LeeCounty

Sheriff’s Office

Bishopville, SC29010

Applicant

Questionnaire

Revised: 11/1/2012 LCSO-2012

Lee County Sheriff’s Office Questionnaire

DIRECTIONS: Follow all directions. Answer EVERY question completely. Failure to complete a question could result in your application not being processed. If your answer requires more space than allotted, you can finish on the back of the page. If you make an error, do not erase or block it out, place one line through the word(s) you are choosing not to use. REMEMBER, these areas will be the subject of a background investigation.

FAILURE TO ANSWER EACH QUESTION FULLY AND TRUTHFULLY WILL RESULT IN YOUR APPLICATION BEING REJECTED.

Print neatly.

NAME: ______DATE OF BIRTH: ______

SSN: ______POSITION APPLIED FOR: ______

AVAILABILITY OF APPLICANT:

1-1Are you willing to work on week-ends, holidays and scheduled days off, if called upon to do so?

1-2Are you willing to work shift work?

Any shift?

1-3Are you willing to work as needed during natural disasters?

If no, why?

EMPLOYMENT HISTORY:

1-4Have you ever been fired or terminated from any job?

If yes, list each job and give the reason(s) you were fired?

1-5Have you ever been asked or forced to resign from any job(s)?

If yes, list the employer’s name and explain the circumstances.

1-6Have you ever received any formal disciplinary action on the job (such as a suspension, written or oral reprimand, letter of warning or counseling, etc.)?

If yes, list every disciplinary action, and include employer’s name, when it was given, and the reason.

1-7How many part-time jobs have you had in the last five years?

How many full-time jobs have you had in the last five years?

1-8Are you now working any full or part-time job(s) that you did not list on the application?

If yes, list it/them, including dates of employment, job title, and name of the business with a contact number.

1-9Have you ever been involved in a physical confrontation with a fellow employee or a supervisor?

If yes, to either or both, explain.

1-10Have you ever been turned down for a job based on the results of a…..

Answer yes or no to each question) If yes, give details.

  1. Background Investigation?
  1. Credit History?
  1. Criminal History Check?
  1. Driving History Check?
  1. Polygraph Examination?
  1. Medical Examination?

1-11Have you ever had a sexual harassment complaint made against you?

If yes, give details.

1-12Have you ever had a racial complaint made against you by a supervisor

or co-worker?

If yes, give details.

1-13Have you ever been sued or named in a lawsuit at any work place?

If yes, give details.

1-14Have you ever called in sick when you weren’t?

If yes, how many times in the last five years?

1-15How many times, in the last five years, have you been late for work?

1-16Have you ever been terminated during a probationary period?

If yes, list the name (s) of the employer(s), dates of employment, and reason for

termination.

DRIVING HISTORY:

1-17Have your driving privilege (license) ever been suspended, revoked, or canceled in

this state or any other state?

If yes, which state(s), when, and for what reason(s)?

1-18How many traffic tickets (not parking violations) have you received in the past

three years?

1-19Have you ever been arrested for operating a motor vehicle while under the

influence of alcohol or other drugs?

If yes, list when and where.

1-20Have you ever been involved in an automobile accident as a driver (regardless of

who was at fault)?

If yes, how many since you began driving?

How many in the past three years?

Has anyone ever been seriously injured or killed as a result of any accident you

were involved in (regardless of who was at fault)?

1-21Have you ever been licensed to drive in any other state(s)?

If yes, name them all and the years licensed in those states, e.g., Nevada,

1985-1989.

EDUCATION:

1-22Did you graduate from high school (do not count GED or High School

Equivalency)?

If yes, list when and where.

If no, state when and where you received a GED or High School Equivalency.

1-23Do you have a college degree?

If yes, list degree, college and year received.

1-24Have you ever been suspended, expelled or dismissed from a High School

or College/University?

If yes, how many times?

CREDIT HISTORY:

1-25Have you ever declared bankruptcy?

If yes, when?

Was it Chapter 7 (were all your debt(s) dismissed) or Chapter 13?

1-26Are you currently involved in a bankruptcy process?

If yes, which chapter did you file?

When did you file?

1-27 Have you ever had any civil action(s) taken against you for failure to pay any debt(s) (liens, judgments, lawsuits, etc.)?

If yes, explain.

1-28Have you ever had anything repossessed (voluntary or involuntarily)?

If yes, list what it was when it occurred, and whether it was voluntarily or

involuntarily repossessed.

1-29Are you now or have ever had to make child support payments?

If yes, have you ever been late making your child support payments?

If yes, are you currently behind in your child support payments?

If yes, how many payments are you behind?

1-30Have you ever had a government subsidized educational/student loan?

If yes, have you ever received a deferment?

Have you ever been declared in default?

Are you currently in default?

1-31Have you ever bounced a check that resulted in a warrant being issued for your

arrest?

If yes, when?

What was the outcome of the warrant?

