Osceola County Sheriff's Office

Application

AUTHORIZATION FOR RELEASE

OF PERSONAL INFORMATION

I, _________________________________________, do hereby authorize a review of and full disclosure of all records concerning myself to any duly authorized agent of the Osceola County Sheriff’s Office, whether the said records are of a public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of records of education institutions; financial or credit institutions, including records of loans, the records of commercial or retail credit agencies (including credit reports and/or ratings) and other financial statements of records whenever filed; medical and psychiatric treatment and/or consultation, including hospitals, clinics, private practitioners, and the U.S. Veteran’s Administration; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me; and the recollections of attorneys at law, or of other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by Osceola County. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) for any and all liability which may be incurred as a result of furnishing such information. I further release the Osceola County Sheriff and Osceola County from any and all liability which may be incurred as a result of collecting such information.

I HEREBY SWEAR AND AFFIRM THAT EACH STATEMENT AND ALL INFORMATION IN OR SUPPLEMENTING THIS APPLICATION (PERSONAL AND PHYSICAL EVALUATION) ARE COMPLETE, TRUE AND ACCURATELY6 RECORDED TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT PROVIDING FALSE, MISLEADING AND/OR INCOMPLETE INFORMATION ON THIS APPLICATION IS GROUNDS FOR EXCLUSION FROM THE SELECTION PROCESS OR DISCHARGE IF DISCOVERED SUBSEQUENT TO EMPLOYMENT.

A photocopy of this release form will be valid as any original thereof, even though the said photocopy does not contain an original writing of any signature.

I have read and fully understand the contents of this “Authorization for Release of Personal Information”.

_______________________________________

(Signature of Applicant)

_______________________________________

(Date)

Osceola County Sheriff’s Office is an equal opportunity employer.

OFFICE OF SHERIFF – OSCEOLA COUNTY

EMPLOYMENT APPLICATION-DEPUTY SHERIFF

A. Applicant identification: Information provided in this section is used for

identification purposes only.

1. NAME:_________________________________________________________________________

Last First Middle

2. ADDRESS:______________________________________________________________________

Number Street

_____________________________________________________________________

City State Zip

3. TELEPHONE NUMBER:________________________ _________________________

Work Home

4. DATE OF BIRTH:_______________________(CHAPTER 80B IA CODE)

5. NICKNAME(S), MAIDEN NAME, OR OTHER NAMES WHICH YOU HAVE BEEN KNOWN:

______________________________________________________________________________

6. SOCIAL SECURITY NO:______________________

ARE YOU ELIGIBLE TO WORK IN U.S.? Yes___ No___

7. PLACE OF BIRTH:_________________________________________________

8. DRIVERS LICENSE#:_______________________STATE OF ISSUE:________

B. RESIDENCES – List all addresses where you have lived during the past 5 years.

Beginning with present address, list date by month and year. Attach extra page if

necessary.

FROM TO ADDRESS

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Osceola County is an equal opportunity employer and does not discriminate against any employee or applicant because of race, religion, creed, color, age, sex, ancestry, or physical or mental disability.

C. WORK HISTORY – Beginning with your present or most recent job, list all

employment since the age of 16, including part-time, temporary/seasonal

employment. Include all periods of unemployment. Attach extra pages if

necessary.

1. FROM_______________TO______________EMPLOYER________________________________ ADDRESS______________________________________________________________________

PHONE NUMBER(_____)______/_________ JOB TITLE________________________________ DUTIES________________________________________________________________________ _________________________________________________LAST RATE OF PAY?___________

SUPERVISOR____________________NAME OF CO-WORKER__________________________

REASON FOR LEAVING_________________________________________________________

2. FROM_______________TO______________EMPLOYER________________________________ ADDRESS______________________________________________________________________

SUPERVISOR____________________NAME OF CO-WORKER__________________________

REASON FOR LEAVING_________________________________________________________

3. FROM_______________TO______________EMPLOYER________________________________ ADDRESS______________________________________________________________________

SUPERVISOR____________________NAME OF CO-WORKER__________________________

REASON FOR LEAVING_________________________________________________________

4. FROM_______________TO______________EMPLOYER________________________________ ADDRESS______________________________________________________________________

