Fillable Pembina County Sheriffs Dept. Employment Application (Pembina County)

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Pembina County Sheriffs Dept. Employment Application (Pembina County)

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Pembina County Sheriff’s Dept. Employment Application
INSTRUCTIONS
For assistance in completing this application, please call 701-265-4122.
IDENTIFICATION
1. Name (Last, First, Middle)
2. Present Address
City
State
Zip Code
3. Home Telephone Number
Work Telephone Number
4. Social Security Number
In compliance with the Federal Privacy Act of 1974, the disclosure of your social security
number is voluntary. The social security number is used for record keeping.
5. Can you provide proof, if hired, that you are eligible
to work in the United States?
6.
DO YOU CLAIM VETERAN'S PREFERENCE?
NO
YES - Attach Report of Separation DD-214
DO YOU CLAIM DISABLED VETERAN'S PREFERENCE?
NO
YES - Attach Current VA Disability Certification and Report of Separation DD-214
VETERAN ELIGIBILITY: You must be a North Dakota resident and have served in the active military forces during a period of war as established
in the North Dakota Century Code 37-01-40, or received the armed forces expeditionary or other campaign service medal during an emergency
condition, and must have been released therefrom under honorable conditions. Applicants claiming veteran's preference must attach a copy of
REPORT OF SEPARATION DD214. Disabled veterans must also include a letter less than one year old from the Veteran's Administration
indicating such disability.
If you are not a high school graduate, do you
NO YES
have a GED Equivalency Certificate?
COLLEGE, UNIVERSITY, NURSING SCHOOL, BUSINESS COLLEGE, VOCATIONAL SCHOOL, OR ANY OTHER SCHOOL YOU HAVE ATTENDED:
NUMBER OF
CREDITS EARNED
FIELD
TYPE OF DEGREE
QTR.
SEM.
MAJOR
MINOR
Provide information on education/training you have which is not covered above. Indicate special skills you possess; languages you speak, write or
understand; voluntary and unpaid work experience, etc. Also, list any professional license you currently hold.
ARREST RECORD
8. Have you ever been charged, posted bond or convicted in court for any traffic or criminal violation of the law in a federal, state, or civil court?
NO
YES-If "YES" - complete details below (use separate sheet in same format if more room is needed):
STATE
PLACE
CHARGE
DISPOSITION
NO YES
308 Courthouse Dr. #2, Cavalier, ND 58220
9.
YOUR EMPLOYMENT HISTORY: Be specific. This information may be used to determine if your application will be accepted. Start with your present
or most recent job. Include armed forces service and any self-employment. Indicate any change of job title under the same employer as a separate
position. If you need additional space, attach separate sheets using this same format.
Your Employer
Your duties, responsibilities, size of operation, supervision, etc.
REASON FOR LEAVING
MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES
NO
Kind of Business
City
State
Your Title
Name of Your Immediate Supervisor
Supervisor’s Tel. No.
Full Time
Part Time
Hours Worked Per Week
FROM (Month and Year)
TO (Month and Year)
Beginning Monthly Salary
Ending Monthly Salary
Your Employer
Your duties, responsibilities, size of operation, supervision, etc.
REASON FOR LEAVING
MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES
NO
Kind of Business
City
State
Your Title
Name of Your Immediate Supervisor
Supervisor’s Tel. No.
Full Time
Part Time
Hours Worked Per Week
FROM (Month and Year)
TO (Month and Year)
Beginning Monthly Salary
Ending Monthly Salary
Your Employer
Your duties, responsibilities, size of operation, supervision, etc.
REASON FOR LEAVING
MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES
NO
Kind of Business
City
State
Your Title
Name of Your Immediate Supervisor
Supervisor’s Tel. No.
Full Time
Part Time
Hours Worked Per Week
FROM (Month and Year)
TO (Month and Year)
Beginning Monthly Salary
Ending Monthly Salary
Your Employer
Your duties, responsibilities, size of operation, supervision, etc.
REASON FOR LEAVING
MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES
NO
Kind of Business
City
State
Your Title
Name of Your Immediate Supervisor
Supervisor’s Tel. No.
Full Time
Part Time
Hours Worked Per Week
FROM (Month and Year)
TO (Month and Year)
Beginning Monthly Salary
Ending Monthly Salary
Your Employer
Your duties, responsibilities, size of operation, supervision, etc.
REASON FOR LEAVING
MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES
NO
Kind of Business
City
State
Your Title
Name of Your Immediate Supervisor
Supervisor’s Tel. No.
Full Time
Part Time
Hours Worked Per Week
FROM (Month and Year)
TO (Month and Year)
Beginning Monthly Salary
Ending Monthly Salary
10. Do you hold a valid North Dakota Motor Vehicle
Driver's License?
NO
YES
Class
Number
Restrictions
11. Do you, or have you ever had a motor
vehicle driver's license from another state?
NO
YES
If "yes", which state(s)?
Driver’s License Number
12. Have you ever been the driver of a vehicle involved in a
motor vehicle accident?
NO
YES
If "yes", list dates and locations of each below.
13. Are you related to a member of the County
Commission or a County Employee?
If "yes", to whom?
14. Are you capable of performing, with or without reasonable accommodation, the essential functions of the job for which you are applying?
15. How did you learn about this opening?
Salary Desired:
Date Available:
NO YES
NO YES
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16. Have you ever been present where controlled substances such as marijuana, amphetamines, barbiturates,
NO YES
hallucinogenic, hashish, cocaine, opiates, etcetera, were being used?
Explain how many occasions, months and dates of last use.
17. Would you have any reluctance to strictly enforce any and all laws regulating the controlled substances
previously mentioned?
NO
YES
18. Have you ever pled or been found guilty of a felony or ever been charged with a felony that was later dismissed
under a deferred imposition of sentence?
NO
YES
If yes, explain:
