SHERIFF S OFFICE S H E R I F F S A S S O C I AT I O N GA. Ezell Brown, Sheriff COMMITTED TO EXCELLENCE

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1 GEORGIA NEWTON S H E R I F F S A S S O C I AT I O N GA. COUNTY Ezell Brown, Sheriff COMMITTED TO EXCELLENCE Ph: (678) Fax: (678) An Equal Opportunity Employer.

2 GEORGIA NEWTON S H E R I F F S A S S O C I AT I O N GA. COUNTY NEWTON COUNTY EZELL BROWN, SHERIFF INSTRUCTION SHEET To be considered for employment, applicants must meet the following minimum qualifications: Applicants must be at least 21 years of age for Deputy Sheriff positions, 18 years of age for Detention Officer and civilian positions, possess a high school diploma or equivalent, possess a valid driver s license, honorable discharge (if prior military), be a US citizen, have no adverse driving record nor felony or family violence convictions, and be of good moral character. The applicant must complete ALL FORMS ACCURATELY, LEGIBLY, and COMPLETELY. DO NOT LEAVE ANY BLANK SPACES. If a question does not apply to you write N/A in the space. PRINT ANSWERS to questions with a BLACK INK PEN ONLY. Be absolutely truthful, a false statement or the omission of requested information is grounds for automatic rejection before appointment or termination after employment. If you answer yes to a question, you need to be complete in explaining the circumstances. Do not omit an explanation because you think the incident was minor and of no importance. If the space is insufficient to complete your answers, please attach supplementary pages. The following documents are required to begin the application process and must be mailed in with the application: A copy of your high school diploma or equivalent A copy of your birth certificate A photo copy of your current driver s license A full MVR from Department of driver s services A copy of your COMPASS or ASSET scores The completed application and required documents must be returned to Newton County Human Resources at the following address: Newton County Human Resources 1124 Clark Street Covington, GA **NOTE: Some pages require Notary. Upon submission, your application and supporting documents will be reviewed for completeness. If your application is incomplete, it will be returned to you. Applications that are complete and meet the minimum requirements will be forwarded to the Newton County Sheriff s Office, Office of Professional Standards for processing. The hiring process includes but is not limited to the following: an oral board interview, an intensive background investigation, voice stress analysis, and, following a conditional job offer, medical examination, drug screen and psychological examination. If you have any questions concerning this process please contact the Newton County Sheriff s Office at (678) The Newton County Sheriff s Office is an Equal Opportunity Employer and does not discriminate on the basis of race, color, National origin, sex, religion, or disability in employment or provision of services. The following documents are required if they are applicable to you and must be mailed in with the application: Long DD214 Form, showing Honorable Discharge (if former military) Certified College Transcripts (sealed) Any name change documents Citizenship Papers Copy of Bankruptcy discharge papers COMMITTED TO EXCELLENCE Ph: (678) Fax: (678)

3 15151 Alcovy-Jersey Rd., NE Covington, Georgia Position Applied For: Deputy Sheriff Detention Officer Civilian Reserve Deputy I. PERSONAL INFORMATION Name (Last, First, Middle) Social Security # Home How long have you lived at your current address? Home Telephone: Cellular Telephone: Business Telephone: Address: Are you a citizen of the United States? Yes No If no, are you a permanent resident? Yes No Place of Birth (City, County, State/Country) Have you ever used another name or had your name changed? Yes No (This includes Maiden Names, Former Married Names, Adopted Names, Nicknames, etc.) If you answered yes, please provide the following information: Previous Name Date of Change Location of Change Reason for Change Have you ever applied with the Newton County Sheriff s Office before? Yes No Position last applied for and date: Are you currently employed with Newton County? Yes No Were you previously employed with Newton County? Yes No If yes: Date started/ Date left/ Position(s) held: Page 1 of 28

4 Do you have any relatives employed with Newton County? Yes No If yes, indicate each: Relative s Name Relationship Department Employed How did you learn of this position? Please list all organizations, Clubs and Associations which you are now, or have ever been a member of: Name of Organization Date Began Date Ended Position Held Please list any technical skills that you possess that may relate to the position applied for: Skill How Long Related Training Please list any foreign language that you have learned and the extent of your proficiency: Language Proficiency (some, moderate, fluent) Page 2 of 28

