St. Augustine Beach Police Department - APPLICATION FOR EMPLOYMENT
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St. Augustine Beach Police Department
APPLICATION FOR EMPLOYMENT
2300 A1A South
St. Augustine Beach, Florida 32080
(904) 471-3600 Office
(904) 471-0737 Fax
APPLICANT NAME:
THE ST. AUGUSTINE BEACH POLICE DEPARTMENT IS A EQUAL EMPLOYMENT
OPPORTUNITY EMPLOYER
Revised 01/31/2019APPLICATION INSTRUCTIONS & REQUIREMENTS
This application must be either typed or printed in legible form. Applications which are not legible or
complete will be considered unacceptable and given no further consideration. All required documents must
accompany your completed, notarized application. Return the application and attachments to the St. Augustine
Beach Police Department, 2300 A1A South, St. Augustine Beach, FL 32080.
Begining October 1, 2016 all applicant's (sworn law enforcement positions only), in addition to any other
listed requirements, must have a minimum of 60 college credit hours from a college or other institution
accredited by the Southern Association of Colleges and Schools, Commission on Colleges or three (3)
continuous years of law enforcement/police experience or two (2) continuous years of active military service
with an honorable discharge.
Answer all questions. If they do not apply, place a N/A by the number.
1. Provide names, complete mailing addresses including zip codes, and telephone numbers of former
employers, date of employment (to include month and year) and your job title.
2. References should be longtime friends but not neighbors, supervisors or co-workers.
Please attach copies of the following documents to your completed application.
Birth Certificate
Driver’s License and Social Security Card
Florida High School Diploma or State Equivalency (GED). If you have an equivalency diploma
from ANY state other than, Florida you MUST provide a copy of your transcript.
Police Standards Certification, if applying for a Law Enforcement Position. If you are an out of state
officer, Military Police Officer or Federal Officer who has requested exemptions from Florida Basic
Recruit Training Programs, you MUST provide an equivalency of training.(CJSTC 76 + CJSTC 76A
Forms).
Basic Recruit Exam scores, if certification date is after June 30, 1993.
BAT test results, if attended academy after January 1, 2002. This includes the successful completion
of the SABPD PAT and swim test refresher.
Form DD214, if you are former military (see the listed military requirements). Also complete
“Request Pertaining to Military Records” form (page 19 of this application).
College Degree (see the listed college requirements and sealed transcript(s) must be supplied).
Documents showing legal changes of name from birth to present (example: marriage
license, divorce papers, adoption papers, etc.).
Appropriate “Application Disqualifiers” form – Sworn or Civilian (page 3 or 4, whichever
applies – sworn or civilian).
Contact the St. Augustine Beach Police Department at (904) 471-3600 regarding any change in this
application such as: residency, phone number of employment (permanent or part-time), name changes, military
status, etc.
Please note that a thorough background investigation, including information as to your character, general
reputation, personal characteristics and mode of living will be part of your processing. This information is solely
for the purpose of evaluating your qualifications for employment within this agency. The submission of this
application carries the understanding that you are authorizing this agency to contact any and all available sources
for the purpose of obtaining information as to your qualifications.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
2 of 19APPLICATION DISQUALIFIERS
Tattoos - (Sworn Applicants)
Effective October 1, 2013, no person will be considered for employment if they have tattoos or body art that is exposed and
visible on the body while wearing short sleeves and shorts, such as but not limited to; on the lower arms, elbows, hands,
neck, head, calves, knees or lower thighs .
Criminal Convictions
A person who after July 1, 1981 has pled guilty or nolo contendere to or has been found guilty of a felony is not eligible for
appointment as a law enforcement officer, regardless of whether adjudication was withheld or sentence was suspended. FSS
943.13(4)
A person who after July 1, 1981 has pled guilty or nolo contendere to or has been found guilty of a misdemeanor involving
perjury or false statement is not eligible for appointment as a law enforcement officer, regardless of whether adjudication
was withheld or sentence was suspended. Note: any such person who had been found guilty or entered a plea prior to
December 1, 1985 and has had the record sealed or expunged is considered eligible for appointment by operation of the
statute, FSS 943.13(4). However, the applicant may be deemed ineligible upon further review of the applicant’s application
and the case.
Any applicant who has pled guilty or nolo contendere or been found guilty of the criminal offense of DUI within the last five
years while employed as a law enforcement officer, corrections officer, or military policeman is disqualified for employment
as a sworn member of this agency.
Any domestic violence convictions.
Driving
3 moving violations within the past 24 months.
Three (3) moving violations within the past 24 months. Any driver’s license suspensions / revocations in the last
five (5) years. (Suspensions for financial responsibility and failure to pay will be evaluated on a case-by-case basis.)
Unlawful Drug Activity
Any illegal drug use in the last 5 years prior to the date of application. Any sale or delivery of any illegal drug / controlled
substance, after the age of 17 (up to the 18th birthday.) All SABPD employees are subject to random drug screens
throughout their employment with the SABPD.
