Fillable Sheriffs Office Application PDF (Walton County Board of Commissioners)

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Sheriffs Office Application PDF (Walton County Board of Commissioners)

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Sheriff’s Office
Applicant
Packet
WWW.WALTONCOUNTYGA.GOV
WALTON COUNTY SHERIFF’S OFFICE
APPLICANT’S QUESTIONNAIRE
(Please print or type. All questions should be answered completely.)
Position Applied For:_________________________________________________________
A. Personal Information
1. Name:_________________________________________________________________
(First) (Middle) (Last)
2. Date of Birth:______________________Height:___________Weight:___________
Where were you born?__________________________________________________
(City) (County) (State)
Hair Color:______________ Eye Color:______________
Social Security Number:______________________________
3. Address:_______________________________________________________________
(Number) (Street) (Apartment #)
__________________________________________________________________
(City) (State) (Zip Code)
4. Phone #: Home:_________________________ Business:____________________
Other:_________________________
5. Are you: ______Single _______Married
______Separated _______Divorced
6. Provide the following information for your spouse:
Name:
________________________________________________________________________
(First) (Middle/Maiden) (Last)
_____________________________________________ ________________________
(Social Security Number) (Date of Birth)
7. Is your spouse employed? _______ Yes _________ No
________________________________________________________________________
(Employer’s Name)
________________________________________________________________________
(Address)
_________________________________
(Telephone Number)
8. If married, are you living with your spouse? _______ Yes ________ No
If not, state reasons: ___________________________________________________
________________________________________________________________________
9. List below every child born to you, adopted, and any stepchildren and
children supported by you.
Name Date of birth With Whom & Where Resides
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
10. Are you supporting all children listed above, if not explain.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
11. Have you ever been bonded? ________ Yes _________ No
If yes, give details: _____________________________________________________
_______________________________________________________________________
12. Are you related to any person who is the owner or employee of a Bail
Bonding Company or have you worked for anyone in the bonding
business? ____ Yes ____ No. If yes, explain fully: ____________________
________________________________________________________________________
________________________________________________________________________
13. Have you ever been arrested? _____ Yes _____ No. If yes, explain.
Date Charge Disposition of Case Arresting Agency
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
14. List the names of the following family members.
Father:________________________________________________________________
Mother:________________________________________________________________
Brothers:______________________________________________________________
________________________________________________________________________
Sisters:________________________________________________________________
________________________________________________________________________
B. EDUCATION:
15. Circle the highest year completed:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
College Graduate? _____ Yes _____ No
High School Graduate? _____ Yes _____ No
High School Equivalency? _____ Yes _____ No
College Name:_________________________________________________________
Address:_______________________________________________________________
Year Graduated:__________ Degree:_____________________________________
High School:___________________________________________________________
Address:_______________________________________________________________
Year Graduated:__________
Vocational School:_____________________________________________________
Address:_______________________________________________________________
Year Graduated:__________ Major:_______________________________________
16. Were you ever expelled or suspended from any school, or were you ever
disciplined by any school official? _____ Yes _____ No
If yes, explain:_________________________________________________________
________________________________________________________________________
________________________________________________________________________
C. EMPLOYMENT
17. What is your present occupation or calling? ____________________________
________________________________________________________________________
18. Are you seeking permanent employment with this department?
____ Yes _____ No
19. Do you have any relatives who work with this department?
_____ Yes _____ No
If yes, list their name(s) and your relationship? _________________________
_______________________________________________________________________
20. Why did you leave your last job or why would you leave your present job
for this position? ______________________________________________________
________________________________________________________________________
21. Did a supervisor ever reprimand you for being late or for being absent?
_____ Yes _____ No
If yes, explain: _________________________________________________________
_______________________________________________________________________
22. Did a supervisor ever reprimand you for misconduct or not doing your
job? _____ Yes _____ No
If yes, explain: _________________________________________________________
_______________________________________________________________________
23. Did you ever have any arguments concerning job duties/working
conditions? _____ Yes _____ No
If yes, explain: _________________________________________________________
________________________________________________________________________
24. Have you ever experienced shift work? _____ Yes _____ No
Explain: _______________________________________________________________
________________________________________________________________________
D. WORK SAFETY
25. Have you ever been disciplined for unsafe work practices, or unsafe
operation of tool, vehicles, or other equipment? _____ Yes _____ No
If yes, explain: _________________________________________________________
________________________________________________________________________
26. Have you ever injured yourself or another person on the job due to an
improper or unsafe work practice, or unsafe operation of equipment?
