________(MM/DD/YYYY)

Sex: Male Female

Racial/Ethnic Data

Please identify yourself in terms of the racial / ethnic groups listed below. (Check only one)

AFRICAN-AMERICAN (not of Hispanic origin): All persons having origins in any of the black racial groups of Africa.

AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

ASIAN OR PACIFIC ISLANDER: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example: China, Japan, Korea, the Philippine Islands, and Samoa.

HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin, regardless of race.

WHITE (not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

OTHER (specify): ________________________________________________________________________

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SOCIAL MEDIA

63. Do you currently have or have you ever had ANY Social Media accounts? Yes No

If yes, list ANY and ALL Social Media (websites and applications that enable users to create and/or share contentor to participate in social networking) accounts you CURRENTLY HAVE or HAVE EVER HAD in the pastalong with the applicable username, screen name, handle, blog name, channel name, URL (web address), or otheridentifying information for the account. Examples of Social Media accounts include, but are NOT limited to,Facebook, MySpace, Twitter, Instagram, SnapChat, Skype, Zello, WhatsApp, Pinterest, LinkedIn, Google,Google+, Vimeo, Four Square, Tumblr, Flickr, Yelp, Live Journal, and Vine. Do NOT omit any Social Mediaaccounts. Attach additional sheets as necessary.

Social Media Platform Username/Screen Name URL (Web Address) Active? Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

_______________________________________ __________________________ (MM/DD/YYYY) Signature of Applicant Date


40 of 62

*****READ EXTREMELY CAREFULLY*****

I hereby swear that there are no willful misrepresentations or omissions in, or falsifications of,

the foregoing statements and answers to questions. I am aware that should an investigation

disclose such willful misrepresentations, falsifications or omissions, my application WILL be

rejected and I WILL be disqualified from applying in the future for any position of service in

the Florida Highway Patrol or if after my acceptance for employment, subsequent investigation

should disclose omissions, misrepresentations, or falsifications, it WILL be just cause for

immediate dismissal. Furthermore, the intentional false execution of this affidavit SHALL

constitute a Misdemeanor of the Second Degree, punishable as provided in § 775.082, §

775.083, or § 775.084, Florida Statutes.

Applicant’s Signature: ____________________________________ Date: _______________________ (MM/DD/YYYY)

AFFIDAVIT

STATE OF__________________________ COUNTY OF __________________________

Before me personally appeared the said _______________________________________ who says that the execution of

the above instrument is by free will and accord, with full knowledge of the purpose therefore.


_______________________________________________________ My Commission expires __________, 20______.

Notary Public


___________________________________________________

Notary Seal

Date below photograph taken: ______________ Date below photograph taken: ______________

Attach a passport style, uncovered, color,

individual photograph of your FACE here.

(Photo MUST have been taken within

the last 30 days of this affidavit being

notarized.)

Attach FULL BODY, clothed, individual

photograph here.

(No nudity, revealing clothing or bathing

suits. Nothing containing offensive,

demeaning, or otherwise unprofessional

language, graphics, or references. Nothing

containing information related to drugs or

any illegal activity.)

(Photo MUST have been taken within

the last 30 days of this affidavit being

notarized.)

41 of 62


BACKGROUND INVESTIGATION AGREEMENT

If at any time during the application or selection process the applicant is arrested, taken into custody, detained for investigation or charged with a crime by any law enforcement agency or state/federal attorney’s office, declares bankruptcy, or becomes the defendant in a civil suit, changes employers, relocates, or information on this supplemental affidavit changes, the applicant SHALL immediately notify the Florida Highway Patrol’s Background, Recruitment & Selection Section or the background investigator conducting the applicant’s background investigation.

FAILURE TO DO SO WILL RESULT IN IMMEDIATE DISQUALIFICATION.

The applicant is responsible for providing complete information and any or all reports, records or other documentation related to any factor discovered that requires further review or evaluation. The application will be suspended temporarily until all requested information is received.

HAVE YOU READ AND DO YOU UNDERSTAND THIS AGREEMENT? Yes No

_____________________________________________ __________________________ (MM/DD/YYYY)

Signature of Applicant Date

_________-_____-__________

Social Security Number

42 of 62


PERSONAL INQUIRY WAIVER

AUTHORITY FOR RELEASE OF INFORMATION

TO: Concerned Person or Authorized Applicant’s Name: ____________________________________

Representative of Any Organization, Date of Birth: __________________________(MM/DD/YYYY)

Institution or Repository of Records Social Security Number: _______-_______-__________

I respectfully request and authorize you to furnish the Florida Highway Patrol any and all information that you may have concerning my work record, school record, reputation, financial, and/or credit status. Please include any and all medical, physical, and mental records or reports including all information of a confidential or privileged nature and copies of same, if requested. This information is to be used to assist the Florida Highway Patrol in determining my qualifications and fitness for the position I am seeking with said agency.

I have been advised and am fully aware that I will be requested to submit to a Florida Highway Patrol polygraph examination. The purpose of the examination is to assist in verifying all information furnished in this application and obtained during the applicant investigation. The examination will primarily cover past employment, drinking habits, drug habits, criminal activity and basic honesty. I am fully aware that my refusal to submit to the polygraph examination will terminate further consideration for employment with the Florida Highway Patrol.

I am willing to take the Florida Highway Patrol polygraph examination. Yes No

I hereby release you, your organization or others from any liability or damage which may result from furnishing the information requested above.

