Please detach this sheet from the application and keep for future reference

Please detach this sheet from the application and keep for future reference

LUMPKIN COUNTY SHERIFF’S OFFICE

EQUAL OPPORTUNITY EMPLOYERS

APPLICATION INFORMATION FORM SO-1

TO: APPLICANT FOR THE LUMPKIN COUNTY SHERIFF’S OFFICE POSITION

Attached is an application for employment with the Lumpkin County Sheriff's Office. You must be at least 21 years of age and meet certain other standards to be considered for employment as a Deputy Sheriff. You must be at least 18 years of age to be considered for employment as a Detention Officer or Communications Officer.

THE FOLLOWING DOCUMENTS ARE REQUIRED TO BE SUBMITTED WITH YOUR APPLICATION.

Certified copy of Birth Certificate

Certificate of Citizenship if naturalized or repatriated citizen of the United States

Certified copy of High School / college Diploma or GED

Certified copy of Military Discharge (Form DD214, Member 4), if a veteran of the Armed Forces

Georgia P.O.S.T. Certificate if certified by the State of Georgia as a Law Enforcement Officer

(A) Applicants will be required to have fingerprints made as a part of the criminal history background investigation. The Lumpkin County Sheriff's Office will arrange to have this completed.

(B) Applicants considered for employment may be required to submit to a pre-employment Polygraph examination at the request and expense of the Lumpkin County Government. Polygraph questions may be drawn from the following areas. Driving Record, Illegal Drugs, Criminal Activity, Physical Health, Thefts, Work Record.

(C) Applicants considered for employment are required to complete a pre-employment health screen at the request and expense of the Lumpkin County Government.

(D) Applicants considered for employment are required to complete a pre-employment Drug Screen at the request and expense of the Lumpkin County Government.

(E) Applicants who do not successfully complete any part of the pre-employment process will not be considered as eligible for employment.

(F) a background investigation of all Applicants will be conducted by the Lumpkin County Sheriff's Office. The investigation will include viewing records concerning criminal and driver’s histories. If any, contacting/interviewing past employers and personal references as listed on the application, and contacts with other parties that might arise from the investigation to confirm suitability for employment.

(G) the duration of the pre-employment process from the receipt of the application to the pre-employment interview is approximately 60-120 days.

(H) Applicants considered for employment with the Lumpkin County Sheriff's Office may be required to participate in an oral assessment conducted by the Sheriff's Office.

(I) Upon successful completion of all aforementioned requirements, applicants being considered for employment with the Lumpkin County Sheriff's Office are scheduled for an interview with the Sheriff.

Questions regarding the status of your application or questions related to employment, interviews, etc. should be directed to the Lumpkin County Sheriff's Office (706) 864-0414.

LUMPKIN COUNTY

APPLICATION FOR EMPLOYMENT

DATE________________________

LUMPKIN COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER. QUALIFIED APPLICANTS ARE CONSIDERED FOR POSITIONS WITHOUT REGARD TO AGE, COLOR, DISABILITY, MARITAL STATUS, NATIONAL ORIGIN, RACE, RELIGION, OR SEX.

All applications are evaluated based on individual merit. Information MUST BE COMPLETE so all applications can be given equitable consideration. Application must be typed or printed. YOU MUST SIGN AND DATE YOUR APPLICATION IN INK. INCOMPLETE APPLICATIONS WILL BE REJECTED.

POSITION APPLIED FOR:

POSITION:_________________________________________ JOB CODE:___________________________

__________________________________________________ ____________________________________

Last Name First Name Middle Name SOCIAL SECURITY NUMBER

(For Application Identification)

__________________________________________________ (________)__________________________

Address Number, Street, Apt. Number Area Code Home Phone

__________________________________________________ (________)__________________________

City State Zip Code Area Code Work Phone

PREVIOUS ADDRESS ____________________________________________________________________________________________

Street City State Zip Code

How long did you live at that address? _____________________Years ____________________Months

Have you previously been employed by Lumpkin County?_________________________________________________________

If yes, when and what department? _____________________________________________________________________________

WILL YOU ACCEPT: Temporary Work_______ Part-Time Work_______ Shift Work _______ Weekend/Holiday _________

Are you able to perform the essential job functions of the position you are applying for without an accommodation?

_________Yes __________No

If no, please describe the accommodations necessary for you to perform the essential job functions.

