ÐÏà¡±á>þÿ <>þÿÿÿ789:;ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á5@ ù¿žùbjbjÏ2Ï2 ˜‚XX£jÿÿÿÿÿÿˆŠŠŠŠŠŠŠDV>Œ>Œ>Œ€¾Œ4òŽ|VÌ¶z“´.¤.¤.¤.¤.¤ø&¦2§ˆ*É,É,É,É,É,É,É$ÑÌR#ÏÚPÉ…Š@«.¤.¤@«@«PÉŠŠ.¤.¤ÕË°°°@«LŠ.¤Š.¤*É°@«*É°¼°Ú°ŠŠÚ°.¤n“ `‡ô¤Å>ŒŒ«@Ú°±ëË0ÌÚ°ýÏÌ«BýÏÚ°Îä²¤ŠŠŠŠýÏŠÚ°<º§ Z¨r°Ì¨\(©º§º§º§PÉPÉVV„kÚod°VVÚoAPPLICATION FOR NOMINATION TO THE FORMTEXT COURT(Please attach additional pages as needed to respond fully to questions.)DATE: FORMTEXT Florida Bar No.: FORMTEXT GENERAL:Soc. Sec. No.: FORMTEXT 1. Name FORMTEXT E-mail: FORMTEXT Date Admitted to Practice in Florida: FORMTEXT 2. State title currently held; including professional position and any public or judicial office. FORMTEXT 3. Business address: FORMTEXT City FORMTEXT State FORMTEXT ZIP FORMTEXT Telephone FORMTEXT FAX FORMTEXT 4. Residential address: FORMTEXT City FORMTEXT State FORMTEXT ZIP FORMTEXT Since FORMTEXT Telephone FORMTEXT 5. Place of birth: FORMTEXT Date of birth: FORMTEXT Age FORMTEXT 6. Length of residence in State of Florida FORMTEXT 7. Marital status FORMTEXT If married:Spouse s name FORMTEXT Date of marriage FORMTEXT Spouse s occupation FORMTEXT If ever divorced give for each marriage name(s) of spouse(s), current address for each former spouse, date and place of divorce. FORMTEXT 8. ChildrenName(s)Ages(s)Occupation(s)Residential address(es) FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT 9. Military Service (including Reserves)ServiceBranchHighest RankDates FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT Rank at time of discharge FORMTEXT Type of discharge FORMTEXT Awards or citations FORMTEXT HEALTH: 10. Are you currently addicted to or dependent upon the use of narcotics, drugs, or intoxicating beverages? If yes, state the details, including the date. FORMTEXT 11a. During the last ten years have you been hospitalized or have you consulted a professional or have you received treatment or a diagnosis from a professional for any of the following: Kleptomania, Pathological or Compulsive Gambling, Pedophilia, Exhibitionism or Voyeurism? Yes FORMCHECKBOX No FORMCHECKBOX If your answer is yes, please direct each such professional, hospital and other facility to furnish the Chairperson of the Commission any information the Commission may request with respect to any such hospitalization, consultation, treatment or diagnosis. ["Professional" includes a Physician, Psychiatrist, Psychologist, Psychotherapist or Mental Health Counselor.] Please describe such treatment or diagnosis. FORMTEXT 11b. In the past ten years have any of the following occurred to you which would interfere with your ability to work in a competent and professional manner? • Experiencing periods of no sleep for 2 or 3 nights • Experiencing periods of hyperactivity • Spending money profusely with extremely poor judgment • Suffered from extreme loss of appetite • Issuing checks without sufficient funds • Defaulting on a loan • Experiencing frequent mood swings • Uncontrollable tiredness • Falling asleep without warning in the middle of an activity Yes FORMCHECKBOX No FORMCHECKBOX If yes, please explain. FORMTEXT 12a. Do you currently have a physical or mental impairment which in any way limits, your ability or fitness to properly exercise your duties as a member of the Judiciary in a competent and professional manner?Yes FORMCHECKBOX No FORMCHECKBOX 12b. If your answer to the question above is Yes, are the limitations or impairments caused by your physical or mental health impairment reduced or ameliorated because you receive ongoing treatment (with or without medication) or participate in a monitoring or counseling program?Yes FORMCHECKBOX No FORMCHECKBOX Describe such problem and any treatment or program of monitoring or counseling. FORMTEXT 13. During the last ten years, have you ever been declared legally incompetent or have you or your property been placed under any guardianship, conservatorship or committee? If yes, give full details as to court, date and circumstances. FORMTEXT 14. During the last ten years, have you unlawfully used controlled substances, narcotic drugs or dangerous drugs as defined by Federal or State laws? If your answer is "Yes," explain in detail. (Unlawful use includes the use of one or more drugs and/or the unlawful possession or distribution of drugs. It does not include the use of drugs taken under supervision of a licensed health care professional or other uses authorized by Federal law provisions.) FORMTEXT 15. In the past year, have you ever been reprimanded, demoted, disciplined, placed on probation, suspended, cautioned or terminated by an employer as result of your alleged consumption of alcohol, prescription drugs or illegal use of drugs? FORMDROPDOWN If so, please state the circumstances under which such action was taken, the name(s) of any persons who took such action, and the background and resolution of such action. FORMTEXT 16. Within the last five years, have you ever been formally reprimanded, demoted, disciplined, cautioned, placed