5 II. EDUCATION What is your highest grade completed? Are you a high school graduate? Yes No Name of High School: Dates Attended: How long have you lived at your current address? Telephone Number: Date Graduated: Did you receive a GED certificate? Yes No Name of School or Local Board of Education: List all colleges, universities, business/technical schools or graduate schools that you have attended: Name of school Address Start Date End Date Major/Minor Degree Earned III. LAW ENFORCEMENT EXPERIENCE List all law enforcement or corrections agencies that you have applied with. List the agency name, date of application, and status of your application (how far are you or did you get in the process). Agency Name Date of Application Application Status Contact name (if known) Page 3 of 28

6 III. LAW ENFORCEMENT EXPERIENCE Are you currently a Georgia P.O.S.T. Certified Peace Officer Yes No Georgia P.O.S.T. PBLE number: Have you been awarded any Georgia P.O.S.T. certification or certification from another state? Yes No If yes, please provide: State of Issuance Type of Certification Certification Number How many years and months experience do you have as a certified law enforcement officer? Is your Law Enforcement, Correction, Jailer, Probation, or Parole Officer Certification under investigation by any state or federal Law Enforcement Training Council? Yes No If yes, please attach a narrative on a separate sheet of paper explaining in detail the cause for the investigation. Has your Law Enforcement, Correction, Jailer, Probation, or Parole Officer certification ever been revoked or placed on probation by any state or federal Law Enforcement Training Council? Yes No If yes, please attach a narrative on a separate sheet of paper explaining in detail the cause for the revocation or probation. Page 4 of 28

7 III. LAW ENFORCEMENT EXPERIENCE List ALL disciplinary action received while working in a law enforcement position. Include any oral or written reprimands, suspensions, demotions or termination, the date of the action, reason for the action, and indicate whether you are currently involved in an internal investigation. Agency Name Disciplinary Action Date of Action Internal Affairs Investigation (open or closed) Reason for disciplinary action Have you ever resigned from employment while under active internal investigation? Yes No If yes, explain: IV. MILITARY SERVICE Have you ever served in any branch of the United States Armed Forces? This also includes Reserves, National Guard, and Coast Guard. Yes No If yes, what branch? What type of military discharge did you receive? (Honorable, Dishonorable, General, Under Honorable Conditions, Entry Level Separation, Medical, etc.) Be specific: Have you ever been involved in, or been accused of being involved in, a subversive act against the United States Government, or any other government, such as mutiny, treason, sabotage, espionage, etc.? Yes No If yes, fully explain on a separate attached narrative. Page 5 of 28

8 IV. MILITARY SERVICE Applicants that served in the military must complete the following: Branch of Service Enlistment Period Highest Rank Held Service Number Have you ever been court-martialed, tried on charges, or subject of an Article 15, company punishment, or any other disciplinary action while a member of any branch of the Armed Forces? Yes No *If yes, please explain in detail on a separate attached narrative. Include type of disciplinary action taken, branch of service, date of action, disposition of action and explanation of offense. V. PERSONAL REFERENCES Please list five (5) personal references. These must be people who are responsible adults of reputable standing in their community and who have known you for at least 4 years. They may not be relatives, anyone living within your household or current/former employers. Confirm that all the addresses and telephone numbers are current before submitting your application. Reference 1: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Page 6 of 28

9 Reference 2: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Reference 3: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Reference 4: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Reference 5: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Page 7 of 28

10 VI. NEIGHBOR REFERENCES Please provide three (3) current neighbor references. The neighbor reference may live next door to you or within three (3) houses or apartment units in any direction of your residence. Please confirm that all addresses and telephone numbers are current before submitting your application. Reference 1: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Reference 2: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Reference 3: Name: Relationship: Home Phone Number: Occupation: Years Known: Cellular Telephone Number: Page 8 of 28

11 VII. RESIDENCE HISTORY Please list all of your addresses for the last ten years. Start with your present address. You must include all permanent, temporary, part-time, military, and school addresses in which you have resided. FROM MO/YR TO MO/YR STREET ADDRESS CITY COUNTY STATE ZIP Page 9 of 28

12 VIII. EMPLOYMENT HISTORY List all jobs worked in the last 15 years. Include military, volunteer experience, self-employment, internships, and periods of unemployment, ALL part-time work and ALL full-time work. For any gap of unemployment, write UNEMPLOYED under Employer section and explain your means of support (i.e. parents, spouse income, unemployment benefits, etc.). All periods of time should be accounted for during the last fifteen years. A resume may be attached ONLY as additional information and WILL NOT be accepted in lieu of completing this section. If more space is needed, attach additional pages including all information that is asked. Begin with your most recent or current employment. Please provide current telephone numbers (including area code) for all employers. Employer 1: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Employer 2: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Page 10 of 28

