Fill - Free fillable Packet Application (Hall County) PDF form

HALL COUNTY SHERIFF’S OFFICE

DEPUTY SHERIFF

APPLICATION FOR EMPLOYMENT

Application for testing

(Applicants must be at least 21 years of age by closing of the application period)

Date of Application:

How did you learn about this position?

 Advertisement  Friend  Walk-in

 Employment Agency  In-House Advertisement Other

Last Name First Name Middle Name

Street Address City State Zip

Telephone Number(s) Driver’s License Number/State

Email Address

When will you be able to begin work? Date:

Are you prevented from lawfully becoming employed in

this country because of Visa or Immigration Status? Yes  No 

Applications may be mailed to Hall County Sheriff’s Ofc. For further information

or dropped off at: 111 Public Safety Dr. (308) 385-5200

Grand Island, NE 68801

EDUCATION (Include college diplomas or transcripts to receive credit)

Elementary

High School

College/Tech

Graduate

School Name

and Location

Years completed

4 5 6 7 8

9 10 11 12

1 2 3 4 5

1 2 3 4

Diploma/Degree

Describe course of study

Describe any honors

you have received

MILITARY

Complete this section if you served in the U.S. Armed Forces

Branch of Service

Describe your duties and any special training

Period of Active Duty

From To

Rank at Discharge

Date of Final Discharge

SPECIAL SKILLS AND QUALIFICATIONS

Summarize special job-related skills and qualifications acquired from employment or other experience:

Foreign Language

List languages that your consider yourself fluent:

LAW ENFORCEMENT CERTIFICATION

Are you currently law enforcement certified?

Yes ______ In what state? __________________________ Date of Certification ___________

INCLUDE COPIES OF CERTIFICATES

No ________

This position is subject to a veteran’s preference. Are you eligible for and requesting a veteran’s preference?

 Yes  No

(A veteran requesting preference must submit with his/her Application for Employment a copy of the veteran’s

Department of Defense Form 214. A spouse of a veteran requesting preference must submit with his/her

Application for employment a copy of the veteran’s Department of Defense Form 214, a copy of the veteran’s

disability verification from the United States Department of Veteran Affairs demonstrating a 100 percent permanent

disability rating, and proof of marriage to the veteran.)

SPECIALIZED LAW ENFORCEMENT TRAINING

List any Specialized Law Enforcement Training obtained through the Nebraska Law Enforcement Training

Center or other recognized training facility. Only list certified training with a minimum of twenty-four classroom

hours. Include copies of all certificates. Credit will only be given to those with proper documentation.

Title of Course & Credit Hours Facility or Instructor(s)

1.

2.

3.

4.

5.

Have you been convicted of any violations of the law other than parking violations? Yes  No 

If yes, complete the following. Be completed, add additional pages if needed.

Violation

Date

Place

Court

Disposition

1.

2.

3.

4.

5.

6.

7.

8.

EMPLOYMENT EXPERIENCE

P

LEASE GIVE ACCURATE, COMPLETE EMPLOYMENT RECORD. ADD ADDITIONAL

PAGES IF NEEDED

. START WITH PRESENT OR MOST RECENT EMPLOYER.

1. Company Name

Telephone

Address

Employed

From To

Name of Supervisor/Title

Annual/Hourly Pay

Your Job Title/Position

Reason for Leaving

2.

Company Name

Telephone

Address

Employed

From To

Name of Supervisor/Title

Annual/Hourly Pay

Your Job Title/Position

Reason for Leaving

3. Company Name

Telephone

Address

Employed

From To

Name of Supervisor/Title

Annual/Hourly Pay

Your Job Title/Position

Reason for Leaving

4.

Company Name

Telephone

Address

Employed

From To

Name of Supervisor/Title

Annual/Hourly Pay

Your Job Title/Position

Reason for Leaving

We may contact the employers listed above unless DO NOT CONTACT

you indicate those you do not want us to contact. Employer Number(s) Reason

PERSONAL REFERENCES

PLEASE LIST REFERENCES WHO ARE NOT RELATED TO YOU AND ARE NOT PREVIOUS

EMPLOYERS

.

1.

Name:

Address: Phone:

Occupation: Years Acquainted:

2.

Name:

Address: Phone:

Occupation: Years Acquainted:

3.

Name:

Address: Phone:

Occupation: Years Acquainted:

4.

