Applicant:
You must complete this application in its entirety. Failure to do so may result in the rejection of your application. You may be asked to furnish copies of additional records (i.e. birth certificate, proof of citizenship, Military records, educational information, ect.) Please note the specific areas that require a notary signature. DO NOT sign these pages until you have a notary public witness your signature. If you are unable to locate a notary public, one will be available to assist you when you return you application to this office.
Thank you for your interest in a position with our agency. We appreciate your enthusiasm and we understand that writing can be difficult. Please know that your application is being processed in the order in which it was received and that the process itself may take up to several weeks. You will be contacted when that process has been completed. Thank you for your interest in the Dawson County Sheriff’s Office.
INSTRUCTIONS ON HOW TO COMPLETE IN DIGITAL FORM
You will need to download this application to your computer. At the end of each question you will need to click on the grey box that looks like this “”. After clicking on the grey box, you can begin to type. Please note that there are some areas that require your personal handwriting and signature.
DO NOT EMAIL THIS APPLICATION BACK TO THE DAWSONCOUNTYSHERIFF’S OFFICE. YOU CAN EITHER RETURN IN PERSON OR BY MAIL.
Dawson County Sheriff’s Office Employment Application
Sheriff Gary W. Reiber
Release of Information
I understand that if I am chosen as a top candidate my background information will be checked and considered as a result of my application for employment. This information may include, but is not limited to the following:
- Employment Verification
- Reference Checks
- Motor Vehicle Driving Record
- Criminal History
- Sexual Offender Registry
- Verification of educational credentials through original transcripts, which you may be asked to provide
- Access to Social Media Sites you are subscribed too
I understand that any false information on my application will be sufficient reason for rejection of my application or termination of my employment. I herewith authorize and request each and every former employer, person, firm, corporation and educational institution to answer any and all questions that may be asked and herewith hold such persons harmless for giving any and all information within their knowledge or records.
My signature on this document will serve as authorization to release any and all information to the Dawson County Sheriff’s Office. A photocopy or facsimile of this document is as valid as the original.
______
Applicants Name (Please Print)
______
Applicants Signature Date
Personal Information for Background Checks / Investigations
The Dawson County Sheriff’s Office conducts driving and national background checks and/or investigations on top candidates requesting employment with the Dawson County Sheriff’s Office. This includes the following areas: employment, volunteers and internships. A conviction does not automatically bar an individual from employment. Each case will be considered individually. In order to complete the process the information below is required.
* CLICK ON THE GRAY BOX TO FILL IN THE FIELD
Print Full Name
Date of Birth
Social Security Number
Place of Birth
Sex
Race
Height
Weight
Eyes
Hair
Driver’s License Number
Expiration Date
Position Applying For
Have you ever been convicted, served probation or pretrial diversion for a violation of the law other than a minor traffic violation?
Yes No If yes, please give details and specific dates (Month and Year)
______
Signature Date
I certify that the above information is true and complete to the best of my knowledge. I authorize a complete background investigation based on the information I have provided.
Pre-Employment Investigation Discovery Waiver
As an applicant to the Dawson County Sheriff’s Office for the position of , I recognize that an employing law enforcement agency has a legal, as well as moral, obligation to take every reasonable effort to ensure that persons employed by them as peace officers, or in other positions, conform to the very highest of standards.
Therefore, I release and hold harmless the Dawson County Sheriff’s Office, and their officers, agents, or assigns, now and in the future, from any claim or damages in law of inequity on behalf of myself, my heirs and assigns, for their refusal to make available any and all information contained in this pre-employment investigation, including, but not limited to, the identity(ies) of any person(s) and/or organization(s) which may have supplied information in the course of this investigation, as well as the substance of any information supplied.
I hereby waive my right, now and in the future, to examine, review, or otherwise discover the contents of this investigation and all related documents thereto.
______
Applicants Signature Date
Subscribed and Sworn to before me the ______day of ______, 20____.
Notary Public in and for said County of ______.
State of ______.
______
Notary Public
Letter of Understanding
I am applying for a position with the Dawson County Sheriff’s Office. I understand that there are certain requirements I must meet before I can be accepted into this position. I understand that I must submit to an extensive background investigation, which consists of the following areas of concern, at a minimum:
- Review of my completed Personal History Statement
- Evaluation of Personal History Questionaire
- Thorough Criminal Background Check
- Thorough examination of prior employment
- Examination of my personal credit/financial report
A Hiring Review Board will evaluate the results of this investigation and make a preliminary decision as to my potential suitability for employment. I may, at this point, receive a conditional offer of employment, which will be followed by a completion of some or all of the following tests, depending upon the position being sought:
- Polygraph Examination
- Drug screening test
- Standard medical examination
- Hearing test
- Psychological evaluation
- Physical abilities test
- T.A.B.E. test
The aforementioned tests will be administered in a manner selected by the Dawson County Sheriff’s Office. I understand that the results of the tests are the property of the agency to which I have applied, and that I will not receive copies of the reports nor any information contained in them, except as it may relate to a serious medical condition discovered by the examining physician.
