BACKGROUND/HISTORY INFORMATION
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital, sexual orientation or veteran status, the presence of non-job-related medical conditions or handicap, or any protected status.
(PLEASE PRINT)
Position applied for______Date of Application______
How did you learn about us?
Advertisement______Friend______Walk in______
Employment Agency______Relative______Other______
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Last NameFirst NameMiddle Name
______
AddressStreetCityStateZip Code
______
Telephone NumberDriver’s License number/StateSocial Security Number
Have you ever filed an application with us before?Yes______No______
If yes, give date______
Have you ever been employed with us before? Yes______No______
If yes, give date______
Are you currently employed? Yes______No______
May we contact your present employer? Yes______No______
On what date would you be available to work?______
Are you currently on “lay off” status and subject to recall? Yes______No______
Can you travel if the job requires it? Yes______No______
Have you ever been convicted of a misdemeanor crime? Yes______No______
If yes, please list:
(a) The crime(s)______
(b The date(s) of conviction______
(c) The court(s) in which you were convicted______
If you are applying for a position involving the operation of a county owned vehicle, please answer the following:
(a) List all traffic infractions or offenses you were found to have committed, or for which you paid a fine or forfeited bail.
______
______
Have you ever been incarcerated at this facility or any other correctional facility? Yes______No______
If yes, please list:
(a) The charge(s)______
(b) The date(s) of incarceration______
(c) The place(s) of incarceration______
Have you ever used any type of illegal drug or prescription drug that did not belong to you?______
When/Type of drug used?______
Have you ever been a successful or unsuccessful candidate for another position with a law enforcement agency or correctional facility?
Yes______No______If yes, please give details (including when, where and circumstances):
______
______
______
You may use the back of the questionnaire pages to further explain your answers if necessary. If you answer “YES” to any answer, please write an explanation on the back. Be as detailed as possible. If you are not completely honest and up front with your responses, the result will be termination from the employment process.
Crimes:
1. Have you ever committed an act that you were not caught doing, but if caught, you would have been arrest?
Yes______No______
2. Have you ever been involved in any of the following? (if yes, please include when, where, and value on the back of this page).
A. Switching price tagsYes______No______
B. Car TheftYes______No______
C. Theft of car partsYes______No______
D. RobberyYes______No______
E. Burglary (home/business)Yes______No______
F. EmbezzlementYes______No______
G. Concealed weaponsYes______No______
H. Fires you startedYes______No______
I. Con GamesYes______No______
J. Leaving the scene of an accidentYes______No______
K. CounterfeitingYes______No______
L. Drug Trafficing (illegal or prescription)Yes______No______
M. MuggingYes______No______
N. AssaultYes______No______
O. Buy, sell or possess stolen propertyYes______No______
P. Using a stolen credit cardYes______No______
Q. Fail to pay alimony or child supportYes______No______
R. Illegally obtaining public assistance, Yes______No______
Workers comp, or unemployment fraud
3. Have you ever filed an insurance claim that was not accurate (overestimating losses)? Yes______No______
4. Has a law-enforcement agency ever been called because of something that you were involved in?
Yes______No______
5. Were you ever involved in a fight in which a weapon was used? Yes______No______
6. Have you ever injured or caused the death of another person? Yes______No______
7. Have you ever physically abused a spouse, boy/girlfriend or child? Yes______No______
8. Have you every intentionally damaged property belonging to another person?
Yes______No______
9. Have you ever filed a false police report? Yes______No______
10. What is the most serious thing you have ever done wrong in your life?
11. Have you ever participated in a riot or disturbance? Yes______No______
12. Since you have been an adult (18), have you ever had any sexual involvement with someone under 18 years old? Yes______No______
13. Have you ever sexually assaulted anyone? Yes______No______
14. Have you ever engaged in prostitution or used the services of a prostitute?
Yes______No______
15. Have you ever been accused of misconduct? Yes______No______
16. Have you ever been questioned by a law enforcement agency as a suspect in an investigation?
Yes______No______
17. Other than what has already been covered, have you been involved in anything that you could have been arrested for? Yes______No______
18. Have you ever belonged to, or associated with anyone belonging to any organization, past or present that would place integrity of MCCC in question (e.g. KKK, Nazi organization, AB, gang member, terrorist group or organized crime)? Yes______No______
19. Do you now or have you ever had regular associations with persons whom you knew or should have known were under criminal investigation, or who had a reputation in the community or with law enforcement agencies for involvement in criminal behavior? Yes______No______
Military
1. Have you ever served in any military organization? Yes______No______
If yes, what branch? ______
2. What type of discharge did you receive? ______
3. What were your dates of active service? ______to ______
4. Have you ever received a court martial, article 15, been tried on charges, or were you the subject of a summary court, deck court, Captain’s Mast, Company punishment, or any other type of disciplinary action while a member of the armed forces? Yes______No______
Arrest Records
1. Have you ever been arrested, charged, or detained by a law-enforcement agency, including military apprehensions? (include ANY arrests in which the charges were dropped, reduced, found not guilty, or in which the records were sealed or expunged. Failure to do so could result in termination of the application process. A Notice to Appear/Summons is considered an arrest and must also be listed.) (if yes, explain on back)
Yes______No______
2. Have you ever been on Probation, Parole, Community Control, Community Service or been in a diversion program? Yes______No______