PAT & SPE (Sworn Applicants)
Required to complete the Annual SABPD Physical Abilities Test (PAT) and the SABPD Swim Proficiency Evaluation (SPE).
The Annual SABPD PAT is a basic physical assessment for all sworn members to ensure compliance with the job
requirements, recognize individual abilities and encourage a healthy lifestyle in the demanding field of law enforcement. The
periodic SPE is a basic assessment for all sworn members to ensure compliance with job requirements, recognize individual
abilities and satisfy the demands associated with public safety in a beach community. The successful passing of the PAT and
SPE will be required for all applicants actively processing for a sworn law enforcement position with the SABPD after June 1,
2016.
Tobacco/Nicotine
The Tobacco/Nicotine use policy of the St. Augustine Beach Police Department (SABPD) is that all members shall not use
tobacco in their assigned vehicle, in public while in uniform or on any official SABPD business. Additionally, members will
not use tobacco, whether on or off-duty around any other on-duty SABPD member, City of St. Augustine Beach member or
in or around the SABPD building or any other government building anytime. Tobacco/nicotine use can include but is not
limited to smoking, vaping, and chewing tobacco.
Military
Any discharge other than honorable or uncharacterized from any of the Armed Forces of the United States.
Other
Incomplete or improperly completed applications. The SABPD has no responsibility to notify any applicant of incomplete or
improperly turned in applications.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
3 of 19Statement of Understanding
I, , have read the above-listed disqualifiers as a part of the application process
with the St. Augustine Beach Police Department. I acknowledge that I am qualified to apply with the St. Augustine Beach
Police Department. Further, should one of these disqualifiers be discovered during the background investigation / selection
process, I understand that my application process will be terminated immediately. I further understand that my arrest
history will be reviewed and that the facts and circumstances of any arrest will be considered in determining whether I can
be employed as a sworn law enforcement officer.
_____________________________________ _______________________
Signature of Applicant Date
NOTICE TO PERSONS REGARDING
COLLECTION OF SOCIAL SECURITY NUMBERS
The St. Augustine Beach Police Department collects the Social Security number of persons who:
1. Apply for employment or are employed by this agency;
2. Apply to qualify with a firearm pursuant to HR 218, the Nationwide Concealed Carry Act for Retired
Law Enforcement Officers;
3. Apply to volunteer with this agency; and
4. Are arrested by this agency.
Social Security numbers are collected by the St. Augustine Beach Police Department for the following
reasons, which are imperative for the performance of duties and responsibilities prescribed by law:
1. To verify identity;
2. To conduct employment background investigations;
3. To properly pay an employee and to credit the withholding of income taxes, social security and Medicare
taxes, retirement and other items pursuant to State and Federal law; and
4. To determine criminal history and to verify wants, warrants, and/or capiases.
PUBLIC RECORD
Applications for employment with a government agency are, except for “Personal Information,” a matter of public
record and are not subject to confidentiality.
Examination questions and answers are not public record; but the applicant has the right to review his/her
application and any completed exams that he/she has taken.
The St. Augustine Beach Police Department determination of the qualifications of an applicant for employment is
final.
No employee of the St. Augustine Beach Police Department is required to render an opinion or explanation
beyond what is contained in the public record.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
4 of 19AFFIRMATIVE ACTION
FOR STATISTICAL USE ONLY
Dear Applicant:
It is the policy of this agency that no member (sworn, non-sworn or volunteer) of, or applicant to, the SABPD is
to be discriminated against on the basis of race, color, sex, sexual orientation, political affiliation, religion,
national origin, age, handicap or marital status.
All members are entitled to work in an environment free of offensive or disparaging conduct. Therefore, it is the
policy of this agency to strictly prohibit any conduct by its members which defames or demeans the nationality,
culture, color, creed, belief, sex or sexual orientation of any person.
The information required in this portion is requested only so that we meet our Equal Opportunity / Affirmative
action obligations. Your completion of this form is purely voluntary and will not in any way affect your
consideration for employment. This insert will be separated from your application and will be separately
maintained. Thank you for your assistance.
1. Sex: Male Female
2. Ethnicity Hispanic Latino Neither
If you checked “neither” for ethnicity, please identify your race by checking one of the boxes below.
White
Black or African American
3. Race Native Hawaiian or other Pacific Islander
Asian
American Indian or Alaska Native
Two or more races
4. Handicapped Yes No
5. Veteran Yes No
6. Age
7. How were you referred to our agency?
Media (specify) Career/Job Fair (which one) Walk In Agency (specify)
Employee (whom) Internet Other (specify)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
5 of 19PERSONAL DATA
Email Address: _____________________________ Date:
1. Position Sought:
Sworn Non-Sworn Volunteer
I understand that misrepresentation is sufficient cause for rejection of employment or dismissal.