A second Hiring Review Board will evaluate all tests in light of the requirements of the job, along with the previous information, and will make a final decision as to my suitability for employment.
I agree to assist in the expedient conclusion of these reviews and examinations. I understand that successful completion of this process does not guarantee employment with the Dawson County Sheriff’s Office, only that I will be considered for positions as they become available, pursuant to established rules and regulations of the Department. I have read and understand the content and purpose of this Letter of Understanding. I agree to abide by these requirements of employment with the Dawson County Sheriff’s Office.
______
Applicants Signature Date
Subscribed and Sworn to before me the ______day of ______, 20____.
Notary Public in and for said County of ______.
State of ______.
______
Notary Public
Certification and Penalty
I hereby declare that all statements and information provided to the Dawson County Sheriff’s Office in this Personal History Statement, as well as any other statements, and information provided for my pre-employment background investigation or any other phase of my pre-employment screening, are true and complete to the best of my knowledge and belief.
I understand that any misstatement of material fact, willful omission of material fact, or willful deception, will be cause for disqualification and rejection as a candidate for employment, without appeal.
I further understand that these aforementioned misstatements, omissions or deceptions are also grounds for termination after employment, without notice and without any right of appeal.
______
Applicants Signature Date
Subscribed and Sworn to before me the ______day of ______, 20____.
Notary Public in and for said County of ______.
State of ______.
______
Notary Public
Child Support / Alimony
Please check the box next to the appropriate responses. Failure to check a box that applies in each section, Child Support and Alimony, will result in denial of your application.
Child Support
I am subject to a Court order for the support of one or more children and I am in compliance with a Court order, or I am in compliance with a plan by the County Attorney (or other public agency) enforcing the order for the repayment of the amount owed pursuant to the order.
I am subject to a Court order for the support of one or more children and I am NOTin compliance with the order or a plan approved by the County Attorney (or other public agency) enforcing the order for the repayment of the amount owed pursuant to the order.
I am not subject to a Court order for the support of one or more children.
Alimony
I am subject to a Court order for payment of Alimony and I am in compliance with the Court order.
I am subject to a Court order for payment of Alimony and I am NOT in compliance with a Court order.
I am not subject to a Court order for Alimony.
Applicants Social Security Number:
______
Applicants Signature Date
Subscribed and Sworn to before me the ______day of ______, 20____.
Notary Public in and for said County of ______.
State of ______.
______
Notary Public
Personal Information
The following information is required of you for verification and contact purposes:
1. Your name (Please click on the gray box to fill in your information)
Last
First
Middle
List other names you have used or been known by. Include maiden names, married, adopted names and nicknames.
2. List the physical address of the residence where you live:
Number
Street
City
State
Zip Code
List your mailing address if different than your physical address:
3. List telephone number(s) at which you can be contacted and the hours when you will be available at these numbers:
Home
Work
Cell
4. Date of Birth
5. Place of Birth (City, State or Country)
U.S. citizenship is required for this position. Proof is required showing that
you are a legal resident of this Country.
6. Social Security Number: . In accordance with the Federal/Privacy Act of 1974, disclosure is voluntary. This information will be used for identification purposes to ensure that proper records are obtained.
Relatives, References, Acquaintances
During the course of the background investigation, persons who know you will be asked to comment upon your suitability for the position for which you have applied. Inquiries will be confined to job relevant matters.
7. Please supply the appropriate information in the spaces below. If a category is not applicable, type “N/A/”. Provide the name, address where the person can be contacted, include the City, State and Zip Code and provide a phone number where the person can be contacted.
Father
Mother
Father-in-law
Mother-in-law
Spouse
Former Spouse(s)
Brothers and Sisters
Step-Father
Step-Mother
Step-Brother and Sisters
List all offspring: (Please indicate “Son” or “Daughter” and whether natural, adopted, from another marriage, ect. List current address and phone numbers as listed above)
8. List as personal or professional references 3 – 5 individuals who have knowledge of you and your qualifications.
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
9. List individuals with whom you have resided within the past 10 years. List no information prior to your 15th birthday. Exclude family members.
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Name/Relationship
Address
Telephone
Residence
10. Please list all of your residences during the last 10 years. Begin with your most current residence and proceed backwards. If a residence was rented, give the landlord’s name, address and telephone number. List no information prior to you 15th birthday.
Address of residence
Date (From / To)
Reason for Leaving
Landlord Information
Address of residence
Date (From / To)
Reason for Leaving
Landlord Information
Address of residence
Date (From / To)
Reason for Leaving
Landlord Information
Address of residence
Date (From / To)
Reason for Leaving
Landlord Information
Address of residence
Date (From / To)
Reason for Leaving
Landlord Information
Education
11. The Commission on Peace Officer Standards and Training requires peace officer to possess a high school diploma or it’s equivalent. Please indicate your current status with regard to this requirement by checking the appropriate box.