19. Are you now or have you ever been a member of any organization, association, movement, group, or combination of persons which advocates the
overthrow of our constitutional form of government, or which has adopted a policy of advocating or approving the commission of acts of force or
violence to deny other persons their rights under the Constitution of the United States or the State of North Dakota, or of seeking to alter the form of
government of the United States or the State of North Dakota by unconstitutional means?
NO YES
20. Do you have any objection to a thorough background investigation being made on you, to include copies of your
fingerprints being submitted to the FBI for examination?
NO
YES
20b. Have you ever had a civil judgment against you for failure to pay any bills:
If yes, explain:
NO YES
21. CERTIFICATION AND AGREEMENT: PLEASE READ BEFORE SIGNING
I certify that all information contained in this application and my attachments is true and complete to the best of my knowledge. I understand that any willful
misrepresentation, false statement, or omission by me in the application or interview process will be cause for rejection of my application or termination of my
employment. I authorize investigation of all statements made on this application and any attachments. I authorize Pembina County to contact my reference and
verify the information that is obtained. I release all persons, companies, and organizations from liability from providing or receiving such information. I further
understand that this employment application and other employment related documents are not contracts of employment; and, that any oral or written
statements to the contrary are hereby expressly disavowed. I hereby acknowledge that if offered a position with Pembina County, my appointment will include a
probationary period of a minimum of six months.
I certify that I will hold no person, corporation, or organization liable for giving or receiving information on the investigation.
ALL INFORMATION IS SUBJECT TO THE NORTH DAKOTA OPEN RECORDS LAW
EQUAL EMPLOYMENT OPPORTUNITY STATEMENT
The County of Pembina does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in
employment or the provision of services, and complies with the provisions of the North Dakota Human Rights Act.
POLICY OF NON-DISCRIMINATION ON THE BASIS OF DISABILITY
The Pembina County Sheriff’s Department does not discriminate on the basis of disability in the admission, or access to, or
treatment, or employment in, its programs or activities.
MAIL APPLICATION TO
Pembina County Sheriff’s Dept.
308 Courthouse Dr. #2
Cavalier ND 58220
Signature of Applicant:
Date:
Referral Source
Employment Agency
PCSO
Employee(s)
Other (Explain)
Newspaper
APPLICANT DATA RECORD
(Completion of this form is voluntary)
Please Print
AFFIRMATIVE ACTION SURVEY
Government agencies require periodic reports on the sex, ethnicity,
handicapped, and veteran status of applicants. These data are for analysis
and affirmative action only.
PLACE AN "X" OR CHECK IN THE APPROPRIATE BOXES
Sex
Male
Female
Handicapped
Yes
No
Ethnic Origin
Caucasian
1
Black
2
Asian/Pacific
American
Hispanic
Islander
Indian
3 4
5
Veteran Service
Yes
No
Beginning Date
Ending Date
Disabled Veteran
Yes
No
Percent
Disabled
Surviving Spouse
Yes
No
Qualified applicants are considered for all positions, and during employment employees are treated
without regard to race, color, religion, sex, national origin, age, or marital or veteran status.
As employers, we comply with government regulations and affirmative action responsibilities.
This data is for periodic government reporting and will be kept in a File SEPARATE from the
Application for Employment.
Position Applied For:
Application Date:
EQUAL EMPLOYMENT OPPORTUNITY FORM
We invite you to complete the enclosed Equal Employment Opportunity form and return it in a separate
envelope from your application.
This information will be forwarded to our Title VI Coordinator and kept completely separate from your
application. This information is used for statistical purposes only as part of our ongoing efforts to
maintain Title VI compliance.
Submission of this information is completely voluntary and will be kept confidential.
EQUAL EMPLOYMENT OPPORTUNITY
Pembina County (5-2014)
Due to the receipt of federal aid funds, Pembina County is subject to certain governmental recordkeeping
and reporting requirements for the administration of civil rights laws and regulations. In order to comply
with these laws, the County invites you to voluntarily self-identity your race or ethnicity. Submission of
this information is voluntary and refusal to provide it will not subject you to any adverse treatments. The
information obtained will be kept confidential and may only be used in accordance with the provisions of
applicable laws, executive orders, and regulations, including those that require the information to the
summarized and reported to the federal government for civil rights enforcement. When reported, data will
not identify any specific individual.
This form will not be part of your applicant file or included in any documentation provided to the
supervising official.
Please Print
Name:
Date: Position for which you are applying:
Location: Birthdate: Gender
Racial/Ethnic Heritage (Check one)
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe,
the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black
racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in
any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China,
India, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of
the original peoples of North and South America (including Central America), and who maintain
tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the
above five races.
How did you learn about the job for which you applied? (List the name of the newspaper, employment
agency, organization, agency employee, or other source):
Your Home Address
City State Zip Code
We are an Equal Opportunity Employer
Male
Female
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Completed 18 July 2020

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