1-32Have you ever had your wages garnisheed?

If yes, are they currently being garnisheed?

When were they garnisheed?

What was/is the reason for the garnishment?

CRIMINAL HISTORY:

1-33Have you ever been arrested for any crime other than minor traffic offenses?

If yes, GIVE DETAILS, Regardless if you were convicted or not. (WHAT WAS/

WERE THE CHARGES? WHEN? WHERE?

1-34Do you now have any criminal charge(s) pending against you in any court in any

state?

If yes, give details

1-35Have you ever stole anything?

If yes, what?

When?

1-36Have you ever been involved in any investigation in reference to a theft at any

work place?

If yes, were you asked to take or were give a polygraph test?

If you took a polygraph examination, what were the results?

1-37Have you ever given confidential information from your job to any unauthorized

person?

If yes, give details.

1-38Since age 18, have the police come to your residence for any domestic dispute

(whether or not you were involved)?

If yes, give the details (When and reason for call? Was anyone arrested, and what

was the outcome of the arrest?) For each time the police have been called to your

residence due to a domestic issue.

1-39At any time in your life, have you ever committed any of the following crimes?

(ANSWER YES OR NO TO EACH QUESTION REGARDLESS OF WHETHER YOU

WERE CAUGHT OR NOT)

  1. Arson?
  2. Assault and Battery?
  3. Breaking onto a Motor Vehicle?
  4. Burglary?
  5. Criminal Domestic Violence (Assault of or threats to a spouse, etc.?)
  6. Criminal Sexual Conduct (Rape, Sodomy, etc.)?
  7. Driving Under Influence?
  8. Embezzlement?
  9. Forgery
  10. Grand Larceny?
  11. Homicide (Murder)?
  12. Indecent Exposure?
  13. Kidnapping?
  14. Petit Larceny (Shoplifting)
  15. Sexual Crimes (Peeping Tom, Molestation, etc.)?
  16. Vandalism (Malicious Injury to Property Crime)?

TO EVERY QUESTION YOU ANSWERED “YES”, LIST THE LETTER BELOW

AND GIVE AN EXPLAINATION (IF YOU NEED MORE SPACE, USE THE BACK OF

THIS PAGE):

PERSONAL HISTORY:

1-40Have you ever used a surname (last name ) other than the name listed on your

application?

If yes, list all other name(s) (including married, maiden and nicknames,

and any other legal name changes).

1-41Have you ever used any social security number other than the one you listed

on the front page?

If yes, list each number.

Explain why you used a different social security number.

1-42Have you ever used a date of birth other than the one you listed on the front

page?

If yes, list each.

Explain why you used a different date of birth.

1-43Where are you currently living (ADDRESS-INCUDINGCITY, STATE)?

If you currently reside in South Carolina, how long have you lived here

and what brought you here?

If you currently do not live in South Carolina, when do you plan to move

to South Carolina?

1-44Are you a U.S. Citizen?

1-45Are you now, or have ever been, a member of a support group

whose views are contrary to those of the U.S. Constitution?

If yes, give details.

1-46Are you now or have ever been a member of gang?

If yes, give details.

VICE ACTIVITES:

1-47Do you drink alcoholic beverages?

If yes, how often?

How much?

What type of beverage do you drink?

1-48Have you ever gone to work or school intoxicated?

If yes, explain.

1-49Have you ever missed work or school due to being intoxicated or due to a

hangover/alcohol induced illness?

If yes, explain.

1-50Have you ever operated a motor vehicle while you were under the influence?

If yes, when was the last time you operated a motor vehicle while under the

influence.

1-51Do you gamble?

If yes, what is the greatest financial loss you have ever sustained due to gambling?

(at one time)?

1-52Do you currently owe any person(s) or institution any money or property due to a

gambling debt?

1-53Do you currently have any subscription to magazines which contain or promote

child pornography?

If yes, name the magazine(s).

1-54Have you ever viewed child pornography on video, in magazines, or on the

internet?

If yes, give details.

1-55Do you have a/any tattoo(s)?

If yes, give a description of the tattoo(s) and where its/located on

your body.

1-56Have you, at any time, ever tried, used, or experimented with any of the following

drugs? (ANSWER YES OR NO TO EACH QUESTION):

  1. Acid (LSD, Hallucinogens, Mushrooms)?
  2. Amphetamines (Speed)?
  3. Cocaine (Powder)?
  4. Crack (Rock Cocaine)?
  5. Crystal Meth?
  6. Depressants (Valium, Quaaludes)?
  7. Ecstasy?
  8. Hashish?
  9. Inhalants (Glue, Gas, White Out, Nitrous Oxide, etc)?
  10. Marijuana?
  11. Opiates (Morphine, Heroin)?
  12. Oxycontin?

TO EVERY QUESTION YOU ANSWERED “YES”, LIST THE LETTER AND WRITE

THE LAST TIME YOU USED THE DRUG(S) (GIVE THE MONTH AND YEAR). ALSO,

GIVE AN APPROXIMATE NUMBER OF TIMES YOU USED IT/THEM.