Signature ___________________________________________ Date ______________________
2. Social Security: 3. Name:
(Last, First, Middle)
4. Other: List all other names you have used including circumstances and time periods you used them.
(For example: maiden name, former name(s), alias(s), or nickname(s).
Name Circumstances Dates From Dates To
(Mo/Year) (Mo/Year)
5. Residence Address:
(Street)
(Mailing Address)
(City, State, Zip Code)
(Area Code and Phone Number) (Cell Number)
6. Date of Birth: / / Place of Birth:
(Mo.) (Day) (Year) (City and State)
7. U. S. Citizen: Yes No Naturalized? Yes No
(If yes, provide the certificate number of your naturalization papers)
8. Do you have any relatives working for the City of St. Augustine Beach? Yes No
If yes, Name: Relationship:
9. Have you ever worked for or applied to the St. Augustine Beach Police Department before?
Yes No
If yes, please give the year and position applied for:
The St. Augustine Beach Police Department is an Equal Opportunity Employer
6 of 1910. Have you ever applied to any other law enforcement agency? Yes No
If yes, list name of agency and date of application:
* If you apply to any other law enforcement agency after having turned in this application, please notify this agency
11. Are you now on any eligibility lists? Yes No
If yes, list the name(s) of the agency:
12. Have you had any law enforcement training by any local, state or federal agency? Yes No
Did you receive a certificate for this training? Yes No If yes, the date?
In what state? Type of certificate:
13. Has your law enforcement certificate ever been suspended, revoked, relinquished or subject to
discipline or investigation by the CJSTC? Yes No If yes, please explain:
ARREST HISTORY / COURT DATA
14. Have you ever been convicted of a felony or misdemeanor? Yes No
If yes, please explain (list name of agency and date):
15. Have you ever been arrested, received a notice or summons to appear, charged, convicted, pled nolo
contendere or pled guilty to any criminal violation, regardless if the record was sealed or expunged?
Yes No If yes, please explain (list name of agency and date) :
16. Have you ever been detained, questioned, interviewed or in any way been contacted by a law
enforcement agency for any reason (including investigative purposes)? Yes No If yes, please
explain (list name of agency and date):
17. Have you ever been a respondent in an injunction for protection, domestic violence injunction or
a restraining order? Yes No If yes, please explain (list name of agency and date):
18. Have you ever been a plaintiff or defendant in a court action? Yes No If yes, please explain
(list name of agency and date):
____________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
7 of 19U. S. MILITARY RECORD
19. Are you registered for Selective Service? Yes No
If yes, you’re Selective Service Number: (www.sss.gov to verify)
20. Have you ever served on active duty in the Armed Forces of the United States? Yes No
Branch of Service: Highest Rank:
Duty Dates: From: To:
From: To:
From: To:
From: To:
21. Date and type of discharge:
22. Are you now or have you ever been a member of a reserve unit or the National Guard? Yes No
If yes, state the branch of service, name and location of your unit and whether you attend drills,
meetings, etc.:
23. Was any type of disciplinary action taken against you in the service? Yes No If yes,
please provide:
Date: Place:
Nature of Offense:
Action Taken:
MOTOR VEHICLE OPERATOR RECORD
24. Do you possess a valid driver license? Yes No
Driver license type or class: ___________________
Endorsements: _____________________________ Number State
25. Do you hold or have you ever held an operator or chauffeur license in another state? Yes No
If yes, please provide state(s), name used, driver license(s) number and approximate dates license(s)
was/were held.
26. Have you ever had a driver license suspended or revoked? Yes No
If yes, explain below: List the state and details.
If yes, was your license ever restored? Yes No
27. Have you ever received a traffic citation (other than parking)? Yes No
If yes, list below the city, county, state, name of agency issuing the citation, date, charges and final
disposition. Complete information must be supplied.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
8 of 19CREDIT DATA
28. Have you been involved in any bankruptcy proceedings? Yes No
If so, what year?
29. Are you currently involved in any pending litigation? Yes No
If so, list case number and county.
INTERNET INFORMATION
30. Do you have, under your name or any other name or identifier, any current or previous social media accounts,
websites, blogs, dating sites or any other form of electronic communication, including but not limited to Facebook,
MySpace, Twitter, Instagram, SnapChat, LinkedIn, YouTube, Google+, Pinterest, Tumblr, Flickr, Periscope,
Reddit, Zoosk, Plenty of Fish, Craigslist, Backpage, Tinder, Match or any and all other form of electronic or
internet posting or receiving capability? Yes No Please list any and all accounts or sites for
content review.
The St. Augustine Beach Police Department recognizes free speech and expression but requires all members to adhere to the strict guidelines of the
SABPD Social Media Policy. Any failure to identify or the concealment of any social media site as defined may terminate the application process.