_______________________________________ __________________________ (MM/DD/YYYY) Signature of Applicant Date

_______________________________________________________________________________________ Street Address City State Zip Code

AFFIDAVIT






_____________________________________________ Notary Seal

DEPARTMENT OF HIGHWAY SAFETY

AND MOTOR VEHICLES

APPLICANT CERTIFICATION AND

BACKGROUND INFORMATION RELEASE� � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� ! � � " # # $ % & ' ( ( )* + , � - � � � � . / . � 0 1 2 � 3 0 � 4 5 2 � - - 3 � 0 5 6 7 6 5 6 � 3 � . 8 �� ! � � " # # $ % & ' ( ( )� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �9 � - - � 4 + : ; � � 6 0 0 - � . . �< = > ? ? = @ A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A AB C = D @ E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E < = F = ? @ E E E E E E E G C H B I J ? @ E E E E E E E E E E E E E E E E E EK � L � � M N C = ? O P F Q R S T U > C Q F V T W ? > C Q F V X C Y H F V C Q S Z F = C V I T Y C F V T W ? > C Q F V [ V J C F V S T P F Y R F \ F = C ] ?\ F = C ] ? X F ^ F C C F V S _ = N ? > ` F Q C U C Q [ Y P F V J ? > O F P F V Q ? S _ = N ? >a � b � c d e � + � ; f g 3 - + , � h h h h S h h h h S h h h h h h h h" " i i j j j j g 3 - + , k � � L � 1 9 3 + l 5 a + � + � 5 9 ; � 4 + - l 8 �a ; L 3 � � a � L � - 3 + l m � h h h h h h h h h n h h h h h h n h h h h h h h h h h e - 3 o � - p 3 L � 4 . � � � � q � - r a + � + � �6 s s p t 9 6 u t * � 9 v K u t � t 9 6 u t * �[ Q ? > = C U D = N F = [ N F ] ? > ? ] C ? ^ ? J W D a + � + � ; f � � ; - 3 0 � v � k � ; l � � 4 + 6 k k � 3 L � + 3 ; 4 w F V J @x y T P P ? W H P I D W ? V = H I Y C = C I V Y [ N F ] ? N ? P J F > ? U z P P D F V J F Q Q z > F = ? P D J ? Y Q > C { ? J | [ z V J ? > Y = F V J = N F = W D > ? U ? > ? V Q ? Y ^ C P P { ?Q N ? Q R ? J F V J = N F = [ Q F V V I = { ? ? W H P I D ? J z V P ? Y Y F } I { > ? U ? > ? V Q ? C Y I { = F C V ? J |~ y U F C P z > ?= I J C Y Q P I Y ? ^ C P P { ? > ? � F > J ? J F Y U F P Y C U C Q F = C I V ^ N C Q N C Y � > I z V J Y U I > J C Y W C Y Y F P | t � � + , ; - 3 � � e : a 2 � + ; o � - 3 f l � l L - 3 � 3 4 � �, 3 . + ; - l - � L ; - 0 �y 1 t f � k k � 3 L � q � � 8 � ? P F = C ] ? Y Q z > > ? V = P D ^ I > R C V � U I > � X < c � F > ? @\ F W ? @ h h h h h h h h h h h h h h h h h h h h h h h � ? P F = C I V Y N C H @ h h h h h h h h h h h h M I > R Z I Q F = C I V @ h h h h h h h h h h h h h h h h h h h h h\ F W ? @ h h h h h h h h h h h h h h h h h h h h h h h � ? P F = C I V Y N C H @ h h h h h h h h h h h h M I > R Z I Q F = C I V @ h h h h h h h h h h h h h h h h h h h h hK v u t K v 2 v � u 9 v K u t � t 9 6 u t * �[ F W > ? = C > ? J U > I W = N ? U I P P I ^ C V � d P I > C J F � ? = C > ? W ? V = < D Y = ? W � Q N ? Q R { I � = N F = F H H P C ? Y y @d � < ` ? V Y C I V ` P F V d � < [ V ] ? Y = W ? V = ` P F V � � _ ` � � < < B _ � � < \ S T� N ? ? U U ? Q = C ] ? J F = ? I U W D > ? = C > ? W ? V = w Q I V Q P z Y C I V I U � � _ ` w I > U C > Y = J C Y = > C { z = C I V U > I W = N ? d � < [ V ] ? Y = W ? V = ` P F V ^ F Y h h h h h h h h h h h h h h h h h h |t � 4 0 � - . + � 4 0 + , � + 3 f t � � + , � . � � � L + � 0 � k k � 3 L � 4 + 5 � 4 l 3 4 f ; - � � + 3 ; 4 t � 3 o � � � l q � 3 4 o � . + 3 � � + � 0 � . � � � ; � � 0 q l � � � � g l� l . 3 � 4 � + � - � 5 t L ; 4 . � 4 + + ; + , � - � � � � . � ; f 3 4 f ; - � � + 3 ; 4 � q ; � + � l � q 3 � 3 + l 5 � � k � ; l � � 4 + , 3 . + ; - l � 4 0 f 3 + 4 � . . f ; - � � k � ; l � � 4 +q l � � k � ; l � - . 5 . L , ; ; � . 5 � � � � 4 f ; - L � � � 4 + � � � 4 L 3 � . � 4 0 ; + , � - 3 4 0 3 o 3 0 � � � . � 4 0 ; - � � 4 3 � � + 3 ; 4 . + ; � � + , ; - 3 � � 0 � � k � ; l � � . ; f� � ; - 3 0 � . + � + � � ; o � - 4 � � 4 + � u , 3 . L ; 4 . � 4 + . , � � � L ; 4 + 3 4 � � + ; q � � f f � L + 3 o � 0 � - 3 4 � � l � � k � ; l � � 4 + � t � 4 0 � - . + � 4 0 + , � + � 4 l; � 3 . . 3 ; 4 . 5 f � � . 3 f 3 L � + 3 ; 4 . 5 � 3 . . + � + � � � 4 + . 5 ; -� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �T H H P C Q F V = < C � V F = z > ? � F = ?s � - . ; 4 4 � � / . � * 4 � l �s ; . 3 + 3 ; 4 6 k k � 3 � 0 � ; - � ` I Y C = C I V � @ h h h h h h h h h h h h h h h � C ] C Y C I V @ h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h hu 3 + � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

y

HSMV 91120 (rev 01/18)43 of 62

44 of 62


CURRENT SPOUSE / FUTURE SPOUSE / ROOMMATE INQUIRY WAIVER

AUTHORITY FOR RELEASE OF INFORMATION

TO: Concerned Person or Authorized Applicant’s Name: ____________________________________

Representative of Any Organization, Date of Birth: __________________________(MM/DD/YYYY)

Institution or Repository of Records Social Security Number: _______-_______-__________

Current Spouse / Future Spouse / Roommate Information: (Include ANYONE, including family members, living in your residence. This form MUST be completed separately

for EACH current/future spouse [whether they reside with you or not], roommate, or family member living in your residence. Make extra copies of this form [as needed] and complete for each person.)