MILITARY INFORMATION:

2-1 Have you ever been in a military organization?

IF NO, GO TO PAGE 16 (QUESTION 2-8)

If yes, which branch?

How long (give dates of enlistment)?

Highest rank achieved?

Rank at discharge/retirement?

2-2 Have you ever received any disciplinary action(s), such as an Article 15 or other

punishment under the Uniform Code of Military Justice while you were in the

military? (Include any kind of reprimand)

If yes, give details.

2-3 Were you ever the subject of a criminal investigation? (FBI,NIS, CID, MPs, etc.)

If yes, what were the circumstances?

2-4 Have you ever been sentenced to the Brig/Military Prison/ Detention Barracks?

If yes, give details.

2-5 What type of discharge did you receive?

2-6 Could you have stayed in the military if you chose to do so?

If yes, why didn’t you stay in the military?

If no, why?

2-7 What was your main job in the military?

LAW ENFORCMENT HISTORY:

2-8 Have you ever worked Law Enforcement in any capacity?

IF NO, GO TO PAGE 20 (CONCLUSION).

IF YES, list every agency where you have been employed (GIVE CITY, STATE)

and state your job title (Sworn, Reserve, Military Police, Corrections, etc.)

2-9 Were you ever the subject of an internal affairs investigation (or its equivalent)?

If yes, explain.

2-10 Have you ever quit or resigned while under investigation?

If yes, explain.

2-11 Were you ever given the option to resign or be fired?

If yes, when and where (list agency and circumstances).

2-12 Did you ever receive a written reprimand?

If yes, how many?

List each one; explain the reason, when, and what discipline was received.

2-13 Were you ever suspended from duty (for a disciplinary reason) or did you ever

receive a demotion or reduction in salary?

If yes, explain each instance.

2-14 Have you ever drink alcoholic beverages while on duty?

If yes, when?

Give details.

2-15 Have you ever used”excessive” force on anyone or been accused of using

“excessive” force?

If yes, explain.

2-16 Have you ever kept anything belonging to a suspect, witness, or victim that you did

not turn in as evidence?

If yes, list each item.

2-17 Have you ever lie in a report to cover up your actions or the actions of another law

enforcement officer?

If yes, explain.

2-18 Have you ever used your badge to get out of a traffic ticket or arrest situation?

If yes, give details.

2-19 How many on-duty traffic accidents have you been involved in as a driver, while

working as a Law Enforcement Officer (regardless of who was found at fault)?

2-20 How many on-duty traffic accidents have you been found at fault?

Did you receiveany disciplinary action(s)?

If yes, give details.

2-12 Have you ever violated any policies for which you would or could have been fired if

you had been caught?

If yes, list it/them.

CONCLUSION:

Is there anything you would like to explain further or clarify regarding any issue that you

feel needs amplification?

If yes, do so in the space below (use the back of this page if you need more space).

Why do you want this job? (Answer in 50 words or less)

GO TO THE LAST PAGE

NAME THREE (3) PERSONAL REFERENCES: (Include Address and Telephone Numbers)

Do not list relatives. Do not list anyone living in the same residence as you.

1)

2)

3)

I UNDERSTAND THAT IT IS AVIOLATION OF THE LAW TO GIVE FALSE OR MISLEADING INFORMATIONTO ANY LAW ENFORCEMENT AGENCY. FURTHER, I UNDERSTAND THAT I WILL NOT BE CONSIDERED FOR EMPLOYMENT IF I HAVE INTENTIONALLY BEEN UNTRUTHFUL IN ANY OF THE ABOVE STATEMENTS I HAVE GIVEN. I HEREBY DECLARE ALL OF THE ABOVE STATEMENTS/ANSWERS ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE______DATE______

POSITION APPLIED FOR______

DOB:______SEX______RACE______

HOME #______CELL #______WORK #______

SSN #______DL # ______STATE______

WHEN YOU RETURN THIS APPLICATION, IT MUST HAVE ATTACHED COPIES OF THE FOLLOWING:

BIRTH CERTIFICATE

HIGH SCHOOL DIPLOMA OR GED

SOCIAL SECURITY CARD

DRIVER’S LICENSE

DD 214

WHEN HIRED YOU ARE EXPECTED TO GIVE (2) WEEKS NOTICE BEFORE LEAVING.

I,______, BY SIGNING THIS STATEMENT, UNDERSTAND I WILL

BE REQUIRED TO TURN IN ALL ISSUED EQUIPMENT IN GOOD CONDITION OR I WILL BE

CHARGED FOR ALL MISSING OR DAMAGED EQUIPMENT. I HAVE READ AND ANSWERED

THE ABOVE QUESTIONS TO THE BEST OF MY KNOWLEDGE AND THEY ARE TRUE AND CORRECT.

______

Signature

______

Date

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