WARNING: GIVING FALSE INFORMATION AND/OR OMITTING INFORMATION WILL IMMEDIATELY DISQUALIFY AN APPLICANT

Transcription

1 Shelby County Sheriff s Office P.O. Box 1095 Columbiana, Alabama Date: File # Accept/Reject/Hold Initials: Reason: SHELBY COUNTY SHERIFF S OFFICE Answer every question in black ink in your own handwriting. Write NO or Not Applicable for questions that do not apply to you. INFORMATION WILL IMMEDIATELY DISQUALIFY AN APPLICANT 1. PRINT YOUR FULL NAME: (FIRST, MIDDLE, LAST) 2. YOUR PRESENT ADDRESS: (Please include mailing and physical address) Physical Address Mailing Address if different from Physical City State Zip Code 3. HOME PHONE: WORK PHONE: PAGER: CELL PHONE: 4. Date of Birth: / / (month/date/year) 5. Place of Birth:,, (City) (County) (State) 6. Social Security Number: INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 1 of 8 Rs. Frm. Rev.

2 7. Have you previously applied to the Shelby County Sheriff s Reserve? Yes No If Yes when? 8. How long have you lived in Shelby County? yrs. mos. 9. How long have you lived at your present address? yrs. mos. 10. Do you live in a: House Apartment Mobile Home Do you: Own Lease Rent 11. List home addresses for the past five (5) years: (begin with most recent) 12. Alabama Drivers License Information: (Attach copy of license to Application) Operators License Number: Expiration Date: Class: Restrictions: Endorsements: 13. HAVE YOU EVER BEEN ARRESTED, PLACED UNDER BOND, CHARGED OR CITED FOR ANY VIOLATION OF ANY LAW, ORDINANCE, OR POLICY REGULATION (INCLUDING TRAFFIC VIOLATIONS, EXCEPT FOR PARKING VIOLATIONS)? NO YES (IF YES EXPLAIN FULLY ON SEPARATE SHEET OF PAPER AND ATTACH TO APPLICATION) FAILURE TO DISCLOSE CRIMINAL HISTORY WILL RESULT IN IMMEDIATE DISQUALIFICATION INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 2 of 8

3 14. Military Service Record: SHELBY COUNTY SHERIFF S OFFICE Have you ever served in the armed forces (active or reserve) of the United States of America or any state thereof? YES NO Branch: Dates of Service: From: to Unit: Rank/ Rating at time of separation: Type of discharge: Are you now an active member of a reserve component? YES NO If YES, name and location of unit: 15. Employment History: Are you presently employed? YES NO If YES, may your employer be contacted regarding this application? YES NO Have you ever been discharged or requested to resign from any job or position? YES NO If YES, give details on a separate sheet and attach to application. List your work experience for the past 5 years: (include any military service) (Start with your present or most recent job, and list in reverse chronological order) Employer: From To Reason for leaving: Job duties: Employer: From To Reason for leaving: Job duties: INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 3 of 8

4 (Job History Continued) Employer: From To Reason for leaving: Job duties: Employer: From To Reason for leaving: Job duties: Describe your present work schedule in hours and days per week: 16. List three (3) personal references who know you well enough to testify as to your character: (Do not list relatives or members of the Shelby County Sheriff s Office) Name: Employer: Address: Phone: (home) (work) Known (years)? Name: Employer: Address: Phone: (home) (work) Known (years)? Name: Employer: Address: Phone: (home) (work) Known (years)? INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 4 of 8

5 17. Educational History: Circle highest grade/years of education completed: High School: Graduated: Year (Diploma: YES NO) ( GED: YES NO) Last date above school attended: month: year: List colleges and/or universities attended, degrees, area of study and number of years: 18. Special Training: List all special schools, institutes, training centers attended: (be sure to list training that is pertinent to law enforcement or associated skills) (list dates, subjects, and certificates received) 19. List any police training or experience you have had including civil defense training: ( list date, place, department, type of experience and name of supervisor) INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 5 of 8

6 20. List your hobbies: 21. List days and hours of the week that you will be available for regular patrol duty if accepted into this program: How many shifts per month are you willing to work? 22. How did you find out about the Shelby County Sheriff s Reserve Program? 23. List the names of present reserves that you know: 23. On the attached sheet, write a 150 word essay in your own handwriting, describing why you want to be a Reserve Deputy, your personal feelings about serving your county and community, and your future plans if accepted into this program. I FULLY UNDERSTAND THAT IT IS A FEDERAL/STATE CRIME PUNISHABLE BY FINE OR IMPRISONMENT, OR BOTH, TO KNOWINGLY MAKE ANY FALSE STATEMENTS CONCERNING THE ABOVE FACTS AS APPLICABLE. (Legal Signature of Applicant) (Date) INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 6 of 8

7 Personal Essay - Approximately 150 Words INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 7 of 8

8 INFORMATION WILL RESULT IN IMMEDIATE DISQUALIFICATION Page 8 of 8 End of Application