Print FULL NAME of Current Spouse/Future Spouse/Roommate: ____________________________________________

Alias / Maiden Name(s):

Date of Birth: ____________________________ (MM/DD/YYYY) Social Security Number: ______-_______-________

Race: ________________ Sex: Male Female

Residential Address: _________________________________________________________________________________ Street Address City State Zip Code

I hereby authorize any employee or authorized representative bearing this release, or copy thereof, to obtain any information in your files pertaining to my criminal history or civil and criminal courts. 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 of the requesting agency. Consent is granted for the agency 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, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, 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. A photocopy of this form will be as effective as the original.

I hereby release you, your organization or others from any liability or damage, which may result from furnishing the information requested above.

_____________________________________________________ ______________________ (MM/DD/YYYY) Applicant’s Current Spouse/Future Spouse/Roommate Signature Date

AFFIDAVIT






_____________________________________________ Notary Seal

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AGREEMENT FOR TRAINING COST REIMBURSEMENT

FOR FLORIDA HIGHWAY PATROL RECRUITS

Date of Agreement: _________________________ (MM/DD/YYYY)

Recruit’s Full Name:

Recruit’s Address: __________________________________________________________________________________ Street Address City State Zip Code

Recruit’s Social Security Number: _______-_______-__________

I understand and agree that, in consideration of my employment with the Florida Highway Patrol and pursuant to the

provisions of §943.16, Florida Statutes (see Attachment A), I will reimburse the Florida Highway Patrol for all costs andexpenses related to my initial training and uniforms required to become a Trooper, subject to the following terms and conditions:

1. I agree to serve as a trooper with the Florida Highway Patrol for a period of not less than twenty-four (24) monthsafter the completion of my initial training at the Florida Highway Patrol Training Academy or after my employmentdate if I am already a Florida Certified Trooper (referred to herein as “employment obligation period”).

2. I agree that if I should voluntarily leave employment with the Florida Highway Patrol at any time prior to theexpiration of my employment obligation period, I will repay 100% of the tuition and other course expenses incurredby the Florida Highway Patrol. (See Attachment A for the itemized tuition and other course expenses.)

3. I agree that my resignation prior to the expiration of my employment obligation period, for whatever reason, shallbe prima facie evidence that I left employment with the Florida Highway Patrol voluntarily.

4. I understand and agree that this agreement does not constitute an employment contract and that the Florida HighwayPatrol reserves the right, as my employer, to reassign, discipline or to terminate me in accordance with law and thepolicies of the Florida Highway Patrol and the Florida Department of Highway Safety and Motor Vehicles.

5. I also understand that this agreement does not grant me any special rights or benefits from the Florida HighwayPatrol and does not require the Florida Highway Patrol to offer me a position as a trooper.

6. I understand that if I complete the Florida Highway Patrol Training Academy or, as a presently certified lawenforcement officer, become a member of the Florida Highway Patrol, this agreement does not alter or affect anyother terms or conditions of my employment with the Florida Highway Patrol.

7. I agree to repay all outstanding expenses for which I am responsible under this Agreement and §943.16, FloridaStatutes, to the Florida Highway Patrol at the time of my resignation.

8. If I am unable to repay the entire amount due within sixty (60) days of the date of my resignation, I understand thatthe Florida Highway Patrol may institute a civil action to collect the amount due. I agree that this document may beused as evidence of my obligation to reimburse the Florida Highway Patrol for all outstanding expenses pursuantto Florida law.

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9. I agree that if judgment is entered against me as a result of such civil action, I will pay all costs and expensesincurred by the State of Florida or the Florida Highway Patrol including attorney fees.

10. I agree that venue for any civil action necessary to enforce this Agreement and judgment will be in Leon County,Florida.

IN WITNESS WHEREOF I have signed this agreement on date printed below my signature.

____________ ______________________________________ Applicant's Signature Witness Signature

______________________________________ Witnessed by: ______________________________________ Applicant’s Printed Name Witness Printed Name

_______________________(MM/DD/YYYY) _______________________ (MM/DD/YYYY) Date Date

AFFIDAVIT






_____________________________________________ Notary Seal


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Attachment A

ITEMIZED COST OF TRAINING AND EXPENSE FOR STATE TROOPER

Listed below are the costs of tuition, travel and field training costs, if these costs apply. Only costs incurred by the Florida Highway Patrol will be required to be reimbursed pursuant to §943.16, Florida Statutes (below costs are maximum).

Tuition to Academy: $0.00

Room & Board: $7,528.00

Other Training Costs*: $3,381.00 ______________________________________________

TOTAL: $10,909.00

*Includes equipment, supplies and other items issued during training such as uniforms and ammunition.

I have read and understand the above listed costs for my training and agree to the total listed.

IN WITNESS WHEREOF I have signed this agreement on date printed below my signature.

______________________________________ ______________________________________ Applicant's Signature Witness Signature

______________________________________ Witnessed by: ______________________________________ Applicant’s Printed Name Witness Printed Name

_______________________(MM/DD/YYYY) _______________________ (MM/DD/YYYY) Date Date

AFFIDAVIT






_____________________________________________ Notary Seal

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DUTY ASSIGNMENT

AGREEMENT

By submission of my application for employment as a law enforcement officer with the Florida Highway Patrol,

I fully understand that, if employed, I MUST be willing to accept a duty assignment ANY place in the State of

Florida. Duty assignments upon employment are made based on existing vacancies at the time of employment.

If employed by the Florida Highway Patrol, I fully understand and agree that I must remain in my duty assignment

for one full year prior to requesting a reassignment to another location in the State of Florida. Certain assignment

locations may not always be available because of low turnover rates or lack of total positions available. I

understand there may be a waiting period involved due to troopers with more seniority having first opportunity

to fill these choice locations.

I fully understand and agree to abide by the above provisions as they relate to assignment with the Florida

Highway Patrol and reassignment after employment.