Name:

Address: Phone:

Occupation: Years Acquainted:

APPLICANT’S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge. I

authorize investigation of all statements contained in this application for employment as may

be necessary in arriving at an employment decision. I also understand to be considered for

employment I must pass a pre-employment drug screen. I understand and agree that the Hall

County Sheriff’s Office may make pre-employment inquiries into my ability to perform job-

related functions, and that I may be offered employment conditioned upon the results of a

medical examination. I further agree and understand that any misstatement or omission of

material fact may constitute cause for dismissal from employment with the aforementioned

agency.

Signature

RICK CONRAD

SHERIFF OF HALL COUNTY

City – County Public Safety Center

111 Public Safety Drive

Grand Island, NE 68801

Office 308-385-5200

JIM CASTLEBERRY

CHIEF DEPUTY

“To Serve and Protect,

Since 1859”

Fax 308-385-5209

(Please do not use blue ink or pencil when completing this form.)

AUTHORITY TO RELEASE INFORMATION

FULL NAME: __________________________________________________________

Printed Name (Signature)

DATE OF BIRTH: ____________ SOCIAL SECURITY NUMBER: _______________

CURRENT ADDRESS: __________________________________________________

__________________________________________________

TELEPHONE NUMBER: _______________________ DATE: ___________________

I have made application for employment at the Hall County Sheriff’s Office (HCSO) in order to become

an employee (deputy sheriff / support staff).

I hereby authorize a review and full disclosure of all records of files, or any part thereof, concerning

myself that may be related to my application for employment to the HCSO, it’s employees or its agents

bearing or furnishing this release, within twelve (12) months of its date, whether the said records are

public or private, and including these which may be deemed to be of a privileged or confidential nature.

I authorize the full and complete disclosure of the records and files of educational institutions; financial

or credit agencies; medical and psychiatric consultation and/or treatment, including hospitals, clinics,

private practitioners, the U.S. Veteran’s Administration, and all military and psychiatric facilities; public

utility companies; employment and pre-employment records, including background investigation

reports, the results of polygraph examinations, efficiency ratings, complaints or grievances filed by or

against me; records of complaints of civil nature made by or against me, including, but not limited to,

the records and recollections of attorneys at law, other counsel representing or having represented me;

and any records of any type whatsoever which concern any arrests or criminal charges involving me.

I further authorize the release of information to the HCSO, concerning all of the above mentioned area,

or any other information which has a bearing on my fitness or ability to become trained and certified as

a law enforcement officer, even though such information is not contained in written records and

regardless of whether such information is considered privileged or confidential in nature.

This release is executed with full knowledge and understanding that the information is for the official

use of the Hall County Sheriff’s Office, and I further understand that such information can be released

to any law enforcement agency where I might later wish to make application for employment.

I release from liability and hold Hall County and the Hall County Sheriff’s Office harmless for all actions

taken as a result of the information they receive.

I, the undersigned, hereby acknowledge that I give the above authority to release information of my

own free will and for the purposed stated therein, and I have voluntarily furnished by Social Security

number.

___________________________________ ___________________________________

SIGNATURE DATE

The next pages contain the Nebraska Law

Enforcement Training’s “Entrance Physical

Standard requirements” that are part of

their certification program.

Please review these (the actual documents

can be found on the Training Center’s

website at http://nletc.nebraska.gov).

This is not a part of our agency’s initial

application process, but it is a requirement

of the law enforcement certification

program, should you be hired by our

department and are not yet a certified

officer.

TC‐919 10/18

AUTHORITYTORELEASEINFORMATION

TOPROSPECTIVEEMPLOYER(791)

FULLNAME_______________________________________ SSN_________________DATEOFBIRTH___________

(PrintorType)

CURRENTADDRESS_________________________________________________________________

Thisreleaseisbeingmadeinconjunctionwithaconditionalofferofemploymentasalaw

enforcementofficerwiththefollowingagency:_____________________________________________________.

(Typeorprintthenameofagencyanditsaddress)

Idoherebyauthorizeareviewandfulldisclosuretotheabove‐mentionedagencyofanyandallrecords,reportsorfiles

(oranypartthereof)pertainingtome,fromanyagencywhereIhavebeenpreviouslyemployedasalawenforcement

officer.Suchrecordsorfilesshallinclude,butnotbelimitedtoemploymentrecordsand/orpersonnelfilesregarding

reasonsforseparationfromemploymentandthecircumstancessurroundingseparationincludingresultsofpolygraph

examinations,efficiencyratings,complaintsand/orgrievancesinvolvingmeaswellascourtrecordsordocumentsin

civilorcriminalcasesinwhichIaminvolved,andanyrecords,filesordocumentsregardinganyarrests,convictionsor

othercriminalinvestigationsorchargespertainingtomewhetherinwritingorinelectronicmediadatabases.

