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APPLICATION FOR EMPLOYMENT
APPLICANT INFORMATION
POSITION APPLIED FOR: ___________________________ DATE OF APPLICATION____________
NAME: LAST: ___________________ FIRST: _______________________ MIDDLE: _____________
ADDRESS: BOX # OR STREET __________________________________ CITY: _________________
DOB: _______________ STATE: ____________ ZIP: ________________ SSN: __________________
PLACE OF BIRTH: _________________ PHONE HOME: _________________CELL: _____________
E-MAIL: _________________________________________ MARITAL STATUS: ________________
NUMBER OF CHILDREN: ______________________________
SCARS, MARKS TATTOOS, AMPUTATIONS: ____________________________________________
ARE YOU A MILITARY VETERAN: YES_____ NO_____ BRANCH: _________________________ TYPE OF DISCHARGE________________________________________________________________
ARE YOU A U.S. CITIZEN: YES_____ NO_____ NATURALIZED CERTIFICATE # (IF APPLICABLE) ______________________________
HAVE YOU FILED AN APPLICATION HERE BEFORE: YES_____ NO_____ IF YES, DATE FILED: ________________________
ARE YOU EMPLOYED NOW: YES_____ NO_____ CAN WE CONTACT YOUR EMPLOYER_____
ON WHAT DATE WOULD YOU BE AVAILABLE TO START WORK: ________________________
HAVE YOU BEEN CONVICTED OF A MISDEMEANOR: YES_____ NO_____ OF A FELONY: YES_____ NO_____ IF YES TO ANY EXPLAIN: (INCLUDE TRAFFIC TICKETS) __________________________________________________________________________________________________________________________________________________________________________
HAVE YOU BEEN INVOLVED IN CIVIL LITIGATION DURING THE LAST THREE YEARS: YES_____ NO_____ IF YES, EXPLAIN: (INCLUDE IF SERVED CIVIL PAPERS OR INVOLVED IN SMALL CLAIMS LAWSUIT):___________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
DO YOU HAVE A VALID DRIVERS LICENSE: YES_____ NO_____ IF YES, LIST TYPE, DATE OF EXPIRATION AND RESTRICTIONS:______________________________________________________ ________________________________ IF NO, EXPLAIN:_____________________________________ _____________________________________________________________________________________
APPLICANT INFORMATION CONTINUED
HAVE YOU EVER BEEN DENIED ISSURANCE OF A LICENSE OR HAD IT SUSPENDED OR REVOKED: YES_____ NO_____ IF YES, EXPLAIN:________________________________________ _____________________________________________________________________________________
DO YOU HAVE ANY PHYSICAL, MENTAL, OR MEDICAL IMPAIRMENT OR DISABILITY THAT WOULD LIMIT YOUR JOB PERFORMANCE FOR THE POSITION YOU AR APPLYING FOR: YES_____ NO_____ IF YES, EXPLAIN: __________________________________________________
EDUCATION
HIGH SCHOOL: ____________________________ ADDRESS:_______________________________
FROM: ____________________ TO: _______________________
DID YOU GRADUATE: YES_____ NO_____ DEGREE:_____________________________________
COLLEGE: ________________________________ ADDRESS: _______________________________
FROM: ____________________ TO: _______________________
DID YOU GRADUATE: YES_____ NO_____ DEGREE: ____________________________________
OTHER: ___________________________________ ADDRESS: ______________________________
FROM: ___________________ TO: _________________________ DEGREE:____________________
DESCRIBE ANY SPECIALIZED TRAINING, SKILLS, AND EXTRA CURRICULAR ACTIVITIES: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
TYPING EXPERIENCE: YES_____ NO_____
COMPUTER EXPERIENCE: YES_____ NO_____
PERVIOUS EMPLOYMENT LAST FIVE YEARS OR LAST THREE EMPLOYERS
DATES OF EMPLOYMENT FROM: _________________TO _________________
EMPLOYER: __________________________________ JOB TITLE: ____________________________
ADDRESS: _______________________________________________ PHONE: ___________________
TYPE OF BUISNESS: _______________________ SUPERVISORS NAME: _____________________
STARTING SALARY: $______________________ ENDING SALARY: $_______________________
REASON FOR LEAVING: ______________________________________________________________
COMPLETE DESCRIPTION OF DUTIES: _________________________________________________ _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________
DATES OF EMPLOYMENT FROM: _________________TO _________________
EMPLOYER: __________________________________ JOB TITLE: ____________________________
ADDRESS: _______________________________________________ PHONE: ____________________
TYPE OF BUISNESS: _______________________ SUPERVISORS NAME: ______________________
STARTING SALARY: $______________________ ENDING SALARY: $________________________
REASON FOR LEAVING: _______________________________________________________________
COMPLETE DESCRIPTION OF DUTIES: __________________________________________________ _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________
REFERENCES
FULL NAME:__________________________RELATIONSHIP:______________________ ADDRESS:____________________________ PHONE: ___________________
FULL NAME:__________________________RELATIONSHIP:______________________ ADDRESS:____________________________ PHONE: ___________________
FULL NAME:__________________________RELATIONSHIP:______________________ ADDRESS:____________________________ PHONE: ___________________
DISCLAIMER AND SIGNATURE
I CERTIFY THAT MY ANSWERS 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. IN THE EVENT OF EMPLOYMENT. IF THIS APPLICATION LEADS TO EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION IN MY APPLICATION OR INTERVIEW MAY RESULT IN MY RELEASE.
_________________________________________________________ SIGNATURE OF APPLICANT DATE
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BRULE COUNTY SHERIFF’S DEPARTMENT APPLICANT SCREENING SURVEY
THIS DOCUMENT IS PREPARED BY THE UNDERSIGNED TO INFORM THE BRULE COUNTY SHERIFF’S DEPARTMENT OF MY BACKGROUND AND EMPLOYMENT HISTORY. I, _______________________________________DO HEREBY VOLUNTARYIL, WITHOUT DURESS, COERCION, THREATS OR PROMISE OF REWARD OF IMMUNITY, AGREE TO AN EXTENSIVE BACKGROUND INVESTIGATION CONDUCTED BY MEMBERS OF THE BRULE COUNTY SHERIFF’S DEPARTMENT. I UNDERSTAND THAT THIS PROCEDURE WILL INVOLVE PERSONAL INTERVIEWS WITH THOSE WHOM I HAVE LISTED ON THIS APPLICATION AS REFERENCES FOR EMPLOYMENT, AS WELL AS OTHER FORMER BUSINESS AND PERSONAL ASSOCIATES. I HEREBY RELEASE AND HOLD FOREVER HARMLESS THE MEMBERS OF THE BRULE COUNTY SHERIFF’S DEPARTMENT, ALL THOSE LISTED ON MY APPLICATION AS REFERENCES AND ALL OTHERS WITH WHOM THE INVESTIGATION MIGHT SPEAK REGUARDING MY BACKGROUND, FROM ALL LIABILITY RESULTING FROM SUCH RESEARCH INTO MY BACKGROUND.
__________________________________________________________________ APPLICANT’S SIGNATURE D/O/B DATE
__________________________________________________________________ WITNESS SIGNATURE, TITLE DATE
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