_______________________________ ___________________________(MM/DD/YYYY)


_____________________________________ ________-________-__________

Applicant’s Printed Name Social Security Number

DUTY ASSIGNMENT “WISH LIST”

While I understand and will abide by the above agreement, below are the five (5) counties in Florida,

in order of preference, where I would prefer to be assigned upon graduation from the FHP Training

Academy (you must list 5 counties):

1. __________________________________

2. __________________________________

3. __________________________________

4. __________________________________

5. __________________________________

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AGREEMENT

TO ALLOW FOR CONTACT OF MY CURRENT EMPLOYER

By submission of my application for employment as a Law Enforcement Officer with the Florida Highway Patrol, I fully understand the necessity of having a thorough background investigation conducted on my person.

I respectively request and authorize you to conduct a complete check into information concerning my work records, school records, reputation, financial records, and credit status.

Upon successful completion of all required phases, to include the Criminal Justice Basic Abilities Test, Physical Abilities Test, polygraph examination, psychological screening, background check, and eye and physical examination. I do hereby give permission to the Florida Highway Patrol to contact my current employer for the purpose of determining my suitability to become a Trooper.

I hereby release you, your organizations or others from any liability or damage, which may result from contacting my current employer.

_______________________________ ___________________________(MM/DD/YYYY) Applicant’s Signature Date

_____________________________________ ________-________-__________ Applicant’s Printed Name Social Security Number


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NOTICE OF DISCLOSURE OF CONSUMER REPORT

FEDERAL FAIR CREDIT REPORTING ACT (FCRA)

TO: Consumer Reporting Agencies Applicant’s Name: ____________________________________

Date of Birth: __________________________(MM/DD/YYYY)

Social Security Number: _______-_______-__________

It is the policy of the Florida Highway Patrol that the credit history and financial condition of the applicant be reviewed. The credit history will not be a sole basis for disqualification, except that an applicant may be denied employment if he/she is indebted to the extent that a salary as a law enforcement officer, as supplemented by other monies that are or could be earned by the applicant and spouse with reasonable diligence, will manifestly be insufficient to pay his/her debts as they fall due. Failure to pay just debts will disqualify an applicant.

I have been advised and am fully aware that a consumer report will be obtained and examined. The purpose of this examination is to assist the Florida Highway Patrol in determining my eligibility for the position I am seeking with the Florida Highway Patrol.

I am fully aware that my refusal to allow a consumer report to be obtained and examined will terminate further consideration for employment.

I am willing to allow a consumer report to be obtained and examined. Yes No

I respectfully request and authorize you to furnish the Florida Highway Patrol any and all information that you may have concerning my financial and credit status. I hereby release you, your organization or others from liability or damage, which may result from furnishing the information requested above.

_________________________________________________ ___________________ (MM/DD/YYYY) Applicant’s Signature Date

_____________________________________________________________________________________ Street Address City County State Zip Code

AFFIDAVIT






_____________________________________________ Notary Seal

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TATTOO and BODY MODIFICATION POLICY AGREEMENT

A Florida Highway Patrol recruit trainee, attending an approved basic recruit training program, who has visible tattoos, does so with the

understanding that they must abide by the following restrictions regarding the type of uniform they will be required to wear in the performance of

their duties and functions. For purposes of this agreement, “member” refers to an active member of the Florida Highway Patrol. “Applicant” refers to

someone attempting to become a member of the Florida Highway Patrol.

A. Under NO circumstances shall any tattoo be visible while the member is in ANY uniform of the Florida Highway Patrol. Members are

permitted to have tattoos provided they conform to the following guidelines:

1. A member with a tattoo anywhere on the arm or wrist area that is visible while wearing any short-sleeve uniform shall be

required to wear the Class A uniform (or Class C uniform with long sleeves, when authorized, by virtue of their assigned

position) anytime a uniform is required.

2. A member with a tattoo anywhere on the neck, face, head, hands, or fingers shall utilize cosmetic cover-up makeup to conceal the

tattoo(s) while the member is in any authorized uniform or attire and/or when representing the Division. The cosmetic cover-up

makeup shall blend in with the natural color of the skin and shall be purchased at the member’s expense.

Trooper applicants with ANY tattoo on the neck, face, head, hands, or fingers SHALL BE DISQUALIFIED. (This section does

not apply to members who have permanent eyeliner, eyebrows or lipstick provided the permanent color is conservative and

compliments the complexion and uniform.)

3. Any tattoo that contains offensive or extremist, sexist, racist, or gang-related material is prohibited. This is a disqualification

factor for Trooper applicants.

4. While at the FHP Training Academy, the recruits with tattoos that are visible in the Recruit Class B uniform shall be required to

wear the Recruit Class A uniform. Those same recruits shall not be issued Class B uniforms and shall be required to wear the

Class A uniform (or Class C uniform with long sleeves, when authorized).

Members who choose to obtain tattoos after their hiring date must ensure that they conform to this policy. Any member with a

prohibited tattoo shall be subject to disciplinary action, up to and including dismissal.

B. Abnormal body modifications to any area of the body visible in any authorized uniform or attire are prohibited. Abnormal body

modifications include, but are not limited to:

1. Tongue splitting or bifurcation.

2. The complete or trans-dermal implantation of any object(s) other than hair replacement.

3. Abnormal shaping of the ears, eyes, or nose.

4. Abnormal filing of the teeth.

5. Branding or scarification.

Nothing in this policy is to be construed as prohibiting body modifications necessitated by any medically or approved procedure. I fully

understand the consequences of this agreement and have had the opportunity to ask questions about it. This form will become part of my official

personnel file.

_______________________________________________ ____________________________(MM/DD/YYYY)


AFFIDAVIT


Before me personally appeared the said _______________________________________ who says that the execution of the above

instrument is by free will and accord, with full knowledge of the purpose therefore.


_______________________________________________________ My Commission expires __________, 20______.

Notary Public


_____________________________________________

Notary Seal

Florida Department of Law Enforcement

AUTHORITY FOR RELEASE

OF INFORMATION

(Background Investigation Waiver)

Incorporated by Reference in Rule 11B-27.0022(2)(a), F.A.C.