Ifurtherauthorizethereleaseofinformationtotheabove‐mentionedagencyconcerningalloftheabovementioned

areas,oranyotherinformationwhichhasabearingonmyfitnessorabilitytoserveasalawenforcementofficerinthe

StateofNebraska,regardlessofwhethertheinformationisconsideredprivilegedorconfidentialinnature,whichrelate

toincompetence,neglectofduty,incapacitation,dishonesty,felonyviolationofstateorfederallaw,misdemeanor

violationofstateorfederallawhavingarationalconnectiontomyfitnessorcapacitytoserveasalawenforcement

officer,violationofoathofoffice,codeofethicsorotherstatutoryduties.

Ireleaseandholdharmlessanypreviousagency,administratororindividualwhoreleasesinformationinaccordance

withthisreleaseforallactionstakenasaresultoftheinformationprovided.

Thisreleaseofinformationform,oradulyexecutedphotocopyand/orfaxisvalidforaperiodofoneyearfromthe

dateofexecution.

I,theundersigned,afterfirstbeingdulysworn,herebyacknowledgethatIgivetheaboveauthoritytorelease

informationofmyownfreewillandforthepurposesstatedthereinandIhavevoluntarilyfurnishedmysocialsecurity

number.

Signature__________________________________

D

ate________________

Subscribedandsworntobeforemeonthis______dayof___________,20____.

______

____________________

NotaryPublic



1

.

PRELIMINARY QUESTIONNAIRE

LAST NAME

FIRST NAME

FULL MIDDLE NAME

BIRTH NAME

STREET ADDRESS

CITY

COUNTY

STATE

ZIP CODE

HOME TELEPHONE (AREA CODE)

BUSINESS TELEPHONE (AREA CODE)

CELL (AREA CODE)

DATE OF BIRTH (MONTH/DAY/YEAR)

AGE

PLACE OF BIRTH

U.S. CITIZENSHIP

YES OR NO

OTHER

NATURALIZED CITIZEN

YES OR NO

SOCIAL SECURITY NUMBER

RACE

GENDER

HEIGHT

WEIGHT

MARITAL STATUS

DRIVER’S LICENSE NUMBER

STATE OF ISSUE

ANSWER THE FOLLOWING QUESTIONS AND INCLUDE BRIEF EXPLANATIONS FOR ANY

“YES” ANSWER(S) OR WHEN DETAILS ARE REQUESTED

ALL ANSWERS TO THE FOLLOWING QUESTIONS MAY BE VERIFIED BY POLYGRAPH

EXAMINATION. SPECIFIC AREAS ADDRESSED BY THE POLYGRAPH EXAMINATION WILL

BE: CRIMINAL HISTORY, INTEGRITY, ILLEGAL CONDUCT, DRUG USE, PERSONAL

HISTORY AND PRIOR EMPLOYMENT. (32.4.1) ANY MISREPRESENTATION, FALSIFICATION

OR OMISSION PERTAINING TO ANY APPLICATION OR DOCUMENT YOU SUBMIT TO THIS

AGENCY WILL BE GROUNDS FOR PERMANENT DISQUALIFICATION.

NOTE! CURRENT AND PRIOR PUBLIC SAFETY OFFICALS

Questions 13 and 14 pertain to the possession and transfer of controlled substances. These questions concern personal possession and

transfer of controlled substance. When answering these questions, DO NOT include or refer to any possession or use of controlled

substances that occurred legally in the course of your official public safety duties.

RICK CONRAD

SHERIFF OF HALL COUNTY

City - County Public Safety Center

111 Public Safety Drive

Grand Island, NE 68801

Office 308-385-5200

JIM CASTLEBERRY

CHIEF DEPUTY

“To Serve and Protect

Since 1859”

Fax 308-385-5209

2

.

1. Have you ever been arrested by any public safety agency (include criminal and serious motor

vehicle violations) either as an adult or as a juvenile? ________________ Have you ever been a

defendant in a criminal case? __________________

DATE:

PLACE:

AGENCY:

CHARGE(S):

DISPOSITION(S):

__________________________________________________________________________________________

2. Have you ever been detained by any public safety agency (include criminal, mental health, and

serious motor vehicle violations) either as an adult or a juvenile? _______________________

DATE:

PLACE:

AGENCY:

CHARGE(S):

DISPOSITION(S):

__________________________________________________________________________________________

3. Have you ever been accused, or has anyone ever claimed that you have beaten, abused, mistreated, or

sexually assaulted your spouse, domestic partner, or significant other? List these details below and a

summary of each incident.

