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APPLICATION FOR EMPLOYMENT

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APPLICATION FOR EMPLOYMENT
RICHLAND COUNTY SHERIFF'S
DEPARTMENT
SHERIFF
LEON LOTT
SOUTH CAROLINA
RICHLAND COUNTY SHERIFF'S DEPARTMENT
APPLICATION FOR EMPLOYMENT
Equal Opportunity Employer
COUNTY OF RICHLAND
Office of the Sheriff
5623 Two Notch Road
P.O. Box 143
Columbia, South Carolina 29223
(803) 576-3000
APPLICATION FOR EMPLOYMENT: EQUAL OPPORTUNITY EMPLOYER
INSTRUCTIONS: Fill out the entire application. PRINT or TYPE in black or blue ink.
NOTE: Filing an application with us does not imply that you will be interviewed or hired
, only that
you will be considered for vacancies based upon the stated occupation preference identified, when
vacancies exist. Applications are considered active for six months unless we are contacted by you.
If you are offered employment, it will be necessary to complete a physical examination (at your
own expense), the results of which must be satisfactory to the Office. Return application to 5623
Two Notch Road.
Initial
Position(s) applied for Date
PERSONAL DATA
1. Name:
Last First Middle
2. Address:
Number Street City State Zip County
3. Telephone
Home
Business
Email
4.
If you have worked under another name, please indicate:
5. Are you a U.S. citizen? Yes
No If no, give Visa type:
Immigration number:
6. Date available to start work:
7. Is there any reason known to you, as to why you could not consistently perform the job you have applied for?
If yes, explain:
8. How many days have you missed from work in the last year due to sickness or injury?
RECORD OF EDUCATION
School Name
&
Address
A
ttendance
Dates
Years
Completed
Did You
Graduate
List
Degrees
High School
Yes
No
Yes No
Technical School
Yes No
Seminars,
Institutes, Etc.
Yes No
College/University
Undergraduate
Yes No
College/University
Graduate
Other Education
Yes No
9. If you did not graduate from high school, have you passed the General Educational
Development (GED)Test?
Yes No If yes, when and where did you complete the GED:
10. Indicate Languages you speak, read or write:
11. List professional license you hold:
License Number:
12. List scholarships, academic honors, awards:
13. List courses that you have taken that would be particularly useful to the position for which
you are applying.
14.
List training skills, and experience you feel would especially fit you for work with our
organization.
15. Typing speed (WPM) List equipment or office machines you can operate.
SOUTH CAROLINA
RICHLAND COUNTY SHERIFF'S DEPARTMENT
5623 Two Notch Road
P.O. Box 143
Columbia, South Carolina 29223
(803) 576-3000
BACKGROUND INVESTIGATION
INSTRUCTIONS: Using a typewriter or legibly printing in ink, fill out this form completely and
accurately. If extra space is needed, use additional pages and identify the information by item
number. If an item does not apply to you, indicate by entering
N/A
in the blank.
NOTE: All statements are subject to verification and any incorrect statements or omissions may
bar or remove you from employment. Truthful statements to any item requested will not
necessarily exclude you from employment. Data is used for periodic reporting and will be kept
in a CONFIDENTIAL FILE.
BIOGRAPHICAL DATA
1. Name:
Last First Middle Maiden Nickname
a. Have you ever used another name? Yes No
If yes, what name?
b. Has your name been legally changed? Yes
No List former name
2. Residence:
Number Street City State Zip
a. How long have you lived at this address?
b. What is your telephone number? Home Business Other
c. List previous addresses in the last 5 years.
1.
2.
Number Street City State Zip
3.
Number Street City State Zip
4.
Number Street City State Zip
5.
Number Street City State Zip
6.
Number Street City State Zip
Number Street City State Zip
d. List complete name of person with whom you are residing and the person's relationship
to you:
Last First Middle Relationship
e. Parents Name: Father
Mother
Last First Middle Nickname
Last First Middle Nickname
3. DOB Place of Birth
a. Has your date of birth ever been changed on a legal document? If yes, explain
4. Social Security No.
5. Sex: Male Female
6. Marital Status: Single Engaged Divorced
Married Separated Widowed
a. Name of Spouse
Last First Middle Widowed
b. Spouse’s Occupation Where Employed
c. Name of former spouse
Last First Middle Relationship
d. List all your children, including any adopted or stepchildren:
Name DOB Name with whom
resides
Address
1.
2.
3.
4.
MILITARY SERVICE Yes
No Branch
Total Years Highest Grade
Type of Discharge Court Martials/punishment
a. Are you registered for Selective Service? Yes No
b. What is the date and location of your last discharge?
c. List all medals and decorations awarded you during your military service
d. If you are presently a member of the National Guard or any military reserve, give the unit, location, and
describe your obligation.
e. Have you ever illegally used any of the following drugs? Yes No
If yes, explain. Date
Amphetamines Marijuana
Barbiturates Morphine
Cocaine Nerve Medicine
Hallucinogens Pep Pills
Hashish Sleeping Pills
Heroin Steroids
f. When was the last time you used any of the above?
g. Are you presently in a physical fitness program? Yes No List type
FINANCIAL STATUS
a. List income other than salary (include salary of spouse).
b. How many persons do you support?
c. Have you ever been sued? Yes No If yes, give details.
d. What is the total amount of your debts at present?
e. List credit references, including businesses to which you make monthly payments.
Name of Business Street City State Zip Telephone No.
WORK HISTORY
a. Have you ever been or are you currently engaged in a private business? Yes
No
If yes, list your capacity and give name of business