Effective: 8/9/2001 Pursuant to Original – Employing Agency 1 of 1 Commission-Approved Revisions: 12/16/10 Sections 943.134(2)(a) and (4), F.S. Form Effective Date: 3/2013

CJSTC

58

To: Concerned Person or Authorized APPLICANT’S NAME: Representative of Any Organization, Institution or Repository of Records DATE OF BIRTH:

LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER:

AGENCY REQUESTING BACKGROUND INFORMATION:

ADDRESS:

Having made application for certification or employment as a law enforcement, correctional, or correctional probation officer within the state of Florida, I hereby authorize for one year, from the date of execution hereof, any authorized representative of a Florida criminal justice agency or a Regional Criminal Justice Selection Center bearing this release to obtain any information pertaining to my employment, credit history, education, residence, academic achievement, personal information, work performance, background investigations, polygraph examinations, any and all internal affairs investigations or disciplinary records, including any files that are deemed to be confidential and/or sealed.

I also authorize release of any criminal justice records of arrests, citations, detentions, probation and parole records, or any police reports or other police records in which I may be named for any reason, including any files that are deemed to be juvenile and confidential. I hereby direct you to release this information upon the request of the bearer, whether in person or by correspondence. I further authorize the bearer to make copies of these records.

This release is executed with the full knowledge and understanding that these records and information are for the official use of a Florida criminal justice agency or Regional Criminal Justice Selection Center in fulfilling official responsibilities, which may include sharing the records or information with other criminal justice agencies, Regional Criminal Justice Selection Centers or the State of Florida or release to third parties as may be required by Florida public records laws. I hereby release you, as the custodian of such records, and employer, educational institution, physician, hospital or other repository of medical records, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, 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. A copy of this form will be as effective as the original.

I hereby authorize the National Records Center, St. Louis, Missouri, or other custodian of my military record to release information or copies from my military personnel and related medical records, including a copy of my DD 214, Report of Separation, or other official documents from the United States Military denoting discharge status or current active military status to:

Section 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former or current employees states: An employer who discloses information about a former or current employee to a prospective employer of the former or current employee upon request of the prospective employer or of the former or current employee, is immune from civil liability for such disclosure of its consequences, unless it is shown by clear and convincing evidence that the information disclosed by the former or current employer was knowingly false or violated any civil right of the former or current employee protected under chapter 760, Florida Statutes. Pursuant to Sections 943.134(2)(a) and (4), F.S., Chapter 2001-94, Laws of Florida, disclosure of information is required unless contrary to state or federal law. Civil penalties may be available for refusal to disclose non-privileged legally obtainable information.


Applicant’s Address

OATH

Pursuant to Section 117.05(13)(a), Florida Statutes

STATE OF COUNTY OF

Sworn to (or affirmed) and subscribed before me this

day of , year , By

Signature of Notary Public – State of Florida

Print, Type, or Stamp Commissioned name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced

Florida Department of Law Enforcement

AFFIDAVIT OF APPLICANT

Incorporated by Reference in Rule 11B-27.002(1)(f), F.A.C.

Created 1/1/1992 Original - Agency Copy – FDLE 1 of 1 Commission-Approved Revisions: 12/16/2010 Form Effective Date: 3/2013

CJSTC

68

Please type or print in black or blue ink and use capital and small letters for names, titles, and addresses

Social Security Number:

Applicant’s Legal Name: Last First MI

Employing agency:

Use this form to verify your compliance with the employment requirements of Section 943.13, F.S. I fully understand that to qualify for employment as a law enforcement, correctional, or correctional probation officer, I shall comply with the following provisions of Section 943.13, F.S.:

• Be at least 19 years of age.

• Be a citizen of the United States.

• Be a high school graduate or equivalent.

• Not have been convicted of any felony or of a misdemeanor involving perjury or false statement. Any person who, after July 1, 1981, pleads guilty or nolo contendere to or is found guilty of a felony or of a misdemeanor involving perjury or a false statement

shall not be eligible for employment or appointment as an officer, notwithstanding suspension of a sentence or withholding of adjudication.

• Have been fingerprinted by the employing agency.

• Have passed a physical examination by a licensed medical specialist approved in Rule11B-27.002(1)(d), F.A.C..

• Be of good moral character.

• Have not received a dishonorable discharge from the U.S. Military.

True False NA In addition, I attest to the following statements: Each statement shall be checked “True” “False” or “NA”

1. I completed my employment application and it is true and correct, and all other informationI furnished in conjunction with my application is true and correct.

2. I provided documentation of proof of my qualifications to the above listed employing agency.

3. I meet the qualifications as specified above.

4. I had a criminal record sealed pursuant to Section 943.059(4)(a), F.S. , or expunged pursuant to Section 943.0585(4)(a), F.S.

5. I am under investigation by a local, state, or federal agency or entity for criminal, civil, or administrative wrongdoing to the best of my knowledge and belief.

6. I separated or resigned from a previous criminal justice employment while under investigation.

7. I am currently serving in good standing in the U.S. Military.

8. I previously served in the U.S. Military.

9. I received a dishonorable discharge from my previous U.S. Military service.

10. I am currently certified as a Florida criminal justice officer in the following area(s): Please check the appropriate box(es).

Law Enforcement Correctional Correctional Probation

11. I authorize the employing agency listed above to apply for my certification. Please check the appropriate box(es).

Law Enforcement Correctional Correctional Probation

NOTICE: This document shall constitute as an official statement within the purview of Section 837.06, F.S., and is subject to verification by the employing agency and the Criminal Justice Standards and Training Commission. Any intentional omission when submitting this application or false execution of this affidavit shall constitute a misdemeanor of the second degree and disqualify the officer for employment as an officer.

PLEASE READ CAREFULLY BEFORE SIGNING. You must complete the remainder of this affidavit in the presence of a notary public. Upon witnessing your signing of this affidavit, a notary public shall complete the notary block by entering the same date the affidavit is signed. I hereby certify that to the best of my knowledge and belief, the information that I’ve entered on this form is true.