_____ Yes _____ No
If yes, explain: _________________________________________________________
_______________________________________________________________________
E. REFERENCES
27. Fill in below the names of six (6) persons not related to you, and not
former employers, who have known you for the past five (5) years.
_______________________________________________________________________
Name Work Phone Home Phone
_______________________________________________________________________
Address City State Zip
_______________________________________________________________________
Business, Occupation or Profession
_______________________________________________________________________
Name Work Phone Home Phone
_______________________________________________________________________
Address City State Zip
_______________________________________________________________________
Business, Occupation or Profession
_______________________________________________________________________
Name Work Phone Home Phone
_______________________________________________________________________
Address City State Zip
Business, Occupation or Profession
_______________________________________________________________________
Name Work Phone Home Phone
_______________________________________________________________________
Address City State Zip
_______________________________________________________________________
Business, Occupation or Profession
_______________________________________________________________________
Name Work Phone Home Phone
_______________________________________________________________________
Address City State Zip
_______________________________________________________________________
Business, Occupation or Profession
_______________________________________________________________________
Name Work Phone Home Phone
_______________________________________________________________________
Address City State Zip
_______________________________________________________________________
Business, Occupation or Profession
F. FINANCIAL
28. Do you have a checking account? _____ Yes _____ No
Bank: _________________________________________________________________
City & State: __________________________________________________________
29. Do you have a savings account? _____ Yes _____ No
Bank: _________________________________________________________________
City & State: __________________________________________________________
30. List the names of Financial Institutions with whom you do business.
Name City & State
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
31. Do you own a car? _____ Yes _____ No
Make:____________________ Model:______________________ Year:___________
Will this car be used for transportation to and from work?
_____ Yes _____ No
32. Do you owe any money on past jobs? _____ Yes _____ No If yes, explain:
_______________________________________________________________________
_______________________________________________________________________
33. Are you behind on any payments or debts? _____ Yes _____ No
Amount: _______________
34. Are any of your creditors pressing you for payment? _____ Yes _____ No
35. Do you: _____ Rent or _____ Own your home?
36. Have you ever filed for bankruptcy, Chapter 7, Chapter 11, or Chapter
13? _____ Yes _____ No If yes, explain: _____________________________
________________________________________________________________________
37. Have you ever been sued? _____ Yes _____ No
Have you ever sued anyone? _____ Yes _____ No
If yes, explain: _________________________________________________________
38. Have you ever had any judgements filed against you? _____ Yes _____ No
If yes, explain: _________________________________________________________
_______________________________________________________________________
G. MILITARY
39. Have you ever served in the military or naval organization of the United
States? _____ Yes _____ No
________________________________________________________________________
Branch Dates
________________________________________________________________________
Highest Rank Service Number
40. What type of discharge did you receive? ________________________________
(Include a photocopy of your DD-214 with this questionnaire)
41. Are you, or have you, ever been a member of the Nation Guard or
Reserve? _____ Yes _____ No If yes, give details: _____________________
________________________________________________________________________
42. Has any disciplinary action been taken against you while a member of
any military organization? _____ Yes _____ No If yes, explain: _________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
43. Are you still on active status in the National Guard or Reserve?
_____ Yes _____ No If yes, list branch, rank, and location: __________
_______________________________________________________________________
_______________________________________________________________________
H. DRIVING RECORD
44. Do you have a current driver’s license? _____ Yes _____ No
State:__________ License Number:_________________________
Class of License:__________ Expiration Date:_________________________
45. Have you ever received any traffic citations? _____ Yes _____ No
If yes, list below:
Date Location Charge Disposition
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
46. Have you ever been involved in a vehicle accident? _____ Yes _____ No
If yes, list below:
________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
47. Has your license ever been suspended or revoked? _____ Yes _____ No
If yes, explain:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
48. Do you have auto liability insurance? _____ Yes _____ No
Please include photocopies of the following documents with your questionnaire.
