PLEASE READ the INSTRUCTIONS! Please Return This Formpostmarked Within 5 Business Days

PLEASE READ THE INSTRUCTIONS!Please return this formpostmarked within 5 business days of submitting yourapplication to:

Sgt. Barry A. Dufek

Employment Services Section

Loudoun County Sheriff's Office

803 Sycolin Road SE

Leesburg, VA 20175

(703) 771-5048

LOUDOUN COUNTY SHERIFF’S OFFICE

APPLICANT SCREENING QUESTIONNAIRE

The purpose of this questionnaire is to determine if you meet the standards established by the Loudoun County Sheriff’s Office. False or misleading information will disqualify you from further consideration. A polygraph examination will be administered as required. Please use the comments section or add additional pages to this form if you need to more fully explain any areas. DO NOT LEAVE ANY SECTIONS BLANK (If an area does not apply, please indicate so). GENDER, HEIGHT AND WEIGHT PERTAINONLY TO THOSE APPLYING FOR SWORN POSITIONS INCLUDING FIELD, CORRECTIONAL AND COURT DEPUTIES. IF YOU FAIL TO COMPLETE ANY SECTION, NO FURTHER ACTION WILL BE TAKEN ON YOUR APPLICATION. Thank you for your cooperation.

Name:______

LAST FIRST MIDDLE

Address:______

Telephone: (home)______(work)______(cell#)______

DOB:______SSN______Male______Female______

U.S. Citizen…………………………………YES NO Height______Weight______

High School Diploma……………………….YES NO

GED………………………………………....YES NO

Position Applied For: Field Deputy / Corrections / Other______

Present Occupation: ______

Experience in Law Enforcement / Corrections / Dispatcher…………………………………….YES NO

Agency:______Years Service:______

Reason for Leaving: (if applicable)______

______

Military Experience………………………………………………………………………………...YES NO

Years Service:______Branch: ______

Discharge: Honorable_____General_____Dishonorable_____ Date______

Any Court Martial / Article 15 Proceedings / Other discipline?...... YES NO

Explain______

______

College Degree (Major and type of degree)______

Driving History

Current Drivers License (state)______Ever held out of state license?...... YES NO

List other states:______

Ever suspended or revoked?...... YES NO

If so, when, where and for what reason______

______

List all traffic charges, tickets, summons’, etc. regardless of final disposition for your entire driving history:

Date (year only):______Charge:______

Location:______Disposition:______

Date (year only):______Charge:______

Location:______Disposition:______

Date (year only):______Charge:______

Location:______Disposition:______

Date (year only):______Charge:______

Location:______Disposition:______

Date (year only):______Charge:______

Location:______Disposition:______

DO NOT LEAVE ANY SECTIONS BLANK (If an area does not apply, please indicate so)

Ever charged with Reckless Driving?...... YES NO

Date:______Location:______

Disposition:______

Ever charged with a drunk driving related offense?...... YES NO

Date:______Charge:______

Location:______Disposition:______

Ever charged with a criminal offense?...... YES NO

Date:______Charge:______

Location:______Disposition:______

Drug Use:

Date of first use Date of last use Comments

Marijuana ______

Cocaine/Crack ______

LSD ______

Mushrooms ______

PCP ______

Speed ______

Steroids ______

Other ______

Do you have any body art? (Tattoos, piercings, brandings) ( ) NO ( ) YES If Yes, provide:

Size______Location______Description______

Other Law Enforcement Applications

Prior applications with the Loudoun County Sheriff’s Office (if yes, when)?______

Results:______

Other agencies:

Date:______Agency:______

Results:______

Date:______Agency:______

Results:______

Date:______Agency:______

Results:______

Date:______Agency:______

Results:______

Civil Action

Ever been sued?...... YES NO

Date:______Circumstances:______

Ever brought suit against another?...... YES NO

Date:______Circumstances:______

Ever declared bankruptcy?...... YES NO

Date:______Circumstances:______

Ever had judgments placed against you?...... YES NO

Date:______Circumstances:______

Ever have any debts go to collection?...... YES NO

Date:______Circumstances:______

GENERAL COMMENTS______

______

How did you learn about this employment opportunity?______

DID YOU LEAVE ANY SECTIONS BLANK? (If an area does not apply, please indicate so)

SIGNATURE:______DATE______

Revised 10/2012