HomeMy WebLinkAboutGregg ICA 2014-1522�
Individuals seeking to utilize City of Cape Canaveral facilities for purposes of providing instruction to members of the public must
satisfactorily undergo a complete criminal background investigation, at their own cost. The City will refer prospective contractors for
fingerprinting. The total cost for screening is estimated to cost $70.00. The City of Cape Canaveral is a Drug Free Environment.
Completed application packets can be submitted to the City of Cape Canaveral, Human Resources Department located at 105 Polk
Avenue, P.O. Box 326, Cape Canaveral, FL 32920-0326.
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1. GENERAL 101FORiDATIO'
Briefly discuss the topic(s) or activity you wish to teach. -e- VQt .Rck
by do you want to teach this class? 1 llr- C I i C:4 -Nc-nc-&Cl�
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School Name/Location
Dates Attended
Degree
Completed(YIN
High School
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Technical/
Certification
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CP
Program
College
Advance
Degree
Last edited 7/12/13
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Ill, EMPLOYMENT HISTORY (Start with most recent employer)
EMPLOYER NAME EMPLOYMENT DATES POSITION TELEPHONE NUMBER
'Do
1. Previous experience providing instruction in this area/topic. Years Months None
If experienced, where when
2. List specific training, courses, and/or workshops you've completed that qualify you to provide instruction?
Ca eralls terms and conditions for Inillependent Contractors.
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APPLICANT'S SIGNITURE DAT =
Last edited 7/12/13
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INSTRUCTOR'S NAME Q160, C-)1(9LqQ,
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Saturday
Monday Tuesday /Q Thursday Friday X El
)4 Wednesday
Start Time f,p :—NO Start Time (j2_: ' Start Time 3b Start Time kQ : 2fJ- Start Time
Start Time W :-bD _LP
End Time End Time End Time -1 :_W End Time -1_:
2?D End Time End Time
Format of Class(s) ( Example: will offer 2 classes a week for 6 weeks).
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Fees you intend to charge each participant per class/session. $ JQ Z=II
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typical activities, equipment needed, etc.
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Last edited 7/12/13
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I )V� okc, evre-a ek, (print name) do hereby authorize the City of Cape
Canaveral and/or thei?d6signated agent to conduct any desired background investigation of my
personal/business history as allowed by law, and to obtain and review any criminal and civil
court findings, consumer credit report, to investigate any action related to employment, and/or
any investigative consumer report in conjunction with said investigation.
I understand the nature and scope of said inquiries may include, but is not limited to,
verification, inspection and/or reporting of any lawfully available records or information
pertaining to work history, business history, education, worker's compensation claims, criminal
and civil court related actions, driving history (including traffic related offenses), personal
financial status including consumer credit reports, and, any other information available from any
public or otherwise documented record, and/or from any past or present business, professional
or personal associates, pertaining to, but not limited to, my work history, character, ethics, mode
of living, and general reputation.
It is my understanding the information being obtained will not be used in violation of any federal
or state equal opportunity law or regulation, and that before any adverse action is taken based
upon review of any consumer credit report and/or investigative consumer report, I will be
provided with a copy of said report as well as a summary of consumer's rights.
I hereby fully release the City of Cape Canaveral and any and all of its employees, directors,
agents, successor and assigns, and any contributing parties or sources from whom any
information is obtained, from any and all claims, actions or liability whatsoever which is in any
way related to this or any subsequent investigation of my personal history.
I hereby state that all information provided by me to the City, of Cape Canaveral, in any form, is,
to the best of my knowledge, true, correct and complete. I also understand that any known
misrepresentation made by me to the City of Cape Canaveral will exclude me from further
consideration as a volunteer, instructor, or candidate for employment or advancement, and may
result in termination of my contract and/or employment with the City.
PERSONAL INFORMATION AND COPY OF DRIVERS LICENSE PROVIDED
VOLUNTARILY FOR BACKGROUND CHECK.
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SPO'Mture b Date
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