1. High School Diploma or GED Certificate
2. Birth Certificate
3. DD-214 (If you have served in the Military)
4. 35 MM Photo or good picture ID
5. Driver’s License (copy)
6. Seven Year Driver’s History (can be obtained through the Department of
Driver Services.)
WALTON COUNTY SHERIFF’S OFFICE
REFERENCE RELEASE STATEMENT
I authorize the addressed individual, company or institution to furnish the Walton County
Sheriff’s Office with any information they may have concerning me, which they have on record
or otherwise. I also release such individual, company, or institution and the Walton County
Sheriff’s Office from any and all liability for any damage whatsoever incurred in furnishing
such information. A photocopy of my signature on this page will suffice as an original.
__________________________________ __________________________________
Printed Name of Applicant Social Security Number
__________________________________ ___________________________________
Signature of Applicant Date of Signature
Applicant—do not write below this line
To: _________________________________ From: _______________________________
_________________________________ _______________________________
_________________________________ _______________________________
_________________________________ _______________________________
Att: ___________________________
Phone:_________________________
Fax: ___________________________
The job applicant named above has applied for employment with the Walton County Sheriff’s
Office and lists your organization as a present or previous employer. We would very much
appreciate your help and cooperation by candidly evaluating this applicant’s performance while
employed by your organization. You may return this form to us by mail (address above), by fax,
or call our representative named above.
Please rate the following Excellent Good Fair Poor
Responsiveness to Supervision
Cooperation
Quality
Quantity of Work
Timeliness of Work
Attendance/Punctuality
Dates of employment: from ________________ to _________________ Position:__________________
Reason for leaving: __________________________________________________________________________
Would you reemploy?:____________ If no, why not: ___________________________________________
Other pertinent comments: __________________________________________________________________
Completed by: ______________________________________________ Date: ______________________
**********Thank you for your time and cooperation**********
AUTHORITY TO RELEASE INFORMATION
To Whom It May Concern:
I hereby authorize the Walton County Sheriff’s Office, or other authorized
representative of the Walton County Sheriff’s Office bearing this release, or
copy thereof, within one year of its date, to obtain any information in your files
pertaining to my employment and/or educational records; including, but not
limited to, academic achievement, attendance, athletic, and disciplinary
records.
I hereby direct you to release such information upon request of bearer.
This release is executed with full knowledge and understanding the information
is for the official use of Walton County Sheriff’s Office. Consent is granted for
the Walton County Sheriff’s Office to furnish such information as is described
above, to third parties in the course of fulfilling its official responsibilities.
I hereby release you, as the custodian of such records, and any school,
college, university, or their education institution, or other consumer reporting
agency, or retail business establishment including its officers, employees, or
related personnel, both individually or collectively, from any and all liability for
damages of whatever kind; which may at any time result to me, my heirs,
family or associates because of compliance with this authorization and request
to release information, or any attempt to comply with it.
Should there be any questions as to the validity of this release, you may
contact me at the address indicated below.
I understand my application will be subject to verification through a
comprehensive background investigation; a part of which may be a polygraph.
Falsification and/or misrepresentation of facts during any phase of the
employment process will be grounds for termination of applicant’s employment
process and/or dismissal.
****************************************************************************************
FULL NAME: _________________________________________
(Signature)
FULL NAME: __________________________________________
(Print or type)
SOCIAL SECURITY NUMBER: __________________________
PHONE NUMBER: _____________________________________
CURRENT ADDRESS: ______________________________________________________
NOTARY PUBLIC: _________________________________________
(Must have signature, date, and seal)
Applicant’s Certification and Agreement
Authorization to Release Information
Conditions of Employment
I hereby declare the information provided by me in this application is true and
complete, and I understand that misrepresentations, omissions of facts, or
falsifications of this information are grounds for refusal to hire, or if hired,
termination.
I authorize any persons or organizations to give you any and all information
concerning my previous employment, education, or any other information they might
have, personal or otherwise, with regard to any of the subjects covered by this
application. I also release all such parties from all liability for any damage, which may
result from furnishing such information to you.
I authorize you to request, receive, and verify all information given in this application.
If I am employed by the Walton County Sheriff’s Office, I agree to conform to the
policies, rules, and regulations of the government set forth in the Walton County
Sheriff’s Officer’s Personnel System, employee handbook, policies, and ordinances;
and acknowledge that these policies, rules, and regulations may be changed,
interpreted, withdrawn, or added to by the employers at any time, at the employer’s
sole option.
