HANCOCK COUNTYSHERIFF'S DEPARTMENT
RESERVE DEPUTY APPLICATION
123 EAST MAIN STREET
GREENFIELD, INDIANA46140
AN EQUAL OPPORTUNITY EMPLOYER
NAME: ______
ADDRESS: ______
CITY/STATE/ZIP CODE: ______
HOME TELEPHONE NUMBER:______
WORK TELEPHONE NUMBER: ______
CELL PHONE NUMBER:______
EMAIL ADDRESS:______
CURRENT EMPLOYER: ______
EMPLOYER ADDRESS: ______
CITY/STATE/ZIP CODE: ______
IN ORDER TO INSURE THE PERPETUATION OF THE PRESTIGE ANDREPUTATION OF THE DEPARTMENT, EACH APPLICANT WILL COMPETEAGAINST OTHER APPLICANT'S IN EACH STEP OF THE SELECTIONPROCESS. ONLY THOSE WHO POSSESS THE BEST MENTAL, PHYSICAL,MORAL AND EMOTIONAL FITNESS FOR THE PERFORMANCE OF POLICEDUTIES WILL BE CONSIDERED. FAILURE TO MEET THE ANY OF THE BASIC ELIGIBILITY REQUIREMENTS LISTED IN THIS APPLICATION WILL RESULT IN IMMEDIATE DISQUALIFCATION.
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BASIC ELIGIBILITY REQUIREMENTS:
1)BE AN AMERICAN CITIZEN.
2)MUST BE AT LEAST 21 YEARS OF AGE.
3)HAVE A HIGH SCHOOL DIPLOMA OR ACCEPTABLE G.E.D.
4)CANNOT HAVE A RECORD OF A FELONY CONVICTION.
5)PASS A PHYSICAL FITNESS TEST.
6)SUBMIT TO DRUG SCREENING AND PSYCHOLOGICAL TESTING .
7)SUBMIT TO BEING FINGERPRINTED.
8)SUBMIT TO THOROUGH CHARACTER INVESTIGATION BYDEPARTMENT PERSONNEL WHICH WILL INCLUDE, BUT IS NOTLIMITED TO:
A. CREDIT RATING
B. PREVIOUS EMPLOYMENT
C. DRIVING RECORD
D. CURRENT AND VALID DRIVERS LICENSE
9)HAVE A THOROUGH PHYSICAL BY A PHYSICIAN.
10)APPEAR FOR AN ORAL INTERVIEW.
11)BE A RESIDENT OF HANCOCKCOUNTY UPON APPLICATION AND DURING YOURAPPOINTMENT TO A RESERVE POSITION.
12)BE WILLING TO WORK A REVOLVING SHIFT SCHEDULE.
13)APPLICATION WILL BE SUBMITTED TO THE MEMBERS OF THE RESERVE DIVISION FOR FINAL APPROVAL.
NO APPLICANT WILL BE DISCRIMINATED AGAINST OR FAVOREDWITH RESPECT TO HIS/HER HIRE, TENURE, TERMS, CONDITIONSOR PRIVILEGES OF EMPLOYMENT OR ANY MATTER DIRECTLY ORINDIRECTLY RELATED TO EMPLOYMENT BECAUSE OF HIS/HERRACE, SEX, COLOR, RELIGION, NATIONAL ORIGIN OR ANCESTRY.EACH APPLICANT WILL BE LIMITED BY HIS/HER OWN ABILITIESAND QUALIFICATIONS AND THE DEPARTMENT WILL ENDEAVORTO SELECT, HIRE AND MAINTAIN IN ITS EMPLOYMENT ONLY THEBEST QUALIFIED PERSON AVAILABLE.
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GENERAL INFORMATION:
APPLICANT'S ARE RESPONSIBLE FOR ALL EXPENSES INCURRED IN CONNECTION WITH THIS APPLICATION.