13 VIII. EMPLOYMENT HISTORY List all jobs worked in the last 15 years. Include military, volunteer experience, self-employment, internships, and periods of unemployment, ALL part-time work and ALL full-time work. For any gap of unemployment, write UNEMPLOYED under Employer section and explain your means of support (i.e. parents, spouse income, unemployment benefits, etc.). All periods of time should be accounted for during the last fifteen years. A resume may be attached ONLY as additional information and WILL NOT be accepted in lieu of completing this section. If more space is needed, attach additional pages including all information that is asked. Begin with your most recent or current employment. Please provide current telephone numbers (including area code) for all employers. Employer 3: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Employer 4: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Page 11 of 28

14 VIII. EMPLOYMENT HISTORY List all jobs worked in the last 15 years. Include military, volunteer experience, self-employment, internships, and periods of unemployment, ALL part-time work and ALL full-time work. For any gap of unemployment, write UNEMPLOYED under Employer section and explain your means of support (i.e. parents, spouse income, unemployment benefits, etc.). All periods of time should be accounted for during the last fifteen years. A resume may be attached ONLY as additional information and WILL NOT be accepted in lieu of completing this section. If more space is needed, attach additional pages including all information that is asked. Begin with your most recent or current employment. Please provide current telephone numbers (including area code) for all employers. Employer 5: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Employer 6: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Page 12 of 28

15 VIII. EMPLOYMENT HISTORY List all jobs worked in the last 15 years. Include military, volunteer experience, self-employment, internships, and periods of unemployment, ALL part-time work and ALL full-time work. For any gap of unemployment, write UNEMPLOYED under Employer section and explain your means of support (i.e. parents, spouse income, unemployment benefits, etc.). All periods of time should be accounted for during the last fifteen years. A resume may be attached ONLY as additional information and WILL NOT be accepted in lieu of completing this section. If more space is needed, attach additional pages including all information that is asked. Begin with your most recent or current employment. Please provide current telephone numbers (including area code) for all employers. Employer 7: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Employer 8: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Page 13 of 28

16 VIII. EMPLOYMENT HISTORY List all jobs worked in the last 15 years. Include military, volunteer experience, self-employment, internships, and periods of unemployment, ALL part-time work and ALL full-time work. For any gap of unemployment, write UNEMPLOYED under Employer section and explain your means of support (i.e. parents, spouse income, unemployment benefits, etc.). All periods of time should be accounted for during the last fifteen years. A resume may be attached ONLY as additional information and WILL NOT be accepted in lieu of completing this section. If more space is needed, attach additional pages including all information that is asked. Begin with your most recent or current employment. Please provide current telephone numbers (including area code) for all employers. Employer 9: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Employer 10: Employer: Telephone Number: Dates Employed (from/to) Total time employed: Job Title: Supervisor s Name: Out of business? Brief description of duties: Reason for leaving: Page 14 of 28

17 IX. APPLICANT QUESTIONNAIRE If you answer YES to questions 4-29, you must explain in full detail on the explanation sheet provided with this questionnaire. Be sure to indicate the question number that you are addressing. 1. Are you available to work any hour of the day, day of the week, including holidays and be available during unusual occurrences for call-outs? Yes No 2. Will you consent to a thorough background investigation of your character? Yes No 3. Will you consent to a medical examination by a physician and a psychological evaluation upon a conditional offer of employment? Yes No 4. Have you ever been rejected for employment, for any reason, by any law enforcement agency? If yes, what agency and why? Yes No 5. Have you ever been terminated by any law enforcement agency? If yes, give the agency, date of termination, and reason. Yes No 6. Have you ever been terminated or asked to resign from any job? If yes, list the name of the employer(s), dates of employment, and reason for termination or resignation under pressure. Yes No 7. Have you ever been physically arrested or given a copy of charges for violation of any city, municipal, state, or federal law? Yes No 8. Have you ever appeared in any court (including juvenile) as a defendant to answer any city, municipal, state, or federal criminal charge? If so, give the court in which you appeared and the disposition of the case (i.e. conviction, First Offenders, charges dismissed, etc). Yes No 9. Have you ever been detained by any law enforcement representative, been the subject of any criminal investigation, or been named as the accused on a warrant? If yes, explain in detail. Yes No 10. Have you ever received any tickets for traffic violations (excluding parking tickets) on any license that you have held since you began driving? If yes, list type of violation, date received, jurisdiction, and disposition (i.e. fine, suspension, charges dismissed). Yes No 11. Have you ever used, tried, ingested, or experimented with marijuana (including as a juvenile or even one experimental use)? If yes, write the number of times used, the first date used, and the date of last use. Yes No 12. Have you ever used, tried, ingested, or experimented with any other type of illegal narcotics or dangerous drugs (i.e. heroin, cocaine, hashish, speed, LSD, anabolic steroids, etc.)? If yes, indicate what type of drug and when you used it? Yes No 13. Have you ever sold any type of illegal drug, delivered illegal drugs, shared drugs with another person, or directed another person where to buy drugs? If yes, indicate what type of drug and when. Yes No Page 15 of 28

