Lake County Sheriff’s Office

Employment Questionnaire

Please fill out this questionnaire using an ink pen only. DO NOT type this questionnaire as typed questionnaires will not be reviewed. Pay attention to detail and do not leave any areas of the questionnaire blank. Fill out all information completely & accurately. Disparaging information does mean you will automatically be dismissed from the hiring process. In most cases candidates that report their information accurately have a better chance of being successful in the hiring process.

Position Applying For ______Today’s Date ______

Name ______

Last FirstMI

* This information is voluntary but required to complete background information

Date of Birth ______Male _____Female_____

List all residences in the last Ten years. Please include addresses and contact information for Landlords or Property Management Companies.

Address / From / To / Landlord contact number

List all your employers for the past ten years:

Employer / From / To / Reason for leaving / Salary

Driving History:

Please list any and all driving infractions, to include DUI, DWAI, Traffic Summons.

Do Not include parking tickets.

______

DRUG / ALCOHOL Use:

Have you used marijuana in the last five years Yes_____ No _____

If yes please provide dates and circumstances:

______

Have you ever used Cocaine, Heroin, LSD, Mushrooms, Crack Cocaine, Methamphetamine, or Any other illegal narcotic? Yes _____ No ______

If yes please provide dates and details:

______

Have you ever taken a prescription narcotic that was not prescribed to you by a Licensed Physician? Yes _____ No _____

If yes please provide dates and details to include what prescription narcotic was used?

______

Have you ever driven a vehicle while impaired by alcohol?Yes _____ No _____

If yes, please explain:

______

How would you describe your alcohol consumption:

__ Daily __ Weekly __ Monthly __ Seldom __ Never

EMPLOYMENT:

Have you ever stolen from an employer? Yes ______No______

If yes please provide dates and times:

______

Have you ever been terminated from an employer?Yes ____ No ______

If yes, please provide details:

______

Have you ever resigned in lieu of termination?Yes _____ No _____

If yes, please explain:

______

Have you ever received disciplinary action?Yes _____ No _____

If yes, please explain:

______

CRIMINAL HISTORY:

Have you ever committed an undetected crime? Yes _____ No _____

If yes please provide details and dates:

______

Have you ever been arrestedfor Domestic Violence? Yes _____ No _____

If yes please provide dates and details:

______

Have you ever had a warrant for your arrest?Yes _____ No _____

If yes, please explain:

______

PERSONAL INFORMATION:

Please provide three Personal References. These cannot be the same as your business references. Please provide Complete Names, Addresses and Telephone Numbers:

______

Please disclose any Family Members or Friends Employed by LakeCounty:

______

Please list your hobbies:

______

What is your favorite thing to do?

______

What is your least favorite thing to do?

______

Why do you want to work for the LakeCounty Sheriff’s Office?

______

Please describe your view on using Deadly Force:

______

______

"I certify that the facts contained in this questionnaire are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for immediate dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning any pertinent information they may have, personal or otherwise, and release the individuals and/or company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of this Office has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing unless it is in writing and signed by the Sheriff or his designee”.

Thank you for completing your application questionnaire with the LakeCounty Sheriff’s Department.

______

Please Print Your Name

______

Please Sign Your NameDate

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