INITIAL REQUIREMENT INFORMATION:
1)ARE YOU A CITIZEN OF THE UNITED STATES? YES NO
2)SOCIAL SECURITY NUMBER: ______
3)AGE: ______
4)DATE OF BIRTH: ______
5)SEX: FEMALE MALE
6)RACE: ______
7)HEIGHT (WITHOUT SHOES): ______FEET ______INCHES
8)WEIGHT (STRIPPED): ______LBS.
9)ARE YOU A GRADUATE OF AN ACCREDITED HIGHSCHOOL? YES NO
10)DO YOU POSSESS A VALID DRIVERS LICENSE? YES NO
11)DRIVERS LICENSE NUMBER: ______STATE: ______
12)IS YOUR LICENSE RESTRICTED? YES NO
13)IF YES, FOR WHAT REASON? ______
14)NUMBER OF YEARS DRIVING EXPERIENCE: ______
15)SOCIAL NETWORKS USED: FACEBOOK TWITTER OTHER______
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FAMILY INFORMATION:
1)MARITAL STATUS:
MARRIED SINGLE WIDOWED DIVORCED SEPARATED
2)DEPENDENTS:
NAMEAGERELATIONSHIP
______
______
______
______
______
______
______
______
______
3)FATHER (FULL NAME): ______
PLACE OF HIS BIRTH: ______
PRESENT ADDRESS (IF LIVING): ______
______
4)MOTHER (MAIDEN NAME): ______
PLACE OF HER BIRTH: ______
PRESENT ADDRESS (IF LIVING): ______
______
5)SPOUSE (MAIDEN NAME) IF APPLICABLE: ______
PLACE OF BIRTH: ______
6)IS SPOUSE EMPLOYED: YES NO
IF YES, WHAT IS THE ANNUAL SALARY? ______
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EDUCATION INFORMATION:
1)SCHOOL NAME/ADDRESS, YEARS COMPLETED, COURSE OF STUDY/DEGREE
HIGH: ______
______
COLLEGE: ______
______
OTHER (SPECIFY): ______
______
EMPLOYMENT INFORMATION:
1)RECORD EMPLOYMENT STARTING WITH GRADUATIONFROM HIGH SCHOOL:
DATES EMPLOYED: ______
EMPLOYER NAME & ADDRESS: ______
______
POSITION HELD & ANNUAL SALARY: ______
REASON FOR LEAVING: ______
DATES EMPLOYED: ______
EMPLOYER NAME & ADDRESS: ______
______
POSITION HELD & ANNUAL SALARY: ______
REASON FOR LEAVING: ______
DATES EMPLOYED: ______
EMPLOYER NAME & ADDRESS: ______
______
POSITION HELD & ANNUAL SALARY: ______
REASON FOR LEAVING: ______
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DATES EMPLOYED: ______
EMPLOYER NAME & ADDRESS: ______
______
POSITION HELD & ANNUAL SALARY: ______
REASON FOR LEAVING: ______
DATES EMPLOYED: ______
EMPLOYER NAME & ADDRESS: ______
______
POSITION HELD & ANNUAL SALARY: ______
REASON FOR LEAVING: ______
2)HAVE YOU EVER LEFT A POSITION DUE TO ILL HEALTH, THENATURE OF WHICH WAS EITHER MENTAL OR PHYSICAL? YES NO
IF YES, EXPLAIN FULLY ON AN ATTACHED PAGE.
3)HAVE YOU EVER BEEN FIRED FROM A POSITION OF EMPLOYMENT? YES NO
IF YES, EXPLAIN FULLY ON AN ATTACHED PAGE.
