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Position

First Name

Middle Name

Last Name

Would you consider part-time employment?

Date of Birth

Driver License #

State Issued

Expiration MO/YR

Address

City

State

Zip

Cell phone

Alt phone

Present Employer

Are you a citizen of the United States?

Do you have a diploma or GED?

Have you served in the military?

Length of Service

Highest rank attained

Have you ever taken a polygraph?

Have you ever bought, sold, or traded any illegal narcotics or drugs?

Have you ever been convicted of a DUI or reckless driving?

Has your driver license ever been suspended or revoked?

Have you ever been convicted, received a suspended or deferred sentence or planned?

Have you ever been a party to a civil or criminal suit?

Have you ever declared bankruptcy, had anything repossessed or an account turned?

Have you ever been fired or asked to resign from a job?

How many jobs have you had in the past five years?

Are you CLEET Peace Officer certified?

Are you OLETS certified?

Agree

By checking this box and submitting this form to the Jackson County Sheriff's Office I am stating the the information provided is accurate and does NOT contain misleading statements. I understand that any false or misleading statements are grounds for rejection

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