_______________________________________________________________________________________________________________

Do you have the legal right to live and work in the United States? ______________Yes ______________No

If offered employment, you will be required to provide documentation to verify employment eligibility. Failure to provide requested documentation may result in a determination that the applicant is ineligible for employment in the United States.

Do you have any relatives working for Lumpkin County Government? ____________ Yes ____________ No

Name Relationship City or County Employee

_____________________________ _______________________________ __________________

Have you ever been convicted of an offense against the law or are you now under charges for any offense against the law? Omit non-moving traffic violations and any offense which was finally adjudicated in a Juvenile Court or under a Youth Offender Law. ______ No ______Yes If yes, give complete details: (Date, Place, Charges, Disposition)

_________________________________________________________________________________________________________

CRIMINAL RECORD: Convictions (felonies, misdemeanors) TRAFFIC RECORD:

CRIME COURT DATE OFFENSE DATE

_________________________________________ ____________________________________

NOTE: A conviction will not necessarily bar you from employment. Each conviction will be judged on its own merits with respect to time, circumstances and seriousness.

Do you have a valid Drivers License? __________No _________Yes License #______________________ State______

EDUCATION RECORD

Circle highest year completed HIGH SCHOOL 1 2 3 4 COLLEGE 1 2 3 4 5 6

Schools Attended Did you Diploma Major

Past & Present Name & Location Graduate? GED or Degree Studies

High School

___________________________________________________________________________________

Associates Degree

___________________________________________________________________________________

Bachelors Degree

___________________________________________________________________________________

Masters Degree

___________________________________________________________________________________

Doctorate Degree

___________________________________________________________________________________

Other (Vocational, Tech,

AIB, Etc.)

___________________________________________________________________________________

List licenses and certificates that have a direct bearing on the job you are seeking:

Type of Certificate Specialization Certificate Number Expiration Date

____________________ ____________________ ____________________ ______________

Have you served in the U.S. Armed Forces? ________ No ________ Yes If yes, what branch?___________________

Rank_________________________________________ Applicable Skills Acquired _______________________________

WORK HISTORY

Describe your work history beginning with your current or most recent job. Include military and volunteer experience. Failure to give complete information regarding each job held may result in your disqualification. Complete address with zip codes and telephone numbers for all employers are necessary. A resume may be attached only as additional information and will not be accepted in lieu of completing this section. May we contact these employers? ________ Yes ________ No

Employer Employed Supervisor’s Name

______________________________ From_____________ Month/Year _______________________________

Address To _______________ Month/Year Your Job Title

______________________________ _______________________________

City State Zip Code Telephone Number

______________________________ __________________________

YOUR SALARY DUTIES:

Start End ___________________________________________________

$______________ $_____________ ___________________________________________________

Reason For Leaving

___________________________________________________________________________________

Employer Employed Supervisor’s Name

______________________________ From_____________ Month/Year _______________________________

Address To _______________ Month/Year Your Job Title

______________________________ _______________________________

City State Zip Code Telephone Number

______________________________ __________________________

YOUR SALARY DUTIES:

Start End ___________________________________________________

$______________ $_____________ ___________________________________________________

Reason For Leaving

___________________________________________________________________________________

Employer Employed Supervisor’s Name

______________________________ From_____________ Month/Year _______________________________

Address To _______________ Month/Year Your Job Title

______________________________ _______________________________

City State Zip Code Telephone Number

______________________________ __________________________

YOUR SALARY DUTIES:

Start End ___________________________________________________

$______________ $_____________ ___________________________________________________

Reason For Leaving

___________________________________________________________________________________

Employer Employed Supervisor’s Name

______________________________ From_____________ Month/Year _______________________________

Address To _______________ Month/Year Your Job Title

______________________________ _______________________________

City State Zip Code Telephone Number

______________________________ __________________________

YOUR SALARY DUTIES:

Start End ___________________________________________________

$______________ $_____________ ___________________________________________________

Reason For Leaving

___________________________________________________________________________________

APPLICANT’S CERTIFICATION AND AUTHORIZATION – Read carefully before signing.

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 understand that false or misleading information given in my application or interviews) may result in disqualification or discharge if hired, and that I am required to abide by all rules and regulations of Lumpkin County. I also consent to undergo a physical examination including a drug screen after I have been offered employment, as deemed necessary.