18 IX. APPLICANT QUESTIONNAIRE If you answer YES to questions 4-29, you must explain in full detail on the explanation sheet provided with this questionnaire. Be sure to indicate the question number that you are addressing. 14. Have you ever used, tried, ingested, or experimented with any drug legally prescribed to another person? If yes, indicate what type of drug and when. Yes No 15. Have you ever filed or declared bankruptcy, had any judgments, repossessions, foreclosures, or collections? Yes No 16. Do you know of anything that might prevent you from obtaining this position? Yes No 17. Have you ever been sued? Yes No 18. Have you ever had your wages garnished? Yes No 19. Are there any unpaid judgments against you? Yes No 20. Are you delinquent in property taxes or other taxes? Yes No 21. Have you ever had a charge, complaint, or lawsuit filed against you alleging the use of excessive force? Yes No 22. Have you ever had a charge, complaint, or lawsuit filed against you alleging false arrest? Yes No 23. Have you ever been a complainant, victim, or been involved in a complaint of domestic violence? Yes No 24. Do you have any visible tattoos and/or brands? Visible is defined as the area that is exposed to public view in short sleeves or the areas that are exposed in shorts. If yes, provide location and meaning of each one on the explanation sheet. Yes No 25. Are you now or have you ever been, engaged in any business as an owner, partner, or corporate member? Yes No 26. Have you received written reprimands from supervisors or employers for not doing your job correctly or conduct violations? Yes No 27. Have you been counseled or received warning for being late or absent from work? Yes No 28. Have you ever been suspended from a job for a period of time with or without pay? Yes No 29. Have you purposely omitted any information from your employment application? Yes No Page 16 of 28

19 X. EXPLANATION TO APPLICANT QUESTIONNAIRE Please make sure that all explanations are detailed, accurate, and true. Be sure to list the number to the question that you are explaining. Attach additional sheets if necessary. Page 17 of 28

20 X. EXPLANATION TO APPLICANT QUESTIONNAIRE Please make sure that all explanations are detailed, accurate, and true. Be sure to list the number to the question that you are explaining. Attach additional sheets if necessary. Page 18 of 28

21 X. EXPLANATION TO APPLICANT QUESTIONNAIRE Please make sure that all explanations are detailed, accurate, and true. Be sure to list the number to the question that you are explaining. Attach additional sheets if necessary. Page 19 of 28

22 XI. APPLICANT SWORN STATEMENT I certify that I have read and understand all questions and instructions in this application, and that my answers are true and complete. I understand that this application is not an offer of or a contract for employment. I understand that any untrue statement in this application may result in my dismissal at any time during my employment with the Newton County Sheriff s Office. I understand that any intentional false statement will result in my disqualification from the hiring process and may result in criminal prosecution under O.C.G.A and Name (First, Middle, Last) Signature: Date: Notary Public: Date: THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT. ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED. Page 20 of 28

