Name Address Address/Apt # City State Zip What type of work do you prefer? What position are you applying for? Give name of friends or relatives employed by PBKC(department) Have you ever been convicted of a felony if yes, please explain (Record of conviction does not disqualify the applicant form employment consideration) YesNo May we contact your present employer? if No, Explain YesNo Have you ever worked at PBKC? (If yes, where and when, and if under a different name than above) YesNo Have you worked at another Pari-mutuel? if yes, where? YesNo Have you ever been discharged or requested to resign from a position? if yes, explain YesNo Date of application Telephone number Alternate phone number Social security number Are you 18 years of age or older YesNo If not, state date of birth Wage or salary required? Date available for work? Would you have steady transportation to work? YesNo Are you interested in: (Check all that apply) Full timePart timeTemporary Have you ever applied for work at PBKC? if yes,explain when, what department and if under a different name than above YesNo Do you have a valid:(check all that apply) Class D security licensePari-mutuel licensePoker dealer certificate Have you ever held a position of trust (Handling money or confidential material) YesNo EDUCATION HIGH SCHOOL Name and Location Course of study # of years Grade Average Maximum grade Degree, Diploma, Certificate and Honors recieved COLLEGE OR UNIVERSITY Name and Location Course of study # of years Grade Average Maximum grade Degree, Diploma, Certificate and Honors recieved OTHER EDUCATION Name and Location Course of study # of years Grade Average Maximum grade Degree, Diploma, Certificate and Honors recieved EMPLOYMENT List all employment (Include U.S. Military Service). Start with present or most recent position. Include all jobs (or last four jobs, whichever is less). You may attach a resume for additionat information, but this area must be completed. From To NAME, TELEPHONE AND ADDRESS Of Employer Job Titles and Duties Reason For Leaving From To NAME, TELEPHONE AND ADDRESS Of Employer Job Titles and Duties Reason For Leaving From To NAME, TELEPHONE AND ADDRESS Of Employer Job Titles and Duties Reason For Leaving Briefly describe the duties of your last two jobs, including supervisory responsibility, if any. Identify Employer. in what work related areas do you consider yourself most proficient? Affirmation (Important- Read Carefully) This application shall remain active for 60 days. After 60 days, if I am still interested in employment with the PBKC, I will complete a new application. I, certify that the answers given by me are true and correct to the best of my knowledge and agree that falsification and/ or omission of material facts in this application may be cause for dismissal or disqualification. I hereby authorize any individual, company, or institution with whom I have been associated to furnish PBKC with any information concerning my employability which they have on record, or otherwise, and do hereby release the individual, company, or institution and all individuals concerned therewith from all liability whatsoever incurred in furnishing such information. I further agree that if employed I shall abide by and comply with all the laws of racing of the State of Florida and the rules and regulations of the State of Florida Racing Commission and the rules of the Palm Beach Kennel Club, including acquiring and/or renewing a pari-mutuel state license at my expense. I understand and agree that a medical evaluation that includes tests to detect the use of drugs or controlled substances and the misuse of prescribed medication is required. A failure or refusal to be drug tested terminates any further pre-employment processing. I understand that any offer of employment is contingent upon the results of any medical evaluations that may be required and the drug test. I further understand that I will be excluded from employment as a consequence of the results of the medical evaluation only if it is determined that I do not fulfill certain employment criteria which are job-related and consistent with business necessities. To comply with the Immigration Reform and Control Act of 1986, I will provide you with documents to establish my identity and my authorization to be employed in the United States of America. Signature of Applicant Date 95901