b. Have you ever been discharged or asked to resign from a job? Yes No
If yes, explain. Date
CRIMINAL RECORDS
a. Have you ever been arrested by law enforcement? Yes No
If yes, give details.
Offense Charged Police Agency State Date Disposition
b. Have you ever been convicted of a felony? Yes No
If yes, give details
c. Have you ever been bonded? Yes No If yes, list jobs.
d. Have you ever been placed on probation? Yes No
If yes, explain.
e. Have you ever had any traffic violations? Yes
No
If yes, explain.
f. Have you ever stolen anything? Yes No If yes, explain
g. Have you ever been court martialed or a subject of disciplinary action while a member of the armed forces?
Yes
No If yes, explain.
h. Can you operate a motor vehicle? Yes No
i. Do you possess a valid South Carolina driver’s license? Yes No
a. Driver’s License Number b. Date Issued
j. Do you possess a driver’s license issued by another state? Yes
No
If yes, give state and number
k. Was your license ever suspended or revoked? Yes
No
State Reason Date
If yes, give details
l. Was your license restored? Yes
No Date Restored
m. Are your driving privileges restricted? Yes No List Restrictions
n. Are you attempting to conceal any information about your background? Yes No
STATE OF SOUTH CAROLINA
COUNTY OF RICHLAND
I hereby certify that all statements on this form are true and complete
and any misstatement or omission of information will subject me to
disqualification or dismissal.
This the day of 20
Full Signature of Applicant
CONFIDENTIAL
EMPLOYMENT HISTORY
List all present and past employment, beginning with most recent.
1.
Employment dates from to Ending Salary
Company Name Telephone Number
Address
Street or P.O. Box City State Zip
Supervisor(s) name:
Job Title Reason for Leaving
Job Duties
2
.
Employment dates from to Ending Salary
Company Name Telephone Number
Address
Street or P.O. Box City State Zip
Supervisor(s) name:
Job Title Reason for Leaving
Job Duties
3.
Employment dates from to
Ending Salary
Company Name Telephone Number
Address
Street or P.O. Box City State Zip
Supervisor(s) name:
Job Title Reason for Leaving
Job Duties
.
4.
Employment dates from to Ending Salary
Company Name Telephone Number
Address
Street or P.O. Box City State Zip
Supervisor(s) name:
Job Title Reason for Leaving
Job Duties
If no, which company do you not wish us to contact? May we contact the employers listed above?
Explain
PERSONAL REFERENCES (No relatives or former employees)
Name Occupation Address Telephone No.
1.
2.
3.
Neighbors: Name Address Telephone No.
1.
2.
3.
I hereby represent that the information provided is correct and complete to the best of my knowledge.
I understand that any incorrect, incomplete or false statements or information, furnished by me may
void this application or subject me to discharge at any time after employment.
Signature of applicant Date
5.
Employment dates from to Ending Salary
Company Name Telephone Number
Address
Street or P.O. Box City State Zip
Supervisor(s) name:
Job Title Reason for Leaving
Job Duties
Richland County Sheriff’s Department
Release for Background Checks
I understand that the employment background check requires my full name, social
security number, and date of birth. I authorize the Richland County Sheriff’s Department
to perform a background check and release those parties supplying such information from
all liability or responsibility with respect to the information provided. The permissive
background checks will be Fair Credit Reporting Act (FCRA) compliant.
I certify that the entries made by me on this form are true, complete and accurate
to the best of my knowledge and are made in good faith and voluntarily. I understand that
any false statements or answers by me may disqualify me for consideration or will be
sufficient grounds for termination. Moreover, I understand that failure to complete this
form will preclude me from employment opportunities with the Richland County
Sheriff’s Department.
________________________ ________________________
Print Name Date
________________________ ________________________
Sign Name Date of Birth
________________________
Social Security Number
APPLICANT:
DATE
FOR OFFICE USE ONLY
APPLICATION:
DATE OUT: DATE IN:
INTERVIEW BY: DL CHECK: YES NO
PHOTOGRAPH: YES NO CRIMINAL HISTORY:
POLYGRAPH: DATE: TIME:
PSYCHOLOGICAL TEST DATE: TIME:
DR.
REMARKS:
POLYGRAPH REPORT:
NO DECEPTION: DECEPTION INDICATED:
INCONCLUSIVE: CONFESSION:
EXAMINER: DATE:
REMARKS:
IT IS THE OPINION OF THE INTERVIEWING OFFICER THAT THE APPLICANT DOES/DOES NOT
HAVE THE BASIC QUALIFICATIONS TO PROCEED WITH THE APPLICATION PROCESS.
SIGNATURE AND RANK DATE:
REMARKS:
APPLICATION STATUS
APPLICATION APPROVED: YES NO DATE:
APPROVED BY:
APPLICANT
CONSENT TO DRUG TESTING
The undersigned applicant for employment understands and acknowledges
that Richland County requires all applicants who are tentatively
selected for employment to submit to and pass a drug test, and that
failure to take the test, failure to cooperate in taking the test,
failure to follow test procedures, or testing positive for the use of
illegal drugs or substances will result in disqualification from
employment.
The drug test will be by urinalysis and if the collector of the test
sample believes that there is a reasonable possibility that the
applicant has or will tamper with or substitute the urine sample, the
sample or an additional sample may be collected under conditions in
which a person of the same gender of the applicant may witness the
collection.
The applicant consents to the foregoing.
Applicant
Date
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APPLICATION FOR EMPLOYMENT

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Completed 23 March 2022

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