on probation, suspended or terminated by an employer? FORMDROPDOWN If so, please state the circumstances under which such action was taken, the date(s) such action was taken, the name(s) of any persons who took such action, and the background and resolution of such action. FORMTEXT 17. Have any of your current or former co-workers, subordinates, supervisors, customers or clients ever filed a formal complaint or accusation of misconduct against you with any regulatory or investigatory agency, or with your employer? FORMDROPDOWN If so, please state the date(s) of such formal accusation(s), and the specific formal accusation(s) made, and the background and resolution of such action(s). FORMTEXT 18. Have you ever refused to submit to a test to determine whether you had consumed and/or were under the influence of alcohol or drugs? FORMDROPDOWN If so, please state the date you were requested to submit to such a test, type of test required, the name of the entity requesting that you submit to the test, the outcome of your refusal and the reason why you refused to submit to such a test. FORMTEXT 19. In the past year, have you failed to meet any deadline imposed by court order or received notice that you have not complied with substantive requirements of any business or contractual arrangement? FORMDROPDOWN If so, please explain in full. FORMTEXT 20. In the past ten years, have you suffered memory loss or impaired judgment for any reason? FORMDROPDOWN If so, please explain in full. FORMTEXT 21. Are you currently the subject of an investigation which could result in civil, administrative or criminal action against you? FORMDROPDOWN If yes, please state the nature of the investigation, the agency conducting the investigation and the expected completion date of the investigation. FORMTEXT 22. In the past ten years, have you been subject to or threatened with eviction proceedings? If yes, please explain. FORMTEXT EDUCATION: 23a. Secondary schools, colleges and law schools attended. Schools Class Standing Dates of Attendance Degree FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT 23b. List and describe academic scholarships earned, honor societies or other awards. FORMTEXT NON-LEGAL EMPLOYMENT: 24. List all previous full-time non-legal jobs or positions held since 21 in chronological order and briefly describe them. Date Position Employer Address FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT PROFESSIONAL ADMISSIONS: 25. List all courts (including state bar admissions) and administrative bodies having special admission requirements to which you are presently admitted to practice, giving the dates of admission. Court or Administrative Body Date of Admission FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT LAW PRACTICE: (If you are a sitting judge, answer this series of questions with reference to the years before you became a judge.) 26. State the names, dates and addresses for all firms with which you have been associated in practice, governmental agencies or private business organizations by which you have been employed, periods you have practiced as a sole practitioner, law clerkships and other prior employment:PositionName of FirmAddressDates FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT 27. Describe the general nature of your current practice including any designated areas of practice or certifications which you possess; additionally, if your practice is substantially different from your prior practice or if you are not now practicing law, give details of prior practice. Describe your typical clients or former clients and the problems for which they sought your services. FORMTEXT 28a. What percentage of your appearance in courts in the last five years was in: Federal Court? FORMTEXT %State County Court? FORMTEXT % State Circuit Court FORMTEXT %Administrative Bodies? FORMTEXT % (General)? FORMTEXT %Criminal Court? FORMTEXT % Probate Court? FORMTEXT %Juvenile Court? FORMTEXT % Appellate Court? FORMTEXT %General Master Hearings? FORMTEXT %28b. For your last five cases, which were either contested or tried, list the names and telephone numbers of trial counsel on either side. FORMTEXT 29a. During the last five years, what percentage of your practice has been trial practice? FORMTEXT %29b. How frequently have you appeared at administrative hearings? FORMTEXT times per month29c. How frequently have you appeared in Court? FORMTEXT times per month29d. What percentage of your practice involving litigation has been civil? FORMTEXT %29e. What percentage of your practice involving litigation has been criminal? FORMTEXT %29f. If your practice was substantially personal injury, what percentage of your work was in representation of plaintiffs? FORMTEXT % defendants? FORMTEXT %29g. How many (number) of the cases you have tried to verdict or judgment were:Jury? FORMTEXT Non-jury? FORMTEXT Arbitration? FORMTEXT Administrative Bodies? FORMTEXT 29h. For the cases you have tried to conclusion in arbitration, before