12. 13. Applicant’s Signature Date Signed

14. OATH

Pursuant to Section 117.05(13)(a), Florida Statutes

STATE OF COUNTY OF

Sworn to (or affirmed) and subscribed before me this

day of , year , By

Signature of Notary Public – State of Florida

Print, Type, or Stamp Commissioned name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced

*NOTE: Private Correctional facilities must submit original and shall forward the completed affidavit stapled to the Registration of Employment, Affidavit of Compliance Form CJSTC-60 to FDLE, Criminal Justice Professionalism Program, Post Office Box 1489, Tallahassee, Florida 32302-1489, Attention Records Section

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FLORIDA HIGHWAY PATROL PHYSICAL ABILITIES TEST INSTRUCTIONS

The Florida Highway Patrol (FHP) Physical Abilities Test (PAT) was designed to assess physical attributes which reflect core enabling knowledge, skills and abilities and essential tasks common for law enforcement, corrections and correctional probation officers. The PAT is to be conducted in a continuous flow manner that is time-dependent to determine the participant’s level of physical conditioning and aerobic capacity. The PAT MUST be completed in a maximum time of six-minutes and four-seconds for successful completion. The test

measures specific physical abilities through a series of tasks which are listed as follows:

1. Unfastening seatbelt, activating trunk release latch, opening door, exiting vehicle and opening trunk2. Removing handgun and baton from trunk, placing handgun on chair, and retaining baton3. 220-yard run with baton4. Obstacle course with baton5. Dummy drag (150 pounds)6. Obstacle course with baton (repeat)7. 220-yard run with baton (repeat)8. Placing baton on chair, dry-firing of handgun (six trigger-pulls) with each hand (while counting aloud), picking-up baton9. Placing handgun and baton in trunk, closing trunk10. Re-entering vehicle, closing door, fastening seatbelt, and placing hands on steering wheel

TASK 1: The test begins with the participant seated in a full-sized motor vehicle, seatbelt on, with hands at the 10 and 2 o’clock positions on the steering wheel. Around the applicant’s waist is a pull-away flag belt with flags positioned over each hip. A handgun and baton are positioned on the front-center of the trunk floor and the trunk lid in the closed/locked position. On the command of “Go,” the stopwatch is started and the participant removes their hands from the steering wheel, unfastens the seatbelt, and exits vehicle leaving the door open. The participant moves to the rear of the vehicle and opens the trunk. Immediately after opening the trunk, the participant touches each flag with the opposite hand, from behind their back, and the belt is removed by the participant (letting the belt fall to the ground). The participant then removes the handgun and baton from the trunk before closing the trunk lid. The participant then moves to the chair and places the handgun on the chair while still retaining the baton. The participant then proceeds to the starting position of the 220-yard run.

TASK 2: While carrying the baton, the participant runs 220-yards on a flat surface to the entrance of the obstacle course.

TASK 3: Upon completion of the 220-yard run, the applicant passes through the pylons at the entrance to the obstacle portion of the course. Ten feet into the obstacle course, the participant must climb over a 40-inch wall, followed by a series of three (24, 12, and 18-inch) hurdles five feet apart, located 10 feet beyond the wall. 10 feet beyond the final hurdle, the participant encounters the first of nine pylons (spaced five feet apart) in a single row. The participant then must serpentine through the pylons. 10 feet beyond the last pylon, the participant must crawl under a 27-in high, eight-foot long low crawl area after which the participant stands, moves to the pylons located seven feet beyond the low crawl and drops the baton beside one of the pylons. (NOTE: If at any time during the obstacle course the applicant knocks over a hurdle or pylon, they must immediately replace the hurdle or pylon and repeat that portion of the obstacle course.)

TASK 4: The participant then sprints 50 feet, grabs the 150-pound dummy and drags it 100 feet on a cut-grass surface.

TASK 5: Upon completion of the dummy drag, the participant sprints back to the pylons, picks-up the baton and reverses course through the obstacles. Following the wall climb, the participant moves through the pylons to prepare for the 220-yard run.

TASK 6: While carrying the baton, the applicants runs 220 yards on a flat surface to the vehicle.

TASK 7: Upon completing the 220-yard run, the applicant places the baton on the chair and picks-up the handgun. The applicant then assumes a proper firing position and dry fires (six trigger pulls) using the dominant hand, followed by the non-dominant hand. The applicant then picks-up the baton in one hand while holding the handgun in the other hand.

TASK 8: Upon completing the two-rounds of dry-firing, the applicant places the handgun and baton in the floor of the already-opened vehicle trunk, then closes the trunk. The applicant then re-enters the vehicle, closes the door, fastens the seatbelt, and places both hands on the steering wheel at the 10 and 2 o’clock positions, at which time the test ends and the stopwatch deactivated.

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FLORIDA HIGHWAY PATROL WEIGHT STANDARDS SCALE

MALE FEMALE

HEIGHT MAXIMUM HEIGHT MAXIMUM

4'5" 133 4'5" 134

4'6" 137 4'6" 138

4’7” 142 4’7” 141

4’8” 147 4’8” 144

4’9” 151 4’9” 148

4’10” 156 4’10” 151

4’11” 140 4’11” 154

5’0” 165 5’0” 158

5’1” 170 5’1” 161

5’2” 175 5’2” 164

5’3” 178 5’3” 169

5’4” 183 5’4” 172

5’5” 187 5’5” 176

5’6” 193 5’6” 181

5’7” 198 5’7” 185

5’8” 203 5’8” 189

5’9” 207 5’9” 194

5’10” 213 5’10” 199

5’11” 218 5’11” 205

6’0” 224 6’0” 210

6’1” 229 6’1” 215

6’2” 235 6’2” 221

6’3” 240 6’3” 227

6’4” 251 6’4” 233

6’5” 258 6’5” 239

6’6” 265 6’6” 246

6’7” 272 6’7” 253

6’8” 280 6’8” 260

6’9” 289 6’9” 267

6’10” 297 6’10” 274

6’11” 305 6’11” 282

7’0” 314 7’0” 290

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Bring your completed Supplemental Application for State Trooper and all accompanying documentation withyou to the PAT Testing site.

Review and complete the Supplemental Application Checklist.

Complete ALL notarizations of signatures and photocopying of documents BEFORE your PAT Testing date.

Birth Certificates issued by hospitals are NOT ACCEPTABLE. Birth Certificates must have beenissued by the State or County Vital Statistics Office.