REFERRAL INFORMATION
The St. Augustine Beach Police Department rewards all full-time employees for their recruitment efforts. If you
were recruited by an existing employee, please list their name below. This will allow us to track your progress
and reward them accordingly.
Referred by:
DRUG USE (Illegal Drugs, Prescription Drugs, Alcohol & Tobacco/Nicotine)
Both applicants and members of the St. Augustine Beach Police Department are prohibited, as defined in
Florida State Statute Chapter 893, from the use, possession or sale of any illegal drug or substance. This includes
the use, possession or sale of any legal prescription drug not prescribed to the applicant or member. Applicants
will not be considered for employment for use of any illegal drug or legal drug prescribed to another person
within 5 years of application to the St. Augustine Beach Police Department. Any applicant may be disqualified
regardless of the 5 year limit or have the 5 year time limit extended due to extenuating circumstances (frequency
of use and/or specific type of illegal or prescribed drug used) at the discretion of the Chief of Police.
Marijuana: Yes ( ) No ( ) How many times used: _______________ Date(s): _________________________
Cannabinoids (Marijuana, Hashish, THC): Yes ( ) No ( ) How many times used: _______________________
Date(s): _______________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
9 of 19Cocaine: Yes ( ) No ( ) How many times used: _______________ Dates(s): __________________________
Crack Cocaine: Yes ( ) No ( ) How many times used: _______________ Dates(s): _____________________
Opioids (Heroin, Opium): Yes ( ) No ( ) How many times used: _________________ Date(s): ____________
____________________
Mescaline or Psilocybin (Mushrooms): Yes ( ) No ( ) How many times used: _______________ Date(s): ___
____________________
Amphetamines (speed): Yes ( ) No ( ) How many times used: _______________ Date(s): ________________
Methamphetamine (Meth): Yes ( ) No ( ) How many times used: _______________ Date(s): _____________
MDMA (Molly, Ecstasy): Yes ( ) No ( ) How many times used: _______________ Date(s): _____________
LSD (Acid), PCP, GHB: Yes ( ) No ( ) How many times used: _______________ Date(s): ______________
Any other illegal drug not mentioned and/or defined in FSS Chapter 893: Yes ( ) No ( ) How many times used:
__________________________________________________ Date(s): ________________________________
Prescription Drugs prescribed to you within the previous 2 years: Yes ( ) No ( ) Name(s): ________________
_______________________________________ Date(s) Used: ______________________________________
Prescription Drugs used prescribed to another person (anytime): Yes ( ) No ( ) Name(s): _________________
_________________________________ How many times used: ___________________________ Date(s) and
circumstances used: _________________________________________________________________________
__________________________________________________________________________________________
Alcohol Consumption: Yes ( ) No ( ) How often: _______________________________ Type(s): ___________
_____________________________ Date & time last consumed: ______________________________________
Have you ever been intoxicated/impaired: Yes ( ) No ( ) How many times (estimate): _____________________
Date, time and circumstances last intoxicated/impaired: _____________________________________________
Tobacco/Nicotine: Yes ( ) No ( ) Are you a current user of tobacco/nicotine (all forms of tobacco, E-cigarettes,
Nicotine patches or other smoking cessation drugs or implements): _____________________________________
Are you a former tobacco user: Yes ( ) No ( ) When was the last time you used tobacco/Nicotine (Dates): _____
____________________________ Do you fully understand the SABPD policy on tobacco use as outlined on page
three (3) of this application: Yes ( ) No ( )
EMPLOYMENT HISTORY
May we contact your present employer? [ ] Yes [ ] No
Begin with your most recent employer and list all (back to high school or 25 years, whichever applies)
previous employers (including temporary, volunteer work, part-time and any period of unemployment.)
Include complete addresses and phone numbers.
The St. Augustine Beach Police Department is an Equal Opportunity Employer
10 of 191. Employer: Dates of Employment From: To:
Month / Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
2. Employer: Dates of Employment From: To:
Month / Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
3. Employer: Dates of Employment From: To:
Month / Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
4. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
The St. Augustine Beach Police Department is an Equal Opportunity Employer
11 of 195. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
6. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
7. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
8. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
The St. Augustine Beach Police Department is an Equal Opportunity Employer
12 of 199. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
10. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
11. Employer: Dates of Employment From: To:
Month/Year Month / Year
Address:
Street City State Zip Area Code/Phone Number
Position Held: Type of Business:
Supervisor:
Reason for Leaving:
Description of Duties:
Salary or earnings: Starting: Per Ending: Per
The St. Augustine Beach Police Department is an Equal Opportunity Employer
13 of 19RESIDENCY
Chronologically list all previous places of residence for the past 15 years (begin with present address and
work backward). Include all places you have resided either temporarily, part-time, military housing, or
dual residence using the format shown below.