administrative bodies or in courts of record during each of the past five years, indicate whether you were sole, associate or chief counsel. Give citations of any reported cases. FORMTEXT 29i. List and describe the five most significant cases which you personally litigated giving case style, number and citation to reported decisions, if any. Identify your client and describe the nature of your participation in the case and the reason you believe it to be significant. Give the name of the court and judge, the date tried and names of other attorneys involved. FORMTEXT 29j. Attach at least one example of legal writing which you personally wrote. If you have not personally written any legal documents recently, you may attach writing for which you had substantial responsibility. Please describe your degree of involvement in preparing the writing you attach.30. If during any prior period you have appeared in court with greater frequency than during the last five years, indicate the period during which this was so and give for such prior periods a succinct statement of the part you played in the litigation, numbers of cases and whether jury or non-jury. FORMTEXT PRIOR JUDICIAL EXPERIENCE OR PUBLIC OFFICE: 31a. Have you ever held judicial office or been a candidate for judicial office? If so, state the court(s) involved and the dates of service or dates of candidacy. FORMTEXT 31b. List any prior quasi-judicial service:DatesName of AgencyPosition Held FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT Types of issues heard: FORMTEXT 31c. Have you ever held or been a candidate for any other public office? If so, state the office, location and dates of service or candidacy. FORMTEXT 31d. If you have had prior judicial or quasi-judicial experience,(i) List the names, phone numbers and addresses of six attorneys who appeared before you on matters of substance. FORMTEXT (ii) Describe the approximate number and nature of the cases you have handled during your judicial or quasi-judicial tenure. FORMTEXT (iii) List citations of any opinions which have been published. FORMTEXT (iv) List citations or styles and describe the five most significant cases you have tried or heard. Identify the parties, describe the cases and tell why you believe them to be significant. Give dates tried and names of attorneys involved. FORMTEXT (v) Has a complaint about you ever been made to the Judicial Qualifications Commission? 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`'€Ùÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ€À!ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿ4Ö 9aö$$If<kd²©$$If–94”“ÖÇÿ`'€™'ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿ4Ö 9aöf4¨pªp¬pÔpÖp¼rÂŸçºgs´N!sgŸçW''s$„ „0ý$If^„ `„0ýLkdú«$$If–9”“Ö0Çÿ `'€Ùÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ€À!ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿ4Ö 9aö$If$$If<kd«$$If–94”“ÖÇÿ`'€™'ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿ4Ö 9aöf4¼r¾rÀrèrêršÂ„Zºgs´N!sgŸçW''s$„ „0ý$If^„ `„0ýLkd^$$If–9”“Ö0Çÿ `'€Ùÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ€À!ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿ4Ö 9aö$If$$If<kdz¬$$If–94”“ÖÇÿ`'€™'ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿ4Ö 9aöf4lution. FORMTEXT (vi) Have you ever held an attorney in contempt? If so, for each instance state name of attorney, approximate date and circumstances. FORMTEXT BUSINESS INVOLVEMENT: 32a. If you are now an officer, director or otherwise engaged in the management of any business enterprise, state the name of such enterprise, the nature of the business, the nature of your duties, and whether you intend to resign such position immediately upon your appointment or election to judicial office. FORMTEXT 32b. Since being admitted to the Bar, have you ever been engaged in any occupation, business or profession other than the practice of law? If so, give details, including dates. FORMTEXT 32c. State whether during the past five years you have received any fees or compensation of any kind, other than for legal services rendered, from any business enterprise, institution, organization, or association of any kind. If so, identify the source of such compensation, the nature of the business enterprise, institution, organization or association involved and the dates such compensation was paid and the amounts. FORMTEXT POSSIBLE BIAS OR PREJUDICE: 33. The Commission is interested in knowing if there are certain types of cases, groups of entities, or extended relationships or associations which would limit the cases for which you could sit as the presiding judge. Please list all types or classifications of cases or litigants for which you as a general proposition believe it would be difficult for you to sit as the presiding judge. Indicate the reason for each situation as to why you believe you might be in conflict. If you have prior judicial experience, describe the types of cases from which you have recused yourself. FORMTEXT MISCELLANEOUS: 