SUPERVISOR____________________NAME OF CO-WORKER__________________________

REASON FOR LEAVING_________________________________________________________

D. EDUCATIONAL HISTORY

1. HIGH SCHOOL CITY & STATE DATES GRADUATED

ATTENDED FROM TO YES NO

__________________________ _________________________ ______________ _____ _____

2. COLLEGE/UNIVERSITY ATTENDED_______________________________________________

CITY & STATE__________________________________DATES_________________________

MAJOR/MINOR____________________________DEGREE(s)___________________________

3. COLLEGE/UNIVERSITY ATTENDED_______________________________________________

CITY & STATE__________________________________DATES_________________________

MAJOR/MINOR____________________________DEGREE(s)___________________________

4. LIST OTHER SCHOOLS ATTENDED (Trade, Vocation, Business, Etc|

_______________________________________________________________________________

5. LIST ANY SPECIALIZED EQUIPMENT WHICH YOU CAN OPERATE.

_______________________________________________________________________________

6. LIST ANY OTHER SPECIAL SKILLS OR QUALIFICATIONS YOU MAY POSSESS. _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

E. ARRESTS, DETENTIONS AND LITIGATION

1. HAVE YOU EVER BEEN ARRESTED OR DETAINED BY POLICE OR

SUMMONED INTO COURT? ____YES ____NO

If yes, complete the following:

CRIME CHARGED POLICE AGENCY DATE DISPOSTION

___________________________ __________________________ __________ ___________

2. HAVE YOU EVER BEEN INVOLVED AS A PARTY IN CIVIL LITIGATION?

____YES ____NO. IF YES, GIVE DETAILS. _______________________________________

_______________________________________________________________________________

F. TRAFFIC RECORD

1. HAS YOUR DRIVER’S LICENSE EVER BEEN SUSPENDED OR REVOKED?

____YES ____NO

IF YES, GIVE DETAILS.___________________________________________________________

_______________________________________________________________________________

LIST THE COMPANY YOU CARRY YOUR AUTO INSURANCE WITH:

_______________________________________________________________________________

LIST ALL DRIVING VIOLATIONS WITHIN THE PAST 12 MONTHS:

_______________________________________________________________________________

LIST TRAFFIC ACCIDENTS IN WHICH YOU WERE INVOLVED:(Dates &

locations) _______________________________________________________________________

_______________________________________________________________________________

G. MEMBERSHIP IN PUBLIC SAFETY ORGANIZATRIONS-(Past &

Present)

List name, address, type of organization and dates:_________________________________________

_______________________________________________________________________________

H. PERSONAL DECLARATIONS

1. Describe in your own words the frequency & extent of your use of intoxicating

liquors.

_______________________________________________________________________________

2. Have you ever used marijuana or any other drug not prescribed by a physician?

____Yes ____No If yes, what were the circumstances?___________________________________

_______________________________________________________________________________

3. Have you ever sold/furnished controlled substances to anyone?

____Yes ____No If yes, what were the circumstances?___________________________________

_______________________________________________________________________________

4. If it becomes necessary to take a human life in the course of your duties as a

Deputy Sheriff, would any religious or other beliefs prevent you from doing so?

____Yes ____No If yes, explain below:_______________________________________________

_______________________________________________________________________________

5. List hobbies you enjoy:______________________________________________________________

_______________________________________________________________________________

6. Do you have any religious or other beliefs which would prevent you from fully

performing the duties of Deputy Sheriff, including working weekends, evenings,

night shifts or some holidays? ____Yes ____No If yes, explain:_____________________________

_______________________________________________________________________________

7. Have you ever made application with this agency before? ____Yes ____No

If yes, give date(s):_________________________________________________________________

8. Are there ANY incidents in your life or details not mentioned herein which may influence this department’s evaluation of your suitability for employment with Osceola County? ____Yes ____No If so, explain:__________________________________________________________________________

_______________________________________________________________________________

I HEREBY CERTIFY THAT THERE ARE NO WILLFUL MISREPRESENTATIONS, OMISSIONS OR FALSIFICATIONS IN THE FOREGOING STATEMENTS AND ANSWERS TO QUESTIONS.

I AM FULLY AWARE THAT ANY SUCH MISREPRESENTATIONS, OMISSIONS OR FALSIFICATIONS WILL BE GROUNDS FOR IMMEDIATE REJECTION OR TERMINATION OF EMPLOYMENT.

________________________________ ______________________

Applicant’s signature Date

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