I possess a high school diploma
I passed the G.E.D. (General Educational Development) test.
I possess the following college degrees (include name of college and year attended)
- List all of the schools you have attended, beginning with the high school. During the background investigation, persons who have known you in a learning environment may be contacted. A review of your school records may be made in conjunction with those contacts.
Name of School
Location (City& State)
Dates attended
Teacher
Name of School
Location (City& State)
Dates attended
Teacher
Name of School
Location (City& State)
Dates attended
Teacher
Name of School
Location (City& State)
Dates attended
Teacher
Name of School
Location (City& State)
Dates attended
Teacher
13. Have you ever been suspended or expelled from any high school or post-secondary school? (Post-secondary schools include colleges and universities, graduate schools, business and vocational schools… any formal education beyond the high school level).
Yes No
If “Yes”, please explain (include school, date and circumstances)
Experience and Employment
14. Beginning with your most current employment, list all jobs you have held in the past 10 years. For purposes of the Personal History Statement, part-time, temporary, and voluntary work should be included. Please list all periods of unemployment in chronological sequence in the spaces provided for you between employment listings.
Should you need to list additional experience / employment information, please use a sheet of paper and include with the return of this application in the EXACT same format as below.
Name & Address of Employer:
Telephone #:
Date of employment: From To
Full-time part-time Voluntary Military Service
Title or Duties:
Name of Supervisor:
Name of co-workers: (1)
(2)
(3)
Reason for leaving:
Unemployed From To
Name & Address of Employer:
Telephone #:
Date of employment: From To
Full-time part-time Voluntary Military Service
Title or Duties:
Name of Supervisor:
Name of co-workers: (1)
(2)
(3)
Reason for leaving:
Unemployed From To
Name & Address of Employer:
Telephone #:
Date of employment: From To
Full-time part-time Voluntary Military Service
Title or Duties:
Name of Supervisor:
Name of co-workers: (1)
(2)
(3)
Reason for leaving:
Unemployed From To
Name & Address of Employer:
Telephone #:
Date of employment: From To
Full-time part-time Voluntary Military Service
Title or Duties:
Name of Supervisor:
Name of co-workers: (1)
(2)
(3)
Reason for leaving:
Unemployed From To
Name & Address of Employer:
Telephone #:
Date of employment: From To
Full-time part-time Voluntary Military Service
Title or Duties:
Name of Supervisor:
Name of co-workers: (1)
(2)
(3)
Reason for leaving:
Unemployed From To
- If you have had no prior employment, please explain here:
17. Have you ever been fired or asked to resign from any place of employment?
Yes No
If “Yes”, give details to include when, name of employer and why:
18. Have you ever applied, successful or unsuccessfully, for another position with any law enforcement agency?
Yes No
If “Yes”, provide the year, agency, and check off the processes which you completed and whether you were disqualified or hired:
Year Name of Agency
Written Test Physical Agility Oral Interview Background
Polygraph Medical Exam Disqualified Hired
Year Name of Agency
Written Test Physical Agility Oral Interview Background
Polygraph Medical Exam Disqualified Hired
Year Name of Agency
Written Test Physical Agility Oral Interview Background
Polygraph Medical Exam Disqualified Hired
Year Name of Agency
Written Test Physical Agility Oral Interview Background
Polygraph Medical Exam Disqualified Hired
Military Service
19. Have you ever served in the Armed Forces, National Guard or Military
Reserves?
Yes No
If “Yes”, please supply the following information:
Branch of Service:
Service Number:
Dates of Service: From To
Type of Discharge:
20. Have you registered with the Selective Service? Yes No
If “Yes”, when?
21. Have you ever been subject of any judicial or non-judicial disciplinary action while in the Military, National Guard, or Military Reserves? Yes No
If “Yes”, please give details to include branch of service, when, where, circumstances, etc.
22. Past commanding officers or other military acquaintances are potential sources of relevant information pertaining to your background. Please list those who know you well enough to provide accurate information about you.
Name
Address
Telephone #
Military Unit
Dates
Name
Address
Telephone #
Military Unit
Dates
Name
Address
Telephone #
Military Unit
Dates
Name
Address
Telephone #
Military Unit
Dates
Name
Address
Telephone #
Military Unit
Dates
Financial
23. The management of personal finances is relevant to an individual’s qualifications for a position with a law enforcement agency. Therefore, please fill in the financial statement that follows. The amount of indebtedness, in itself, will not be used in evaluating your qualifications. The behavior exhibited in meeting your financial obligations will be reviewed. A credit reporting agency will be contacted for a report of your credit history.