34. Have you ever been convicted for violation of any federal, state, county or municipal law, regulation or ordinance? If so, give details. Do not include traffic violations for which a fine of $100 or less was imposed unless it also included a jail sentence. FORMTEXT 35a. Have you ever been sued by a client? If so, give particulars including name of client, date suit filed, court, case number and disposition. FORMTEXT 35b. Have you or your professional liability insurance carrier ever settled a claim against you for professional malpractice? If so, give particulars, including the amounts involved. FORMTEXT 36a. Have you ever filed a personal petition in bankruptcy or has a petition in bankruptcy been filed against you? FORMTEXT 36b. Have you ever owned more than 25% of the issued and outstanding shares or acted as an officer or director of any corporation by which or against which a petition in bankruptcy has been filed? If so, give name of corporation, your relationship to it and date and caption of petition. FORMTEXT 37. Have you ever been a party to a lawsuit either as a plaintiff or as a defendant? If so, please supply style, case number, nature of the lawsuit, whether you were Plaintiff or Defendant and its disposition. FORMTEXT 38. Has there ever been a finding of probable cause or other citation issued against you or are you presently under investigation for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group. If so, give the particulars. FORMTEXT 39a. Have you filed all past tax returns as required by federal, state, local and other government authorities? Yes FORMCHECKBOX No FORMCHECKBOX If no, explain. FORMTEXT 39b. Have you ever paid a tax penalty? Yes FORMCHECKBOX No FORMCHECKBOX If yes, explain what and why. FORMTEXT 39c. Has a tax lien ever been filed against you? If so, by whom, when, where and why? FORMTEXT HONORS AND PUBLICATIONS: 40. If you have published any books or articles, list them, giving citations and dates. FORMTEXT 41. List any honors, prizes or awards you have received. Give dates. FORMTEXT 42. List and describe any speeches or lectures you have given. FORMTEXT PROFESSIONAL AND OTHER ACTIVITIES: 43a. List all bar associations and professional societies of which you are a member and give the titles and dates of any office which you may have held in such groups and committees to which you belonged. FORMTEXT 43b. List, in a fully identifiable fashion, all organizations, other than those identified in response to question No. 43(a), of which you have been a member since graduating from law school, including the titles and dates of any offices which you have held in each such organization. FORMTEXT 43c. List your hobbies or other vocational interests. FORMTEXT 43d. Do you now or have you ever belonged to any club or organization that in practice or policy restricts (or restricted during the time of your membership) its membership on the basis of race, religion, national origin or sex? If so, detail the name and nature of the club(s) or organization(s), relevant policies and practices and whether you intend to continue as a member if you are selected to serve on the bench. FORMTEXT 43e. Describe any pro bono legal work you have done. Give dates. FORMTEXT SUPPLEMENTAL INFORMATION: 44a. Have you attended any continuing legal education programs during the past five years? If so, in what substantive areas? FORMTEXT 44b. Have you taught any courses on law or lectured at bar association conferences, law school forums, or continuing legal education programs? If so, in what substantive areas? FORMTEXT 45. Describe any additional education or other experience you have which could assist you in holding judicial office. FORMTEXT 46. Explain the particular potential contribution you believe your selection would bring to this position. FORMTEXT 47. If you have previously submitted a questionnaire or application to this or any other judicial nominating commission, please give the name of the commission and the approximate date of submission. FORMTEXT 48. Give any other information you feel would be helpful to the Commission in evaluating your application. FORMTEXT REFERENCES: 49. List the names, addresses and telephone numbers of ten persons who are in a position to comment on your qualifications for judicial position and of whom inquiry may be made by the Commission. FORMTEXT CERTIFICATEI have read the foregoing questions carefully and have answered them truthfully, fully and completely. I hereby waive notice by and authorize The Florida Bar or any of its committees, educational and other institutions, the Judicial Qualifications Commission, the Florida Board of Bar Examiners or any judicial or professional disciplinary or supervisory body or commission, any references furnished by me, employers, business and professional associates, all governmental agencies and instrumentalities and all consumer and credit reporting agencies to release to the respective Judicial Nominating Commission and Office