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2. Supplement to Employment Application Veterans’ Preference in Appointment and Retention in Employment Rule, Chapter 22VP-1 of the Florida Administrative Code.
4. First & Last Name*
6. Do you wish to claim veterans’ preference in accordance with the above-captioned rule?*
   -- Select One --YesNo
7. If yes, please complete the following questions, date and sign this supplement. If no, please indicate same, date and sign this supplement.
9. Have you claimed veterans’ preference with any employer since October 1, 1987
   -- Select One --YesNo
10. Were you employed by the City of Inverness prior to entering the military service?
    -- Select One --YesNo
11. Have you been employed by any State, County, City, agency or political subdivision of the State since leaving military service?
    -- Select One --YesNo
13. If yes, name and address of employer:
15. Date Employed (From)
16. Date Employed (To)
18. Are you a disabled veteran who has served on active duty and who has a presently existing service-connected disability which is compensable under public laws administered by the Veterans Administration?
    -- Select One --YesNo
19. Are you a disabled veteran who has an existing service-connected disability for which you are receiving compensation, disability retirement benefits or pension by reason of public laws administered by the Veterans Administration or Department of Defense?
    -- Select One --YesNo
21. Are you a veteran of any war who has served on active duty for 181 consecutive days or more or who has served 180 consecutive days or more since January 31, 1955?
    -- Select One --YesNo
23. Date Military Service Began
24. Date Military Service Ended
25. The branch of military service was
27. Were you separated from the military service of the United States with an honorable discharge?
    -- Select One --YesNo
28. Were you ever classified by any branch of the armed forces of the United States as a deserter?
    -- Select One --YesNo
30. Are you the spouse of any person who has a total and permanent service-connected disability and who, because of this disability, cannot qualify for employment?
    -- Select One --YesNo
31. Are you the spouse of any person who is missing in action, captured in the line of duty by a hostile force, or forcibly detained or interned in the line of duty by a foreign government or power?
    -- Select One --YesNo
33. Are you the unremarried widow or widower of a veteran who died of a service-connected disability?
    -- Select One --YesNo
35. I understand that an applicant eligible for veterans’ preference who believes he or she was not afforded employment preference in accordance with the above-captioned rule may file a complaint with the Florida Division of Veterans’ Affairs, Post Office Box 1437, St. Petersburg, Florida 33731 requesting an investigation. When notice of a hiring decision is given by a covered employee, the complaint shall be filed within 21 calendar days from the date the notice is received by the applicant. When notice of a hiring decision is not given by the covered employer, the complaint may be filed at any time by the applicant. I further understand that if the Florida Division of Veterans’ Affairs finds the complaint to be valid and the complainant and the employer fail to reach a satisfactory resolution, the complainant may petition the Public Employees Relations Commission for a hearing.
37. I understand when claiming veterans’ preference I am responsible for providing required documentation at the time of making an application for a vacant position. Documentation for veterans’ preference shall include the following:
    (a) Veterans, disabled veterans, and spouses of disabled veterans shall furnish a Department of Defense document, commonly known as Form DD-214 or military discharge papers, or equivalent certification from the Veterans Administration, listing military status, dates of service and discharge type;
    (b) Disabled veterans shall also furnish a document from the Department of Defense, the Veterans Administration, or the Division of Veterans’ Affairs certifying that the veteran has a service-connected disability;
    (c) Spouses of disabled veterans shall also furnish either a certification from the Department of Defense or the Veterans Administration that the veteran is totally and permanently disabled or an identification card issued by the Division of Veterans Affairs; spouses shall also furnish evidence of marriage to the veteran and a statement that the spouse is still married to the veteran at the time of the application for employment; the spouse shall also submit proof that the disabled veteran cannot qualify for employment because of the service-connected disability.
    (d) Spouses of persons on active duty shall furnish a document from the Department of Defense or the Veterans Administration certifying that the person on active duty is listed as missing in action, captured in the line of duty, or forcibly detained or interned in the line of duty by a foreign government or power; such spouses shall also furnish evidence of marriage and a statement that the spouse is married to the person on active duty at the time of that application for employment.
    (e) The unremarried widow or widower of a deceased veteran shall furnish a document from the Department of Defense or the Veterans Administration certifying the service-connected death of the veteran, and shall further furnish evidence of marriage and a statement that the spouse is not remarried.
    (f) Spouses of persons eligible to claim preference under Section 22VP-1.008 (2) shall furnish certification from the Veterans Administration that the veteran has a service-connected disability.
    (g) All documents specified in this section must clearly indicate that they are originals or certified copies of originals.
    
39. Signature and date will be obtained if interviewed for position.
41. 
    Signature: ____________________________________

    
    Date:____________________________
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