Dates
Month/Year Street Address City County State
From To
EDUCATIONAL RECORD
High School (Last):
Name: City State
Dates Attended: From: To:
Did you graduate? Yes
No If no, do you have a general education diploma (G.E.D.) or a high school equivalency? Yes No
State: Year:
The St. Augustine Beach Police Department is an Equal Opportunity Employer
14 of 19College:
Name: City State
Dates Attended: From: To: Course of Study:
Degree? Yes
No If no, how many credits did you complete?
College (Post Graduate)
Name: City State
Dates Attended: From: To: Course of Study:
Degree? Yes
No If no, how many credits did you complete?
Other Schools or Significant Training (Academy / Trade / Technical / Business)
Name: City State
Dates Attended: From: To: Course of Study:
Did you graduate? Yes
No If no, describe the training you received:
PERSONAL HISTORY
List any honors or awards you have received:
Indicate any foreign language proficiency:
Language: Ability Fair Good Fluent
Read
Speak
Write
Read
Speak
Write
List all professional clubs, societies, associations of which you have been a member:
Name of Organization City and State Position Held Currently Active
Yes
No
Yes
No
Yes
No
The St. Augustine Beach Police Department is an Equal Opportunity Employer
15 of 19PERSONAL REFERENCES
List four (4) references, other than family members, giving complete information on each reference.
References should be longtime friends. Do not include family members, neighbors, supervisors, or co-
workers as references.
1. Name: Relationship:
Address:
City: State: Zip:
Home Phone: Cell Phone:
2. Name: Relationship:
Address:
City: State: Zip:
Home Phone: Cell Phone:
3. Name: Relationship:
Address:
City: State: Zip:
Home Phone: Cell Phone:
4. Name: Relationship:
Address:
City: State: Zip:
Home Phone: Cell Phone:
EXPLANATION AND CONTINUATION SHEET (If needed)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The St. Augustine Beach Police Department is an Equal Opportunity Employer
16 of 19The St. Augustine Beach Police Department is an Equal Opportunity Employer
17 of 19CJSTC
AFFIDAVIT OF APPLICANT
Florida Department of 68
Law Enforcement Incorporated by Reference in Rule 11B-27.002(1)(f), F.A.C.
Please type or print in black or blue ink and use capital and small letters for names, titles, and addresses
Last Four Digits of Applicant’s 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 18 years of age for correctional officer or 19 years of age for all others. shall not be eligible for employment or appointment as an officer, notwithstanding suspension
of a sentence or withholding of adjudication.
• Be a citizen of the United States.
• Have been fingerprinted by the employing agency.
• Be a high school graduate or equivalent.
• Have passed a physical examination by a licensed medical specialist approved in Rule
• Not have been convicted of any felony or of a misdemeanor involving perjury or false
11B-27.002(1)(d), F.A.C..
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 • 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 information
I 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 or expunged.
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 by means of Physical Presence OR Online Notarization 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
Created 1/1/1992 Original - Agency Copy – FDLE 1 of 1 Commission-Approved Revisions: 8/13/2020
Oath amended pursuant to Section 117.05(13)(a), F.S., effective 1/1/2020 Form Effective Date: 5/2021RELEASE OF INFORMATION AUTHORITY
TO WHOM IT MAY CONCERN:
I respectfully request and authorize you to furnish the St. Augustine Beach Police Department any and all
information that you may have, in the areas listed below. Please include all records and reports (including
all information of a confidential or privileged nature), and photostats of same, if requested. This information
is being used in conjunction with an official investigation. Consent is granted for the St. Augustine Beach
Police Department to furnish to third parties, if requested.
I hereby release you, your organization or others (individually and collectively) from any liability or damage
which may result from furnishing the information requested by the St. Augustine Beach Police Department.
I further release the St. Augustine Beach Police Department and all its agents or employees, 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 to release
information, or any attempt to comply with it. Should there be any questions as to the validity of this
release, you may contact me as indicated below.
INITIAL the specified areas below:
___________________ Criminal History
___________________ Credit History
___________________ Education History
___________________ Employment History
___________________ Medical History (including physical, mental and laboratory records)
___________________ Military History
___________________ All of the above
Printed Name :
Signature: _________________________________________________________________
Address:
Telephone:
(Home) (Work)
Acknowledged before me by means of physical presence or online notarization, this ________Day
of ____________, 20 __who is personally known to me or who produced
as identification and who (did / did not) take an oath.
____________________________________________ ______________________________________
Printed Name of Notary Public Signature of Notary Public
_____________________________________________ NOTARY STAMP
The St. Augustine Beach Police Department is an Equal Opportunity Employer
18 of 19INSTRUCTION AND INFORMATION SHEET FOR SF 180, REQUEST PERTAINING TO MILITARY RECORDS
1. General Information. The Standard Form 180, Request Pertaining to Military Records (SF180) is used to request information from military records.