Applicants who are Naturalized U.S. Citizens MUST bring the ORIGINAL Naturalization Documentalong with a photocopy of the same document for verification purposes. The original document WILLbe returned to you.

Make a photocopy of your completed Supplemental Affidavit for State Trooper and ALL supporting documents for your records. WE WILL NOT MAKE PHOTOCOPIES.

You may mail official college transcripts and other required documents obtained after the PAT Test date to:

Florida Highway Patrol

Background, Recruitment & Selection

2900 Apalachee Parkway, MS 49

Tallahassee, Florida 32399

All documentation mailed to the Background, Recruitment & Selection Section MUST have the applicant’s name and social security number on it so we know in which file to place the documentation.

Applicants who fail to attend ANY scheduled pre-employment testing are considered no longer interestedin a position as a State Trooper. In these cases, the applicant is eliminated from further consideration inthe selection process.

Applicants who fail to attend ANY pre-employment testing and are interested in re-entering the selection process must complete a new State of Florida Employment Application and mail it to:

Florida Highway Patrol

Background, Recruitment & Selection Section

2900 Apalachee Parkway, MS 49

Tallahassee, Florida 32399

If you have any questions, contact the Background, Recruitment & Selection Section at 850-617-2315.

Further information about the Selection Process and the FHP Training Academy may be obtained at theFlorida Highway Patrol website at www.BeATrooper.com.

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STATE TROOPER APPLICANT

SUPPLEMENTAL APPLICATION CHECKLIST

CAREFULLY review this Supplemental Application Checklist. As you proceed through the checklist, review each page of the application in its entirety. Ensure that you have followed ALL directions, completed ALL sections, and that you have signed and received applicable forms notarized PRIOR to attending your scheduled Physical Abilities Test. Failure to follow instructions and include all required information and documentation may result in DISQUALIFICATION of your application. We cannot stress enough the importance of ensuring that all information in this application is complete and accurate. Any falsification or omission of any kind may result in DISQUALIFICATION of your application.

Page 1: ALL instructions CAREFULLY read, understood and followed.

Page 2: ALL instructions CAREFULLY read, understood and followed.

Page 3: Minimum Employment Requirements read and understood, applicable box checked, all fields completed and applicant’s signature affixed.

Page 4: Applicant Information Survey completed with all applicable boxes checked.

Page 5: Applicant Weight Chart understood, all information completed and applicable box checked.

Page 6: Memorandum from Academy Director understood.

Page 7: All fields completed. Florida Highway Patrol Waiver of Liability form READ and UNDERSTOOD. Applicant’s signature attached and the affidavit NOTARIZED.

Page 8: All fields completed. Florida Highway Patrol Medical Release Form completed by YOUR DOCTOR and the applicable box checked reflecting his/her medical recommendation. DOCTOR’S signature affixed.

Page 9: You understand the instructions and have determined which Release Form (page 10, 11, or 12) you must complete based on your PAT Testing location.

Page 10: If you’re completing your PAT Test in Tallahassee (Havana), Florida, you have completed the Florida Highway Patrol Training Academy/Florida Public Safety Institute Release Form and have ensured that it is NOTARIZED. If this is not the location where you will be completing your PAT Test, you have drawn an “X” across the entire page and included it in the packet.

Page 11: If you are completing your PAT Test in Orlando, Florida, you have completed the Valencia Community College Release Form and have ensured that it is NOTARIZED. If this is not the location where you will be completing your PAT Test, you have drawn an “X” across the entire page and have included it in the packet.

Page 12: If you are completing your PAT Test in Miami, Florida, you have completed the Florida International University Release Form and have ensured that it is NOTARIZED. If this is not the location where you will be completing your PAT Test, you have drawn an “X” across the entire page and have included it in the packet.

Page 13: All fields completed and applicable boxes checked. “For Official (FHP) Use Only” section blank.

Page 14: All fields completed and applicable boxes checked. Additional sheets used, if necessary.


Applicant’s Name: ______________________________ Social Security Number: _____-_____-_______

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Page 19: All fields completed and applicable boxes checked. No period of employment omitted. Additional sheets used, if necessary. Copies of military documents attached, if applicable.

Page 20: All fields completed and applicable boxes checked. No period of employment omitted.





Page 25: All fields completed and applicable boxes checked. No period of employment omitted All gaps in employment (if applicable) listed to ensure an unbroken timeline.

Page 26: All applications submitted to other law enforcement agencies listed and none omitted. Additional sheets used, if necessary. All polygraph tests previously taken with other law enforcement agencies listed and none omitted. Additional sheets used, if necessary.

Page 27: All fields completed and applicable boxes checked. If you are or have been a law enforcement officer or correctional officer and have received ANY type of disciplinary action, they are listed and nothing is omitted. Additional sheets used, if necessary.

Page 28: All fields completed and applicable boxes checked. CERTIFIED copies of ALL out-of-state driving records included with packet, if applicable. ANY and ALL traffic citations EVER received during your lifetime listed. ANY and ALL traffic crashes in which you have EVER been involved listed and none omitted. Additional sheets used, if necessary.

Page 29: All fields completed and applicable boxes checked.

Page 30: All fields completed and applicable boxes checked. ANY and ALL occasions in your lifetime listed where you were arrested and none omitted.

Page 31: All fields completed and applicable boxes checked. ALL illegal drugs you have EVER used, experimented with, possessed, injected, inhaled, swallowed, or ingested in any way listed with number of times used and associated dates. None omitted.

Page 32: All fields completed and applicable box checked.

Page 33: All fields completed. THREE Character References (not including relatives, former employers, former supervisors, or individuals living outside of the United States) listed.

Page 34: All fields completed and applicable boxes checked. COMPLETE and ACCURATE Credit History information listed and nothing omitted.

Page 35: All fields completed. COMPLETE and ACCURATE Credit History information listed and nothing omitted. Additional sheets used, if necessary.


Page 37: All fields completed and applicable boxes checked. Residential addresses for the last 10 YEARS listed chronologically beginning with your CURRENT address and working BACKWARD. NO GAPS in dates in which you lived at a residence. If you have lived at your current address for 10 years or more, you have listed the THREE previous addresses where you resided prior to your current residential address. NO ADDRESSES OMITTED. If you have lived at your current residential address for your

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lifetime, only your current residential address listed and indicated on the page. Additional sheets used, if necessary.