3. What fines have you been required to pay, and were they paid on time? (other than traffic)
4. Have you ever been fingerprinted by a law-enforcement agency? Yes______No______
Drug Usage
1. How many times in your life have you used marijuana? ______/ Last time used? ______
2. If you have used marijuana multiple times, how often did you use and how much?
______times per ______(day, week, month, year)
3. Have you used any of the following? (if yes, include the total number of times and last date used)
______Amphetamines (uppers)______another person’s prescription
______Barbituates (downers)______PCP (Angel Dust)
______Mescaline______Crack
______Quaaludes______Cocaine
______LSD______Heroin
______Hash______Ecstasy
______Ice or methanphetamines______Designer Drugs
______Mushrooms______Peyote
______Bath Salts______other illegal substance not listed
4. Have you ever used inhalants or any other illegal substance to get high (paint, paint thinner, aerosol, glue)?
Yes______No______
5. Have you ever been involved in the purchase of any illegal drug? (Any amount from a single joint to a kilo)
Yes______No______
6. Have you ever been involved in the sale of illegal drugs, either directly or indirectly (including prescription drugs)? Yes______No______
7. Have you ever benefited from the sale of illegal drugs to include money, free drugs or sexual favors?
Yes______No______
8. Have you ever set up a drug deal? Yes______No______
9. Have you ever been in the company of people using illegal drugs? Yes______No______
10. What is the total amount of money you have spent on illegal drugs in your life? ______
11. Have you ever stolen money or drugs from a drug dealer? Yes______No______
12. Have you ever driven a vehicle under the influence of illegal drugs? Yes______No______
13. Have you ever tried to grow or cultivate any illegal drugs? Yes______No______
14. Explain in detail any other information relating to illegal drug use or involvement which was not covered, to include transportation, manufacturing, etc…
Theft of Merchandise
1. Estimate the total amount of merchandise, tools and equipment you have ever taken: $______
2. Name the single most expensive item that you have taken: ______
When: ______Value: $______
3. Have you ever taken or shoplifted anything from a business? Yes______No______
4. Have you ever been with anyone that you knew was stealing merchandise or equipment?
Yes______No______
5. Have you ever taken anything from a current or former employer? Yes______No______
6. Estimate the amount of cash that you have stolen in your life and explain each incident. (Include personal cash thefts from family or friends and cash thefts from employers, along with any other incidents)
7. Have you ever purchased, pawned, or sold an item in which you knew or thought might be stolen?
Yes______No______
Employment History
1. Have you ever been terminated from a job or have you been asked/forced to resign? If yes, explain.
Yes______No______
2. Have you ever been disciplined by a current or former employer? Yes______No______
3. Have you ever resigned or been given the opportunity to resign from a job in which you were under investigation for some type of misconduct or policy violation? If yes, explain Yes______No______
4. Did you list ALL of your jobs for the past ten years on your employment application, to include part-time and temporary jobs? Yes______No______
Driving History
1. Has your driver’s license ever been suspended or revoked? Yes______No______
2. What states other than Ohio have you had a driver’s license in? (List all states and include temporary and learning permits)
3. Are all the traffic citations that you have ever received listed on your employment application?
Yes______No______
4. Have you ever been involved in a traffic accident that was your fault? Yes______No______
5. Has your auto insurance ever lapsed? Yes______No______
6. How many times have you driven a vehicle under the influence of alcohol, where if stopped, you could have been arrested? ______When was the last time? ______
Aliases
1. List all names that you have ever used, to include maiden, nick names, married, and legal name changes and dates used:
Additional Questions for Applicants with Correctional Experience
1. Have you ever introduced contraband into a correctional facility? Yes______No______
2. Since becoming a corrections officer, have you had sexual involvement or sexual contact of any kind with an inmate or another officer on duty? Yes______No______
3. Have you ever accepted a bribe from an inmate or their friends/family? Yes______No______
4. Have you ever had or maintained a friendship or relationship with an inmate after they were released?
Yes______No______
5. Have you ever kept, used, or given away an inmate’s property/or money? Yes______No______
6. Have you ever used excessive force with and inmate? Yes______No______
7. Have you ever been accused of using excessive force on an inmate? Yes______No______
8. Have you ever been disciplined for excessive use of force? Yes______No______
It is the policy of the Multi-County Correctional Center to check references including previous employers and conviction records. As part of the MCCC hiring process applicants will be required to take a polygraph test. All information on this application is reviewed and confirmed during the polygraph.
Applicants Statement:
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision.
In the event of employment, I understand that false and misleading information or omissions given in my application or interview(s) may result in immediate discharge. I understand also that I am required to abide by all rules and regulations of the employer.
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Signature of ApplicantDate