_____________________________________________ ________________________________

Applicant’s Signature Date

REFERENCES (At least three – not relatives)

Name and Address Occupation Telephone

___________________________________________________________________________

Please use this space for additional information pertinent to your education, training and experience: __________________________________________________________________________

SHERIFF’S OFFICE QUESTIONNAIRE

THE SHERIFF’S OFFICE IS REQUIRED TO ORDER CREDIT/INVESTIGATIVE BACKGROUND INFORMATION ON APPLICANTS FOR LAW ENFORCEMENT. PLEASE COMPLETE THE FOLLOWING IN ORDER THAT A MORE ACCURATE AND COMPLETE REPORT IS RECEIVED:

POSITIONS REQUIRE SHIFT WORK OR ROTATING SHIFT WORK AND OTHER TYPES OF DEPARTURE FROM STANDARD DAYTIME OPERATING HOURS, WEEKENDS AND HOLIDAY HOURS. AS A NECESSARY CONDITION OF EMPLOYMENT, DO YOU ACCEPT SHIFTS, ROTATING SHIFTS, OR OTHER NECESSARY DEPARTURES FROM STANDARD OPERATING HOURS? ____________

DO YOU HAVE ANY MEDICAL OR EMOTIONAL PROBLEMS, OR DISABILITY THAT WOULD PREVENT YOU FROM PERFORMING ALL DUTIES REQUIRED OF A COMMUNICATIONS DISPATCHER? ____________________________

IF YES, EXPLAIN:_____________________________________________________________________________

HAVE YOU EVER WORKED IN A POSITION OF TRUST THAT GAVE YOU AVAILABILITY TO CONFIDENTIAL, PRIVILEGED INFORMATION, OR INFORMATION OF A SECURITY/LAW ENFORCEMENT NATURE? _____________

IF YES, EXPLAIN:_____________________________________________________________________________

HAVE YOU EVER BEEN ASKED TO RESIGN OR HAVE YOU EVER BEEN TERMINATED (FIRED) FROM A JOB?_____

IF YES, EXPLAIN:_____________________________________________________________________________

IF YOU HAVE EVER BEEN FINGERPRINTED BY A POLICE OR MILITARY AGENCY OTHER THAN FOR AN ARREST, GIVE DETAILS BELOW. (YOUR ANSWER WILL BE CHECKED WITH THE FBI AND OTHER AGENCIES)

___________________________________________________________________________________

WERE YOU EVER THE SUBJECT OF A COMPANY PUNISHMENT, OR ANY OTHER DISCIPLINARY ACTION WHILE A MEMBER OF THE ARMED FORCES, NATIONAL GUARD OR OTHER RESERVE UNIT? ____________________

IF YES, EXPLAIN:_____________________________________________________________________________

DO YOU DRINK ALCOHOLIC BEVERAGES? ___________ IF YES, TO WHAT DEGREE?______________________

HAVE YOU BEEN OR ARE YOU NOW AN UNLAWFUL USER OF MARIJUANA OR A DEPRESSANT, STIMULANT, OR NARCOTIC DRUG? ______________ IF YES, WHAT WERE THE CIRCUMSTANCES?

___________________________________________________________________________________

LIST NAME(S) AND AGE(S) OF CHILDREN AND OTHER DEPENDENTS WHETHER LIVING IN YOUR HOUSEHOLD OR NOT:

NAME RELATIONSHIP AGE

_______________________________ _____________________________________ _________

APPLICANT’S CERTIFICATION (READ THE FOLLOWING STATEMENT BEFORE SIGNING QUESTIONNAIRE):

I HEREBY CERTIFY THAT ALL STATEMENTS MADE ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND AND AGREE THAT ANY MISSTATEMENTS OR OMISSIONS OF MATERIAL FACT HEREIN MAY CAUSE ANY OFFER OF EMPLOYMENT MADE BY THE LUMPKIN COUNTY SHERIFF’S TO BE WITHDRAWN, OR IF EMPLOYED, MY EMPLOYMENT TO BE TERMINATED. I FURTHER UNDERSTAND THAT ANY EMPLOYMENT OFFERED TO ME WILL BE CONTINGENT UPON THE RESULTS OF A COMPLETE CHARACTER AND FITNESS INVESTIGATION. I FURTHER AND FULLY UNDERSTAND AND CONSENT TO A POLYGRAPH EXAMINATION CONCERNING THE VERACITY OF MY RESPONSES TO THE INFORMATION REQUESTED ON THIS APPLICATION/QUESTIONNAIRE. I ALSO UNDERSTAND AND AGREE THAT THIS EMPLOYMENT APPLICATION/QUESTIONNAIRE SHALL BE THE PROPERTY OF THE LUMPKIN COUNTY SHERIFF’S OFFICE. I UNDERSTAND AND AGREE THAT IF EMPLOYED, I WILL NOT DIVULGE TO ANYONE ANY CONFIDENTIAL, PRIVILEGED INFORMATION ACQUIRED BY ME.