DATE:

ACCUSATION(S) / CHARGE(S):

LOCATION:

DISPOSITION(S):

__________________________________________________________________________________________

3

.

4. Have you ever had a driver’s license issued to you from any other state? _______________ List the

state(s) and license number for which you have been issued a permit.

____________________________________________________________________________________

What is the status and disposition of these permits?

SURRENDERED? EXPIRED?

5. How many citations/moving violations have you received in your lifetime? __________________

List the details below.

DATE:

PLACE:

AGENCY:

CHARGE(S):

DISPOSITION(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

6. How many points do you CURRENTY have on your license? __________________

7. Has your driver’s license or your privilege to drive in any state ever been:

Refused? ____________ Suspended? ____________ Revoked? ____________

If you have answered yes to any of the above questions, list the details below.

If you have answered no to the questions, proceed to question eight (8).

DATE(S):

STATE(S):

REASON(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

4

.

8. List the most serious violation(s) of the law in which you have been involved that went undiscovered by

the police?

DATE(S):

PLACE(S):

ACTION(S):

RESOLUTION(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

9. Have you ever stolen anything from any place of employment, past or present? __________________

List the details below.

DATE(S):

EMPLOYER(S):

ITEM(S):

ESTIMATED COST(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

10. Have you ever possessed, tried, experimented with, used or tasted any controlled dangerous

substances/illegal substances? __________________________

If you have answered yes, last date of use_______________________ & list the details below.

If you have answered no, continue to question eleven (11).

SUBSTANCE(S):

Y/N?

AMMOUNTS

METHOD OBTAINED

# TIME(S) USED:

MARIJUANA

HASHISH

COCAINE

CRACK

PCP

HEROIN

LSD

MUSHROOMS

ICE

CRYSTAL METH

KAT

5

.

SUBSTANCE(S):

Y/N?

AMMOUNTS

METHOD OBTAINED

# / TIME(S) USED:

AMPHETAMINE

BARBITURATE

STEROID(S):

ORAL

INJECTED

If additional space is needed, turn to the last page of the document and continue.

11. Have you ever inhaled any substance(s) such as glue, paint thinner, amyl nitrate, “rush”, etc., for the

purpose of getting high? ___________________

If you have answered yes, list the details below.

If you have answered no, continue to question twelve (12).

DATE(S):

AMOUNT(S):

SUBSTANCE(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

12. Have you ever taken any prescribed medication not specifically prescribed for you? ________________

If you have answered yes, list the details below.

If you have answered no, continue to question thirteen (13).

DATE(S):

PLACE(S):

SUBSTANCE(S):

AILMENT/PRESCRIBED TO:

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

13. Have you ever sold, held or passed any illegal drugs or substances? _________________

If you have answered yes, list the details on the next page.

If you have answered no, continue to question fourteen (14).

6

.

EVENT(S):

TIME(S):

SUBSTANCE(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

14. Have you ever been present during or participated in any way in any illegal drug transaction?

_____________________

If you have answered yes, list the details on the next page.

If you have answered no, continue to question fifteenth (15).

DATE(S)/PLACE(S):

SUBSTANCE(S):

CIRCUMSTANCE(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

15. Have you ever been with someone else who bought any illegal drugs or substances? ________________

If you have answered yes, list the details on the next page.

If you have answered no, continue to question sixteen (16).

DATE(S)/PLACE(S):

EVENT(S):

SUBSTANCE(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

16. Have you ever received any verbal or written reprimand in your current or any prior employment, to

include during military service? _______________________

If you have answered yes, list the details on the next page.

If you have answered no, continue to question seventeen (17).

DATE(S)PLACE(S):

EVENT(S):

SUBSTANCE(S):

__________________________________________________________________________________________

7

.

If additional space is needed, turn to the last page of the document and continue.

17. Have you ever received any disciplinary action (included, but not limited to a loss in pay, docked

accrued leave, or any Non-Judicial Punishment under Article 15 of the U.C.M.J.) in your current or any

prior employment, to include during military service? __________________

If you have answered yes, list the details below.

If you have answered no, continue to question eighteen (18).

DATE(S):

AMOUNT(S):

SUBSTANCE(S):

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

18. Have you ever been terminated by an employer or asked to resign? __________________

If you have answered yes, list the details below.