Certain identifying information is necessary to determine the location of an individual's record of military service. Please try to answer each item on the SF
180. If you do not have and cannot obtain the information for an item, show "NA," meaning the information is "not available". Include as much of the
requested information as you can. Incomplete information may delay response time. To determine where to mail this request see Page 2 of the SF180 for
record locations and facility addresses.
Online requests may be submitted to the National Personnel Records Center (NPRC) by a veteran or deceased veteran’s next-of-kin using eVetRecs at
http://www.archives.gov/veterans/military-service-records/ .
2. Personnel Records/Military Human Resource Records/Official Military Personnel File (OMPF) and Medical Records/Service Treatment
Records (STR). Personnel records of military members who were discharged, retired, or died in service LESS THAN 62 YEARS AGO and medical
records are in the legal custody of the military service department and are administered in accordance with rules issued by the Department of Defense and
the Department of Homeland Security (DHS, Coast Guard). STRs of persons on active duty are generally kept at the local servicing clinic. After the last
day of active duty, STRs should be requested from the appropriate address on page 2 of the SF 180. (See item 3, Archival Records, if the military member
was discharged, retired or died in service more than 62 years ago.)
a. Release of information: Release of information is subject to restrictions imposed by the military services consistent with Department of Defense
regulations, the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The service member (either past or present) or
the member's legal guardian has access to almost any information contained in that member's own record. The authorization signature of the service
member or the member's legal guardian is needed in Section III of the SF180. Others requesting information from military personnel records and/or
STRs must have the release authorization in Section III of the SF 180 signed by the member or legal guardian. If the appropriate signature cannot be
obtained, only limited types of information can be provided. If the former member is deceased, the surviving next-of-kin may, under certain
circumstances, be entitled to greater access to a deceased veteran's records than a member of the general public. The next-of-kin may be any of the
following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. Requesters MUST provide proof of death, such as a
copy of a death certificate, newspaper article (obituary) or death notice, coroner’s report of death, funeral director’s signed statement of
death, or verdict of coroner’s jury.
b. Fees for records: There is no charge for most services provided to service members or next-of-kin of deceased veterans. A nominal fee is
charged for certain types of service. In most instances, service fees cannot be determined in advance. If your request involves a service fee, you will
receive an invoice with your records.
3. Archival Records. Personnel records of military members who were discharged, retired, or died in service 62 OR MORE YEARS AGO have been
transferred to the legal custody of NARA and are referred to as “archival records”.
a. Release of Information: Archival records are open to the public. The Privacy Act of 1974 does not apply to archival records, therefore, written
authorization from the veteran or next-of-kin is not required. In order to protect the privacy of the veteran, his/her family, and third parties named in
the records, the personal privacy exemption of the Freedom of Information Act (5 U.S.C. 552 (b) (6)) may still apply and may preclude the release
of some information.
b. Fees for Archival Records: Access to archival records are granted by offering copies of the records for a fee (44 U.S.C. 2116 (c)). If a fee applies
to the photocopies of documents in the requested record, you will receive an invoice. Photocopies will be sent after payment is made. For more
information see http://www.archives.gov/st-louis/archival-programs/military-personnel-archival/ompf-archival-requests.html.
4. Where reply may be sent. The reply may be sent to the service member or any other address designated by the service member or other authorized
requester. If the designated address is NOT registered to the addressee by the U.S. Postal Service (USPS), provide BOTH the addressee’s name AND “in
care of” (c/o) the name of the person to whom the address is registered on the NAME line in Section III, item 3, on page 1 of the SF 180. The COMPLETE
address must be provided, INCLUDING any apartment/suite/unit/lot/space/etc. number.
5. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; SERVICE TREATMENT RECORD (STR) -- The
chronology of medical, mental health, and dental care received by service members during the course of their military career (does not include records of
treatment while hospitalized); TDRL – Temporary Disability Retired List.
6. Service completed before World War I. National Archives Trust Fund (NATF) forms must be used to request these records. Obtain the forms by e-
mail from inquire@nara.gov or write to the Code 6 address on page 2 of the SF 180.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
The following information is provided in accordance with 5 U.S.C. 552a(e)(3) and applies to this form. Authority for collection of the information is 44
U.S.C. 2907, 3101, and 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. If
the requested information is not provided, it may delay servicing your inquiry because the facility servicing the service member's record may not have all of
the information needed to locate it. The purpose of the information on this form is to assist the facility servicing the records (see the address list) in locating
the correct military service record(s) or information to answer your inquiry. This form is then retained as a record of disclosure. The form may also be
disclosed to Department of Defense components, the Department of Veterans Affairs, the Department of Homeland Security (DHS, U.S. Coast Guard), or
the National Archives and Records Administration when the original custodian of the military health and personnel records transfers all or part of those
records to that agency. If the service member was a member of the National Guard, the form may also be disclosed to the Adjutant General of the
appropriate state, District of Columbia, or Puerto Rico, where he or she served.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
Public burden reporting for this collection of information is estimated to be five minutes per request, including time for reviewing instructions and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to National Archives and Records Administration (ISSD), 8601 Adelphi Road, College Park, MD 20740-
6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE APPROPRIATE ADDRESS LISTED ON
PAGE 2 OF THE SF 180.Standard Form 180 (Rev. 11/2015) (Page 1) Authorized for local reproduction
Prescribed by NARA (36 CFR 1233.18 (d)) Previous edition unusable OMB No. 3095-0029 Expires 04/30/2018
REQUEST PERTAINING TO MILITARY RECORDS
Requests from veterans or deceased veteran’s next-of-kin may be submitted online by using eVetRecs at http://www.archives.gov/veterans/military-service-records/
To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW.
SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible.)
1. NAME USED DURING SERVICE (last, first, full middle) 2. SOCIAL SECURITY # 3. DATE OF BIRTH 4. PLACE OF BIRTH
5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.)
DATE DATE SERVICE NUMBER
BRANCH OF SERVICE OFFICER ENLISTED
ENTERED RELEASED (If unknown, write “unknown”)
a. ACTIVE -
b. RESERVE -
c. STATE
NATIONAL -
GUARD
6. IS THIS PERSON DECEASED? NO YES - MUST provide Date of Death if veteran is deceased:
7. DID THIS PERSON RETIRE FROM MILITARY SERVICE? NO YES
SECTION II – INFORMATION AND/OR DOCUMENTS REQUESTED
1. CHECK THE ITEM(S) YOU ARE REQUESTING:
DD Form 214 or equivalent. Year(s) in which form(s) issued to veteran:
This form contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran’s next-of-kin, or other
persons or organizations, if authorized in Section III, below. An UNDELETED DD214 is ordinarily required to determine eligibility for benefits. If you
request a DELETED copy, the following items will be blacked out: authority for separation, reason for separation, reenlistment eligibility code, separation
(SPD/SPN) code, and, for separations after June 30, 1979, character of separation and dates of time lost.
An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box: I want a DELETED copy.
Medical Records Includes Service Treatment Records, Health (outpatient) and Dental Records. IF HOSPITALIZED (inpatient) the FACILITY NAME and
DATE (month and year) for EACH admission MUST be provided:
Other (Specify):
2. PURPOSE: (Providing information about the purpose of the request is strictly voluntary; however, it may help to provide the best possible response and may
result in a faster reply. Information provided will in no way be used to make a decision to deny the request.)
Benefits (explain) Employment VA Loan Programs Medical Genealogy Correction Personal Other (explain)
EExplain here:
SECTION III - RETURN ADDRESS AND SIGNATURE
1. REQUESTER NAME:
2. I am the MILITARY SERVICE MEMBER OR VETERAN identified in Section I am the VETERAN’S LEGAL GUARDIAN (MUST submit copy of Court
I, above. Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit copy of
I am the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit Proof of Authorization Letter or Power of Attorney)
Death. See item 2a on instruction sheet.) OTHER
-
(Relationship to deceased veteran) (Specify type of Other)
3. SEND INFORMATION/DOCUMENTS TO: 4. AUTHORIZATION SIGNATURE: I declare (or certify, verify, or
(Please print or type. See item 4 on accompanying instructions.) state) under penalty of perjury under the laws of the United States of
America that the information in this Section III is true and correct and
that I authorize the release of the requested information. (See items 2a or
Name 3a on accompanying instruction sheet. Without the Authorization Signature
of the veteran, next-of-kin of deceased veteran, veteran’s legal guardian,
authorized government agent, or other authorized representative, only
Street Apt. limited information can be released unless the request is archival. No
signature is required if the request if for archival records. )
______________________________________________________________
City State Zip Code
Signature Required - Do not print Date
* This form is available at http://www.archives.gov/veterans/military-service-
records/standard-form-180.html on the National Archives and
Records Administration (NARA) web site. * Daytime phone Fax Number
Email addressStandard Form 180 (Rev. 11/2015) (Page 2) Authorized for local reproduction
Prescribed by NARA (36 CFR 1233.18 (d)) Previous edition unusable OMB No. 3095-0029 Expires 04/30/2018
The various categories of military service records are described in the chart below. For each category there is a code number which indicates the address at the bottom of the
LOCATION OF MILITARY RECORDS
page to which this request should be sent. Please refer to the Instruction and Information Sheet accompanying this form as needed.