Page 38: All fields completed and applicable boxes checked.

Page 39: ALL Social Media accounts that you CURRENTLY HAVE and have EVER HAD listed. Applicant’s signature affixed.

Page 40: READ and UNDERSTOOD ENTIRE page. CAREFULLY read the consequences of falsification or omissions of anything during the application process and COMPLETELY UNDERSTOOD such consequences. Recent (taken within 30 days of notarization) individual color photographs of your face and full body attached. Applicant’s signature affixed and affidavit NOTARIZED.

Page 41: READ and UNDERSTOOD the Florida Highway Patrol Background Investigation Agreement. Applicable box checked, all fields completed, and applicant’s signature affixed.

Page 42: All fields completed, applicable box checked, applicant’s signature affixed, and the affidavit NOTARIZED.

Page 43: All fields completed, applicable boxes checked, and applicant’s signature affixed.

Page 44: All fields completed and appropriate box checked. Applicant’s Current Spouse, Future Spouse, or Roommate’s Signature affixed and the affidavit NOTARIZED. This form has been completed for EVERY person (including family members) 18 years of age and older that lives in the applicant’s residence.

Page 45: All fields completed. Agreement for Training Cost Reimbursement for Florida Highway Patrol Recruits READ and UNDERSTOOD.

Page 46: All fields completed. Agreement for Training Cost Reimbursement for Florida Highway Patrol Recruits READ and UNDERSTOOD. Applicant and Witness signatures affixed and affidavit NOTARIZED.

Page 47: All fields completed. “Attachment A” Itemized Cost of Training and Expense for Trooper READ and UNDERSTOOD. Applicant and Witness signatures affixed and affidavit NOTARIZED.

Page 48: All fields completed. Florida Highway Patrol Duty Assignment Agreement READ and

UNDERSTOOD. Applicant’s signature affixed. Duty Assignment "Wish List" completed. Page 49: All fields completed. Florida Highway Patrol Agreement to Allow for Contact of My Current Employer

READ and UNDERSTOOD. Applicant’s signature affixed.

Page 50: All fields completed and applicable box checked. Florida Highway Patrol Notice of Disclosure of Consumer Report Federal Fair Credit Reporting Act (FCRA) form READ and UNDERSTOOD. Applicant’s signature affixed and the affidavit NOTARIZED.

Page 51: All fields completed, applicant’s signature affixed, and the affidavit NOTARIZED.

Page 52: FDLE CJSTC 58 Form completed, applicant’s signature affixed, and affidavit NOTARIZED.

Page 53: FDLE CJSTC 68 Form completed, applicable boxes checked, applicant’s signature affixed, and affidavit NOTARIZED.

Page 54: Florida Highway Patrol Physical Abilities Test Instructions READ and UNDERSTOOD.

Page 55: Florida Highway Patrol Weight Standards Scale READ and UNDERSTOOD.

Page 56: ALL INFORMATION ON THIS PAGE READ, UNDERSTOOD AND FOLLOWED.

Page 57: ALL Supplemental Application Checklist boxes checked verifying each page of the packet has been completed accurately and completely.


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Page 61: Florida Highway Patrol Troop Boundaries Map reviewed.

Page 62: Florida Highway Patrol Background, Recruitment & Selection Contact Information retained for future reference.


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TROOP BOUNDARIES

FHP General Headquarters

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General Headquarters Staff

Captain Ryan M. Martina Lieutenant Jeffrey N. Kidder Sergeant James E. Swearingin

2900 Apalachee Parkway, MS 49 2900 Apalachee Parkway, MS 49 2900 Apalachee Parkway, MS 49

Tallahassee, Florida 32399 Tallahassee, Florida 32399 Tallahassee, Florida 32399

(850) 617-2315 (850) 617-3639 (850) 617-2336

[email protected] [email protected] [email protected]

Recruiters / Background Investigators

Troop A Troop B Troop C

Trooper Laramie F. Battle Trooper Michael V. Cagle Trooper Stanley B. Rice

6030 County Road 2321 1350 U.S. Highway 90 W 11305 N. McKinley Drive

Panama City, Florida 32404 Lake City, Florida 32055 Tampa, Florida 33612

Office: (850) 873-7033 Office: (386) 754-6284 Office: (813) 558-1817

Cell: (850) 274-3929 Cell: (386) 220-3345 Cell: (813) 460-0896


Troop D Troop E (1 of 2) Troop E (2 of 2)

Trooper Tara E. Crescenzi Trooper Benjamin F. Hollinger Trooper Michael L. Brown

133 S. Semoran Blvd., Suite A 1011 N.W. 111th Avenue 1011 N.W. 111th Avenue

Orlando, Florida 32807 Miami, Florida 33172 Miami, Florida 33172


Cell: (407) 319-0021 Cell: (305) 619-6983 Cell: (305) 619-2944


Troop F Troop G Troop H

Trooper Kenneth R. Watson Trooper Michael A. Elder Sergeant James E. Swearingin

4010 S. Tamiami Trail 7322 Normandy Blvd., 2900 Apalachee Parkway, MS 49

Venice, Florida 34293 Jacksonville, Florida 33205 Tallahassee, Florida 32399


Cell: (850) 251-2088 Cell: (904) 466-1689 Cell: (850) 274-3733


Troop K Troop L

Trooper Michael D. Thurston Trooper Elliott K. Rosen

Bldg 9330, MM94 Florida’s Turnpike 14190 W. State Road 84

Lake Worth, Florida 33467 Davie, Florida 33325

Office: (561) 357-4274 Office: (954) 837-4016

Cell: (561) 513-3007 Cell: (954) 290-6196

[email protected] [email protected]


BACKGROUND, RECRUITMENT & SELECTION

CONTACT INFORMATION

Documents

FLORIDA HIGHWAY PATROL STATE TROOPER APPLICANT SPECIAL INSTRUCTIONS … · FLORIDA HIGHWAY PATROL STATE TROOPER APPLICANT SPECIAL INSTRUCTIONS ... E. Answer all questions accurately