If you have answered no, continue to question nineteen (19).

EMPLOYER(S)/REASON(S):

DATE:

TIME(S):

ACTION TAKEN:

__________________________________________________________________________________________

If additional space is needed, turn to the last page of the document and continue.

19. List all dates of all periods of military service (indicate active or reserve), to include:

BRANCH(ES):

PERIOD(S):

RANK AT DISCHARGE:

OCCUPATION(S):

__________________________________________________________________________________________

20. Have you ever received any discharge other than an Honorable Discharge (i.e. General Discharge

under Honorable Conditions or Bad Conduct Discharge) from any branch of the service? ____________

If “yes” provide a detailed explanation below.

__________________________________________________________________________________________

8

.

21. What is your reenlistment code? _________ If known, list Narrative Reasons for Separation.

__________________________________________________________________________________________

22. Have you ever been refused entry into military service? __________ If “yes”, provide a detailed

explanation below.

__________________________________________________________________________________________

23. Have you ever had or are you currently experiencing the following credit situation(s)?

 Judgments __________ If “yes”, explain in detail on page 9 of this document.

 Liens _________ If “yes”, explain in detail on page 9 of this document.

 Collections __________ If “yes”, explain in detail on page 9 of this document.

 Bankruptcy _________ If “yes”, explain in detail on page 9 of this document.

 Defaulted loans __________ If “yes”, explain in detail on page 9 of this document.

 Defaulted student loans ________ If “yes”, explain in detail on page 9 of this document.

24. Have you ever applied to any other public safety agency or agencies? __________ If “yes”, explain in

detail on pages 10 and 11 of this document.

 The name of the agency with whom you applied.

 The date you applied.

 What steps of the background investigation were conducted?

 What was the outcome of the investigation?

25. Have you ever been rejected for employment by any other public safety agency or agencies?

___________ If “yes”, explain in detail on pages 10 and 11 of this document.

26. Have you ever manufactured, procured, or ignited; or provided material or assistance to manufacture,

procure, or ignite any explosive device more destructive than that regulated by law as a “firework”? -

____________ If "yes" explain in detail on pages 10 and 11 of this document.

27. Have you ever intentionally burned or caused to be burned, or destroyed by fire any personal property

belonging to another person without the consent of that person or any property with the intent to cause

harm or defraud? ____________ If “yes” explain in detail on pages 10 and 11 of this document.

28. Have you ever knowingly viewed, published, distributed, or solicited the purchase of any image or video

depicting sexually explicit conduct of a child or minor? ______________ If “yes explain in detail on

pages 10 and 11 of this document.

29. The Hall County Sherriff’s Department has a policy regulating visible tattoos. Visible tattoos are not

necessarily prohibitive to hiring and are waiver-able at the discretion of the Sheriff. List and describe

any and all tattoos that you have and include verbatim any words, symbols, or depictions, their location,

9

.

and their meaning: In the “Visible” section of the table, indicate if the tattoo would be visible while

wearing a standard length short sleeve shirt and pants. If you do not find room below, continue with the

above described information in the space available on pages 10 or 11 of this form.

TATOO:

Visible Y/N:

Location

Description

Meaning

1.

2.

3.

4.

5.

6.

7.

8.

9.

RESPONSE TO QUESTION #23:

__________________________________________________________________________________________

A.________________________________________________________________________________________

B.________________________________________________________________________________________

C.________________________________________________________________________________________

I CERTIFY THAT THE ANSEWRS I HAVE GIVEN TO THESE QUESTIONS ARE TRUE,

COMPLETE AND CORRECT. I ALSO UNDERSTAND THAT I WILL NOT BE CONSIDERED FOR

EMPLOYMENT IF ANY OF THESE ANSEWRS CONTAIN ANY FRAUDULENT

MISREPRESENTATIONS OR FALSIFICATIONS, OR IF ANY INFORMATION HAS BEEN

OMITTED.

_________________________________________________________________________________________

PRINT NAME SIGNATURE DATE

10

.

D.________________________________________________________________________________________

E.________________________________________________________________________________________

F.________________________________________________________________________________________

RESPONSE TO QUESTION #24:

AGENCY: DATE APPLIED: STEPS COMPLETED: STATUS/DISP.:

__________________________________________________________________________________________

RESPONSE TO QUESTION #25:

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

11

.

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

RESPONSE TO QUESTION # :

__________________________________________________________________________________________

Fill Online, Printable, Fillable, Blank Packet Application (Hall County) Form

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Fillable Packet Application (Hall County)

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