23 XII. EMPLOYEE REIMBURSEMENT AGREEMENT The Official Code of Georgia Annotated Title 35 Chapter 8 Section 22 (O.C.G.A ) states the following: (GCA 92A ) Reimbursement for Peace Officer s Mandated or Formalized Training (a) Unless otherwise provided by an employment contract to the contrary, if the State of Georgia or any county or municipality thereof employs a peace officer and said peace officer is hired by another agency within 15 months after completing mandated or formalized training requirements, then the total expense of training, including salary paid during training, shall be reimbursed by the hiring agency to the State of Georgia or any county or municipality thereof which initially paid for such training. If said officer is hired by another agency during a period of 15 to 24 months after mandated or formalized training requirements are completed, then one-half of the total expense of training, including salary paid during training, shall be reimbursed by the hiring agency to the State of Georgia or any county or municipality thereof which initially paid for such training. The council shall set standards for reimbursement by hiring agencies based upon actual expenses incurred in mandated or formalized training by individual departments. (b) The State of Georgia or any county or municipality thereof which initially paid for the training of a peace officer shall submit an itemized, sworn statement to the new employer of the peace officer and shall demand payment thereof and may enforce collection of such obligation through civil remedies and procedures. (c) Effective July1, 2003, in order for the State of Georgia or any county or municipality thereof to demand reimbursement, the demanding governmental unit must be able to document that the peace officer in question signed an acknowledgment of the terms of this Code section or an employment contract specifying the provisions of this Code section prior to such peace officers employment with the demanding governmental unit. Otherwise, this Code section shall not apply to such demand for reimbursement. I, (Applicant), have read in full and do agree to abide by the provisions of O.C.G.A Reimbursement for Peace Officer s Mandated or Formalized Training. Applicant Signature: Date: Notary: Date: THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT. ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED. Page 21 of 28

24 XIII. NEWTON COUNTY CONSENT WAIVER I,, do hereby authorize a review of and full disclosure of all records concerning myself to any duly authorized agent of the Newton County Sheriff s Office, or to any authorized agent of a criminal justice agency or any private agency upon request of the Newton County Sheriff s Office, whether the said records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of the records of military service records, authority to release law enforcement or criminal records or information from a law enforcement agency; educational institutions; financial or credit institutions, including records of loans, the records of commercial or retail credit agencies (including credit reports and/or rating) and financial statements and records wherever filed; medical and psychiatric treatment and/or consultation including hospitals, clinics, private practitioners, and the U.S. Veterans Administration; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me and the records and recollections of attorneys at law, or of the other counsel whether representing me or another person in any case, either criminal or civil, in which I presently have or have had an interest. I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly in whole or in part, upon this release authorization, will be considered in determining my suitability for employment by the Newton County Sheriff s Office. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I hereby release said person(s) from any and all liability, which may be incurred as a result of furnishing such information. A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature. Applicant Signature: Date: Date of Birth: Social Security # Notary: Date: THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT. ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED. Page 22 of 28

25 XIV. APPLICANT RELEASE AND HOLDHARMLESS AGREEMENT I,, hereby acknowledge that I am a Peace Officer applicant, or a candidate for appointment or certification to a position as a Peace Officer in the State of Georgia, or for attendance at a basic training course required for such appointment and certification. 1. I hereby request that my former employers release to any law enforcement agency requesting employment related information as defined in O.C.G.A (c)(1) the following: All written information contained in a prior employer s records or personnel files that relates to an applicant s, candidate s, or peace officer s performance or behavior while employed by such prior employer, including performance evaluations, records of disciplinary actions, and eligibility for rehire. Such term shall not include information prohibited from disclosure by federal law or any document not in the possession of the employer at the time a request for such information is received. 2. In consideration of your providing such information to my prospective Law Enforcement employer, I hereby forever release and agree to hold harmless and to defend from all liability for any claims, causes of action or suits or charges by every former employer who provides such complete and accurate information about my employment to the requesting law enforcement agency in accord with O.C.G.A (c)(2). 3. I understand that O.C.G.A (c)(5) provides as follows: Before taking final action on an application for employment based, in whole or in part, on any unfavorable employment related information received from a previous employer, a law enforcement agency shall inform the applicant, candidate, or peace officer that it has received such employment related information, and that the applicant, candidate, or peace officer may inspect and respond in writing to such information. Upon the applicant s, candidate s, or peace officer s request, the law enforcement agency shall allow him or her to inspect the employment related information and to submit a written response to such information. The request for inspection shall be made within five business days from the date that the applicant, candidate, or peace officer is notified of the law enforcement agency s receipt of such employment related information. The inspection shall occur not later than ten business days after said notification. Any response to the employment related information shall be made by the applicant, candidate, or peace officer not later than three business days after his or her inspection. Applicant Signature: Print Name: Date: Notary: Notary Signature: My commission expires: THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT. ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED. Page 23 of 28