BRANCH CURRENT STATUS OF SERVICE MEMBER Personnel
ADDRESS CODE Medical or Service
Record Treatment Record
Discharged, deceased, or retired before 5/1/1994 14 14
Discharged, deceased, or retired 5/1/1994 – 9/30/2004 14 11
Discharged, deceased, or retired 10/1/2004 – 12/31/2013 1 11
AIR Discharged, deceased, or retired on or after 1/1/2014 1 13
FORCE Active (including National Guard on active duty in the Air Force), TDRL, or general officers retired with pay 1
Reserve, IRR, Retired Reserve in non-pay status, current National Guard officers not on active duty in the Air Force, or National Guard
2
released from active duty in the Air Force
Current National Guard enlisted not on active duty in the Air Force 2 13
Discharge , deceased, or retired before 1/1/1898 6
Discharged, deceased, or retired 1/1/1898 – 3/31/1998 14 14
COAST Discharged, deceased, or retired 4/1/1998 – 9/30/2006 14 11
GUARD Discharged, deceased, or retired 10/1/2006 – 9/30/2013 3 11
Discharged, deceased, or retired on or after 10/1/2013 3 14
Active, Reserve, Individual Ready Reserve or TDRL 3
Discharged, deceased, or retired before 1/1/1895 6
Discharged, deceased, or retired 1/1/1905 – 4/30/1994 14 14
Discharged, deceased, or retired 5/1/1994 – 12/31/1998 14 11
MARINE
Discharged, deceased, or retired 1/1/1999 - 12/31/2013 4 11
CORPS
Discharged, deceased, or retired on or after 1/1/2014 4 8
Individual Ready Reserve 5
Active, Selected Marine Corps Reserve, TDRL 4
Discharged, deceased, or retired before 11/1/1912 (enlisted) or before 7/1/1917 (officer) 6
Discharged, deceased, or retired 11/1/1912 – 10/15/1992 (enlisted) or 7/1/1917 – 10/15/1992 (officer) 14
Discharged, deceased, or retired 10/16/1992 – 9/30/2002 14 11
ARMY
Discharged, deceased, or retired (including TDRL) 10/1/2002 – 12/31/2013 7 11
Discharged, deceased, or retired (including TDRL) on or after 1/1/2014 7 9
Current Soldier (Active, Reserve (including Individual Ready Reserve) or National Guard) 7
Discharged, deceased, or retired before 1/1/1886 (enlisted) or before 1/1/1903 (officer) 6
Discharged, deceased, or retired 1/1/1886 – 1/30/1994 (enlisted) or 1/1/1903 – 1/30/1994 (officer) 14 14
Discharged, deceased, or retired 1/31/1994 – 12/31/1994 14 11
NAVY
Discharged, deceased, or retired 1/1/1995 – 12/31/2013 10 11
Discharged, deceased, or retired on or after 1/1/2014 10 8
Active, Reserve, or TDRL 10
PHS Public Health Service - Commissioned Corps officers only 12
ADDRESS LIST OF CUSTODIANS and SELF-SERVICE WEBSITES (BY CODE NUMBERS SHOWN ABOVE) – Where to write/send this form
Department of Veterans Affairs
Air Force Personnel Center National Archives & Records Administration
Records Management Center
HQ AFPC/DPSIRP Research Services (RDT1R)
1 550 C Street West, Suite 19 6 700 Pennsylvania Avenue NW 11 ATTN: Release of Information
P.O. Box 5020
Randolph AFB, TX 78150-4721 Washington, DC 20408-0001
St. Louis, MO 63115-5020
Air Reserve Personnel Center US Army Human Resources Command’s web page:
Division of Commissioned Corps Officer Support
Records Management Branch (DPTSC) https://www.hrc.army.mil/TAGD/Accessing%20or%20
ATTN: Records Officer
2 18420 E. Silver Creek Avenue 7 Requesting%20Your%20Official%20Military%20Pers 12 1101 Wooton Parkway, Plaza Level, Suite 100
Building 390 MS 68 onnel%20File%20Documents
Rockville, MD 20852
Buckley AFB, CO 80011 or 1-888-ARMYHRC (1-888-276-9472)
Commander, Personnel Service Center AF STR Processing Center
(BOPS-C-MR) MS7200 Navy Medicine Records Activity (NMRA) ATTN: Release of Information
US Coast Guard BUMED Detachment St. Louis
13 3370 Nacogdoches Road, Suite 116
3 2703 Martin Luther King Jr Ave SE 8 4300 Goodfellow Boulevard, Building 103 San Antonio, TX 78217
Washington, DC 20593-7200 St. Louis, MO 63120
MR_CustomerService@uscg.mil National Personnel Records Center
(Military Personnel Records)
Headquarters U.S. Marine Corps 1 Archives Drive
AMEDD Record Processing Center
Manpower Management Records & Performance
3370 Nacogdoches Road, Suite 116
14 St. Louis, MO 63138-1002
4 (MMRP-10) 9 San Antonio, TX 78217
2008 Elliot Road eVetRecs:
Quantico, VA 22134-5030 http://www.archives.gov/veterans/military-service-records/
Marine Forces Reserve Navy Personnel Command (PERS-313)
5 2000 Opelousas Avenue 10 5720 Integrity Drive
New Orleans, LA 70146-5400 Millington, TN 38055-3120You can also read