I further acknowledge that if I become employed with the Walton County Sheriff’s
Office, my employment will be at-will and may be terminated with or without cause at
any time by me or by the employer until I become a non-probationary, regular
employee.
If required by the Walton County Sheriff’s Office for the position I am applying, I
consent to undergo a physical examination, after I have been offered employment, as
deemed necessary.
THIS APPLICATION WILL REMAIN ACTIVE FOR 180 DAYS ONLY, UNLESS
RENEWED PERSONALLY BY ME IN WRITING.
Before an applicant can be selected for employment with the Walton County Sheriff’s
Office, he/she must submit to a drug test. Should you be offered a job with the Walton
County Sheriff’s Office, your position may require random drug testing.
May we contact your present employer? ______ No _____ Yes _____ Presently not
employed
You must sign the “Authorization to Release Information” form to enable us to contact
prior employers, even though we may not contact your present employer.
Date: __________________________ Signature: ______________________________________
Alcohol and Controlled Substance Testing
As a condition of employment with Walton County Sheriff’s Office, you will be required
to submit to an alcohol and controlled substance screening test. Employees must, as a
condition of employment, abide by our policy regarding the effects of drug use and the
unlawful possession of controlled substances. Employees must report any convictions
under a criminal drug statue for such violations. A report of the conviction must be
received by this agency within five (5) days after the conviction. (This requirement is
mandated by the Drug-Free Workplace Act of 1988). In order to be employed by the
Walton County Sheriff’s Office, you must successfully pass this screening test.
By signing this form, you are acknowledging that you consent to such an examination
and screening test.
Date: __________________________ Signature: ______________________________________
Walton County Sheriff’s Office Consent Form
I hereby authorize the Walton County Sheriff’s Office to receive any
criminal history record information pertaining to me, which may be in the files
of any state or local criminal justice agency in Georgia.
____________________________________________________________________________
Full Name Printed
____________________________________________________________________________
Street Address
____________________________________________________________________________
City State Zip
________ ________ ___________________ _______________________
Sex Race Date of Birth Social Security Number
__________________________________________________
Signature
_________________________________________ ________________________
Notary Signature Date
WALTON COUNTY SHERIFF’S OFFICE
Pre-employment Drug Testing Policy
I, _________________________________________, attest by my signature
affixed to the bottom of this document that I have been advised it is the policy
of the Walton County Sheriff’s Office to screen employment applicants for the
presence of narcotics and dangerous drugs, through urinalysis test.
As an applicant for consideration of employment with this agency, I
attest that I presently agree to submit to such testing, understanding it is a
condition of employment.
I further understand that should I refuse to submit to this manner of
testing, consideration of my application for employment will immediately cease,
and I will be disqualified from hiring.
____________________________________________
Applicant
_________________________
Date
__________________________________
Witness
Application For Employment
I, _________________________________, by affixing my signature below, submit my
name for the consideration of employment as a _______________________________
with the Walton County Sheriff’s Office.
By this document, I authorize the Walton County Sheriff’s Office to begin an
investigation into my suitability as a candidate for employment.
I further understand that in order to be a candidate for employment, I must be
able to comply with the following requirements:
1. Be at least 21 years of age to be employed as a patrol deputy or 18 years
of age to be employed as a jailer.
2. Be a citizen of the United States.
3. Possess a valid driver’s license.
4. Have a High School Diploma or its recognized equivalent.
5. Be fingerprinted and a search made of local, state, and national files.
6. Be found free of any felony or multiple misdemeanor convictions.
7. Possess good moral character as determined by investigation.
8. Be tested in form of a polygraph and other examinations.
9. Shall be able to work any shift as assigned, day or night, holidays and
weekends as required of the job.
10. Be found, after examination, to be free of any condition that might
adversely affect the applicants job performance.
11. Be able to meet all qualifications set-forth by the Georgia Peace Officers
Standard council.
_______________________________________ _________________________________
Signature Date
_______________________________________ __________________________________
Witness Date
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Sheriffs Office Application PDF (Walton County Board of Commissioners)

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Completed 18 July 2020

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