4)REFERENCES (PLEASE DO NOT USE RELATIVES AS REFERENCES):
NAME: ______PHONE #: ______
ADDRESS: ______CITY/STATE: ______
NAME: ______PHONE #: ______
ADDRESS: ______CITY/STATE: ______
NAME: ______PHONE #: ______
ADDRESS: ______CITY/STATE: ______
5)PLACE OF RESIDENCES LAST FIVE YEARS (OTHER THAN PRESENT):
STREET, CITY, STATE
______
______
______
______
______
MILITARY HISTORY AND STATUS:
1)MILITARY HISTORY:PROVIDE A COPY OF YOUR DD214
ORGANIZATION AND DATES OF SERVICE: ______
______
RANK: ______
REASON FOR LEAVING (DISCHARGE): HON DIS HON OTHER
2)MILITARY CITATIONS OR OTHER AWARDS RECEIVED: ______
______
______
3)ARE YOU NOW A MEMBER OF ANY ORGANIZED RESERVES? YES NO
IF YES, RANK AT PRESENT TIME: ______
4)NAME AND LOCATION OF UNIT: ______
______
MISCELLANEOUS INFORMATION:
1)HAVE YOU VISITED OR RECEIVED TREATMENT FROM APHYSICIAN OR OTHER PRACTITIONER DURING THE LASTTHREE YEARS: YES NO
IF SO, EXPLAIN: ______
______
2)DO YOU HAVE ANY SPECIFIC WORK LIMITATIONS AS THERESULT OF A MENTAL OR PHYSICAL PROBLEM: YES NO
IF SO, EXPLAIN: ______
______
3)LIST PAST OR PRESENT MEMBERSHIP IN ALL CLUBS AND/ORORGANIZATIONS (POLITICAL, FRATERNAL, SOCIAL, ETC.):
______
______
______
4)DO YOU HAVE A CHURCH AFFILIATION: YES NO
IF YES, WHAT CHURCH: ______
5)VEHICLE ACCIDENT RECORD:
LIST DATE AND TIME OF VEHICLE ACCIDENTS IN WHICH YOUHAVE BEEN INVOLVED IN AS A DRIVER:
______
______
______
6)HAVE YOU EVER BEEN ARRESTED OR DETAINEDFOR A CRIMINAL OFFENSEOR RECEIVED A TICKET FOR A TRAFFIC OFFENSE: YES NO
IF YES, EXPLAIN DATE/LOCATION/CHARGE/FINE OR SENTENCE:
______
______
______
7)DO YOU OWN YOUR OWN HOME: YES NO
IF YES, HOW MUCH IS CURRENT MORTGAGE INDEBTEDNESS?
______
8)WHAT IS THE AMOUNT OF YOUR INDEBTEDNESS OTHER THAN HOME?
______
9)ARE YOU A PROPRIETOR OR PART OWNER OF ANY BUSINESSOR FIRM? YES NO
IF YES, EXPLAIN NATURE OFBUSINESS:
______
10)WHAT SPECIAL SKILLS HAVE YOU DEVELOPED THROUGHHOBBIES, EDUCATION, OCCUPATION OR OTHER SPECIAL INTERESTS?
______
______
______
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AFFIX 2.5” X 3.5”
PHOTOGRAPH
IN THIS SPACE
SECURELY
(PHOTOGRAPH TO BE FRONT VIEW, HEAD AND SHOULDERS,)( 2 ½ " X 3 ½” AND TAKEN WITHIN THE LAST SIX MONTHS)
THE FACTS SET FORTH IN MY APPLICATION FOR EMPLOYMENTWITH THE HANCOCK COUNTYSHERIFF'S DEPARTMENT ARE TRUEAND COMPLETE. I UNDERSTAND THAT FALSE STATEMENTS ONTHIS APPLICATION SHALL BE CONSIDERED SUFFICIENT CAUSEFOR ELIMINATION FROM FURTHER CONSIDERATION.
______
SIGNATURE OF APPLICANTDATE
CHECK APPLICATION CAREFULLY. BE CERTAIN ALL ITEMS ARE COMPLETE BEFORE MAILING
MAIL OR RETURN TO:
ATTENTION: RESERVE DIVISION
HANCOCK COUNTYSHERIFF'S DEPARTMENT
123 EAST MAIN STREET
GREENFIELD, INDIANA46140
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