of the Governor any information, files, records or credit reports requested by the commission in connection with any consideration of me as possible nominee for appointment to judicial office. Information relating to any Florida Bar disciplinary proceedings is to be made available in accordance with Rule 3-7.1(q)(2), Rules Regulating The Florida Bar. I recognize and agree that, pursuant to the Florida Constitution and the Uniform Rules of this commission, the contents of this questionnaire and other information received from or concerning me, and all interviews and proceedings of the commission, except for deliberations by the commission, shall be open to the public. Dated this __________ day of _________________________, 20_____. ____________________________________ SignaturePursuant to Section 119.07(3)(i)(1), F.S., . . . The home addresses and telephone numbers of justices of the Supreme Court, district court of appeal judges, circuit court judges, and county court judges; the home addresses, telephone numbers, and places of employment of the spouses and children of justices and judges; and the names and locations of schools and day care facilities attended by the children of justices and judges are exempt from the provisions of subsection (1), dealing with public records. FINANCIAL HISTORYIn lieu of answering the questions on this page, you may attach copies of your completed Federal Income Tax Returns for the preceding three (3) years. Those income tax returns should include returns from a professional association. If you answer the questions on this page, you do not have to file copies of your tax returns.1. State the amount of gross income you have earned, or losses you have incurred (before deducting expenses and taxes) from the practice of law for the preceding three-year period. This income figure should include salary, if the nature of your employment is in a legal field. FORMTEXT 2. State the amount of net income you have earned, or losses you have incurred (after deducting expenses but not taxes) from the practice of law for the preceding three-year period. This income figure should include salary, if the nature of your employment is in a legal field. FORMTEXT 3. State the gross amount of income or losses incurred (before deducting expenses or taxes) you have earned in the preceding three years from all sources other than the practice of law, and generally describe the source of such income or losses. FORMTEXT 4. State the amount of net income you have earned or losses incurred (after deducting expenses) from sources other than the practice of law for the preceding three-year period, and generally describe the sources of such income or losses. FORMTEXT JUDICIAL APPLICATION DATA RECORDThe judicial application shall include a separate page asking applicants to identify their race, ethnicity and gender. Completion of this page shall be optional, and the page shall include an explanation that the information is requested for data collection purposes in order to assess and promote diversity in the judiciary. The chair of the Commission shall forward all such completed pages, along with the names of the nominees to the JNC Coordinator in the Governor's Office (pursuant to JNC Uniform Rule of Procedure).(Please Type or Print)Date: FORMTEXT JNC Submitting To: FORMTEXT Name (please print): FORMTEXT Current Occupation: FORMTEXT Telephone Number: FORMTEXT Attorney No.: FORMTEXT Gender (check one): FORMCHECKBOX Male FORMCHECKBOX FemaleEthnic Origin (check one): FORMCHECKBOX White, non Hispanic FORMCHECKBOX Hispanic FORMCHECKBOX Black FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX Asian/Pacific IslanderCounty of Residence: FORMTEXT FLORIDA DEPARTMENT OF LAW ENFORCEMENT DISCLOSURE PURSUANT TO THE FAIR CREDIT REPORTING ACT (FCRA) The Florida Department of Law Enforcement (FDLE) may obtain one or more consumer reports, including but not limited to credit reports, about you, for employment purposes as defined by the Fair Credit Reporting Act, including for determinations related to initial employment, reassignment, promotion, or other employment-related actions. CONSUMER'S AUTHORIZATION FOR FDLE TO OBTAIN CONSUMER REPORT(S) I have read and understand the above Disclosure. I authorize the Florida Department of Law Enforcement (FDLE) to obtain one or more consumer reports on me, for employment purposes, as described in the above Disclosure. Printed Name of Applicant: FORMTEXT Signature of Applicant: Date: FORMTEXT Rev. 021705-OGC Page Page Page ššš<š>šL›Âçºgs´N!sgŸçW''s$„ „0ý$If^„ `„0ýLkdÂ®$$If–9”“Ö0Çÿ `'€Ùÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ€À!ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿ4Ö 9aö$If$$If<kdÞ$$If–94”“ÖÇÿ`'€™'ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿö™'ööÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿÖÿÿÿÿ4Ö 9aöf4*š,š.š8š:šP›R›f›h›j›t›v›z›¦›žž0ž2ž4ž>ž@ž¬Ÿ®ŸÂŸÄŸÆŸÐŸÒŸ*£,£@£çÒºÒ©Ò©‘ÒºÒ©}©Ò©eÒºÒ©Ò©MÒºÒ©Ò©/jz²hÁohŠ¸CJOJQJU^JaJ/j±hÁohŠ¸CJOJQJU^JaJ&hÁohŠ¸5