Affidavit Of Application Form
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1Florida Department of Juvenile Justice
Affidavit of Application
Please type or print in black ink
1.
People First ID #:
__________________
2.
Applicant’s Name:
________________________________________ ___________________________________ _____
(Please print)
(Last)
(First)
(MI)
3.
Position Title:
________________________________________
Position Number:
__________________
4.
Employing Agency: __________________________________________________________________________________
PLEASE READ CAREFULLY BEFORE SIGNING
I fully understand that in order to qualify as a Juvenile Justice direct care employee, I must comply with the provisions of Section
985.66, Florida Statutes, as follows:
1.
Be at least 19 years of age.
2.
Be a high school graduate or equivalent as determined by the Department.
3.
Not have been convicted of any felony or a misdemeanor involving perjury or false statement, or have received a
dishonorable discharge from any of the Armed Forces of the United States. Any person, who after September 30, 1999,
pleads guilty or nolo contendere to or is found guilty of any felony or a misdemeanor involving perjury or false statement is
not eligible for employment, notwithstanding suspension of sentence or withholding of adjudication. Notwithstanding this
subparagraph, any person who pled nolo contendere to a misdemeanor involving a false statement before October 1, 1999,
and who has had such record of that plea sealed or expunged is not ineligible for employment for that reason.
4.
Abide by all provisions of s. 985.644(1), Florida Statutes regarding fingerprinting and background investigations and other
screening requirements for personnel.
5.
Execute and submit to the department an affidavit-of-application form, adopted by the department, attesting to his or her
compliance with subparagraphs 1-4. The affidavit must be executed under oath and constitutes an official statement under s.
837.06. The affidavit must include conspicuous language that the intentional false execution of the affidavit constitutes a
misdemeanor of the second degree. The employing agency shall retain the affidavit.
In addition, I attest to the following:
I understand that by executing this document I am attesting that I have met the qualifications as specified and have
provided documentation of proof of my qualifications to the above listed employing agency.
Yes
No
I have read my employment application and it is true and correct, and all other information I will furnish in
conjunction with my application is true and correct.
Yes
No
NOTICE:
This document shall constitute an official statement within the purview of Section 837.06, Florida Statutes,
and is subject to verification by the employing agency and/or the Florida Department of Juvenile Justice. Any intentional
omission when submitting application or false execution of this affidavit shall constitute a misdemeanor of the second degree
and disqualify you from employment as a juvenile justice direct care employee.
I hereby certify that to the best of my knowledge and belief, the information that I have entered on this form is true.
________________________________________________________
___________________________________________
Applicant’s signature
Date signed
STATE OF FLORIDA, COUNTY OF _______________________________. The foregoing instrument was acknowledged before
me the _____________________ (date) by _______________________________________________, who is personally known to
me or who has produced ______________________________________________ (type of identification) as identification and who
did (did not) take an oath.
______________________________________________ Notary’s signature
______________________________________________ Notary’s name
___________________________________________
(Seal)
cc: Official Personnel File
Revised 10/06/2011
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