26 XV. CRIMINAL HISTORY CONSENT FORM I hereby authorize, Newton County Law Enforcement Center to receive any and all criminal history record information pertaining to me which may be in the files of any local or national criminal justice agency. This name based criminal history will be completed using the Georgia Criminal Information Center (GCIC) system and the NCIC System. Please print the following: Name (Last, First, Middle) Maiden Name: Social Security # Date of Birth (Month, Day, Year) Race: Sex: Street Address: City: State: Zip Code: Phone Number: Criminal History for mandated position (PC Z ) Criminal History for civilian position (PC J) *Signature (required) *Date of request (required) *****************************************Sheriff s Office Use Only********************************************** Signature of operator completing history request: Date: ****************************This authorization is valid for 90 DAYS from date requestor signs************************* *********************************Release will not be processed if submitted incomplete***************************** THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT. ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED. Page 24 of 28

27 XVI. ACKNOWLEDGEMENT OF AT WILL EMPLOYMENT I hereby acknowledge that my employment relationship with Newton County is strictly one of AT WILL employment. I understand that I may end the employment relationship at any time and for any reason not prohibited by law, and my employer may do the same. I understand that my AT WILL employment status may not be changed except by express written contract approved by the Board of Commissioners. Employee/Applicant signature: Date: Page 25 of 28

28 HUMAN RESOURCES 1124 Clark Street Covington, Georgia Tel: (678) (678) AUTHORIZATION TO RELEASE INFORMATION I have applied to Newton County, Georgia, for employment. Part of the employment process is an investigation and verification of information I provide or will provide on my application for employment and in occasional reports during my employment with Newton County, Georgia. I do hereby authorize a review of and full disclosure of all records concerning me to Newton County. The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; employment records; financial statements and records wherever files; medical and psychiatric treatment and/or consultation including hospitals, clinics and private practitioners, and employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me whether representing me or another person in any case either criminal or civil, in which I presently have or have not had an interest; criminal history record information which may be in the files of the State of Georgia or local criminal justice agency and/or any other information contained in your files relevant to my employment with Newton County, Georgia. I hereby fully and finally release and discharge newton County, Georgia, and its officials, employees and agents from any and all liability for acts and ommissions taken pursuant to this authorization. I similarly release all persons, corporations, and other entities who release any information or documents pursuant to this authorization. I represent and warrant that I will not, directly or indirectly, seek disclosure of information obtained pursuant to this authorization either to me or to anyone else. I also understand that this executed document may be used in any process of promotion, transfer or demotion to a position for which I have applied. I have carefully read and fully understand the contents of this authorization and I execute it voluntarily as my own free act and deed. Full Name (printed or typed) Date: Street Address (City, State, Zip) Social Security Number: Signature: Notary Public (must be notarized) This authorization is valid for 60 days or until application is invalidated. To be completed by Human Resources: Date of Birth: Race: Sex: Purpose Code: Page 26 of 28

29 HUMAN RESOURCES 1124 Clark Street Covington, Georgia Tel: (678) (678) NOTICE TO JOB APPLICANTS NEWTON COUNTY S DRUG SCREENING POLICY Newton County has a strong commitment to its employees to provide a safe work environment and to promote high standards of employee health. The County also has a strong commitment to provide high quality public service. Consistent with the spirit and intent of these commitments, the Board of County Commissioners has determined that there is a compelling need for a county policy on drug use, which includes chemical testing for recent use of controlled substances. Upon an offer of employment by the County and prior to final appointment, job applicants will be asked to consent to a controlled substance screening test. If the initial screening test indicates that the applicant has recently used controlled substances, the applicant will be notified of the test results. Before a test is administered, applicants will be asked to sign a consent form authorizing the test and permitting release of test results to those county officials with a need to know. If an applicant refuses to consent to a test, or if testing indicates use of controlled substances, the offer of employment will be retracted, and the applicant will be denied employment with the County. Applicants will be informed if they are rejected on the basis of test results. All information from an applicant s drug evaluation is confidential and only those with a need to know are to be informed of test results. Disclosure of such information to any other person, agency, or organization is prohibited unless written authorization is obtained from the applicant. Page 27 of 28

30 Employment Data Record Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status. The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a confidential file and are not part of your employment application or personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION. VOLUNTARY SURVEY Government agencies at times require periodic reports on the sex, ethnicity, disabled veteran and other protected status of employees. This data is for statistical analysis. Name: Date: Address: City: State: Zip: Social Security No. Complete Only The Sections Below That Apply Gender: Male Female Age: Check One of the Following: (Ethnic Origin): NOTE: Any choice other than Hispancic/Latino means Not Hispanic/Latino White Black/African American Hispanic/Latino American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander Two or more races Check If Any of the Following are Applicable: Vietnam Era Veteran Disabled Veteran Person with Disability Page 28 of 28