DURING MY EMPLOYMENT, EXCEPT AS MAY BE REQUIRED BY LAW. IT IS UNDERSTOOD THAT, AS A CONDITION OF EMPLOYMENT IN THE LUMPKIN COUNTY SHERIFF’S OFFICE, I WILL, AS PROVIDED BY LAW GOVERNING PROTECTIVE SERVICES PERSONNEL, SUBMIT TO A POLYGRAPH TEST WHEN SPECIFICALLY ORDERED TO DO SO.

_________________________________________________________ ______________________________

SIGNATURE OF APPLICANT DATE

_________________________________________________________

WITNESS

I CERTIFY THAT I HAVE RECEIVED A COPY OF APPLICANT INFORMATION FORM SO-1 (COVERSHEET).

_________________________________________________________ ______________________________

SIGNATURE OF APPLICANT DATE SIGNED

CONSENT FORM

As an applicant for a protective service, ie., Peace Officer, Detention Officer, Dispatcher, etc., or any other classified position wherein I may be located near or around inmates and/or have availability to classified law enforcement data, I hereby authorize Lumpkin County to receive any criminal history records information, driver history records information, or any other pertinent information pertaining to me which may be in the files of any federal, state or local criminal justice agency to be used for the purpose of my background investigation.

___________________________________________________________________________________________

FULL NAME PRINTED: First, Middle, Last

___________________________________________________________________________________________

STREET ADDRESS, APARTMENT NUMBER, ETC. (Do not list Post Office Box Numbers)

DRIVER’S LICENSE NUMBER_______________ STATE OF ISSUE_____________ EXPIRATION DATE__________

In addition to your current state of residence, list all other states where you have lived. If none other, write "none" in this space:

___________________________________________________________________________________________

PLACE OF BIRTH ___________________________________________ DATE OF BIRTH____________________

City/County/State Month/Day/Year

CITIZENSHIP_________________________________ SOCIAL SECURITY NUMBER ________________________

HEIGHT:____________FT. _____________ IN. WEIGHT:___________________ SEX _______________

RACE: ___________________ COLOR OF HAIR: ___________________ COLOR OF EYES _________________

(spell out) (spell out) (spell out)

___________________________________________________________ _____________________________

SIGNATURE OF APPLICANT DATE

___________________________________________________________

NOTARY SIGNATURE

___________________________________________________________

MY COMMISSION EXPIRES

PERSONAL INQUIRY WAIVER

NAME______________________________________________________ DATE________________________

DATE OF BIRTH______________________________________________

SOCIAL SECURITY NUMBER_____________________________________

I respectfully request and authorize you to furnish Lumpkin County with ay and all information that you may have concerning my school record, reputation, or other facts as may be relevant to the nature of this inquiry. This information is to be used to assist the requesting agency in determining my qualifications and fitness for a position with Lumpkin County.

I hereby release you, your organization, Lumpkin County Government, and any others from any liability or damage which may result from furnishing the information requested. This instrument is valid for twelve months from the above date and may be photocopied as needed by the requesting official(s).

___________________________________________________________

Applicant’s Signature

___________________________________________________________

Address (Number, Street, Apartment)

___________________________________________________________

City State Zip Code

AFFIDAVIT

STATE OF GEORGIA, COUNTY OF LUMPKIN

Before me personally appeared the said __________________________________________ who says that he/she executed the above instrument of his//her own free will and accord, with full knowledge of the purpose thereof.

Sworn to and subscribed in my presence this _________ day of __________________________, 20_______.

_________________________________________

Notary Public

My Commission Expires: ____________________

Georgia Bureau of Investigation

Georgia Crime Information Center

Georgia Driver’s History Consent Form

I hereby authorize the __________________________________________________________________

(fire department/law enforcement agency name)

to receive a copy of my Georgia driver’s history information as part of my application for criminal justice employment, or for use relative to the performance of my official duties with this agency.

_____________________________________________________________________________________

Full Name (print)

_____________________________________________________________________________________

Address

__________ ______________________ ________________________________

Sex Date of Birth Driver’s License Number

_________________________________________________________________

Signature

___________________________

Date

GCIC Consent Form

July 2006