EmailMe Form - CLARK COUNTY SHERIFF’S OFFICE

Application for Employment

Name *

First Middle Last

Date of Birth *

MM / DD / YYYY

BASIC ELIGIBILITY REQUIREMENTS FOR MERIT DEPUTY:

• Must be a United States Citizen
• Must be at least 21 years of age on or before the date of employment
• Must meet a minimum vision standard (corrected or uncorrected) of 20/50 acuity in each eye and 20/50 binocular acuity in both eyes
• Must not have a recorded felony conviction
• Must possess a valid driver’s license
• Must have earned a high school diploma or GED
• Must be willing to reside within Clark, Scott, Jefferson or Floyd counties in the State of Indiana within six (6) months of appointment

BASIC ELIGIBILITY REQUIREMENTS FOR CORRECTIONS OFFICERS/CIVILIAN
STAFF:

• Must be a United States Citizen
• Must be at least 18 years of age on or before the date of employment
• Must not have a recorded felony conviction
• Must possess a valid driver’s license
• Must have earned a high school diploma or GED

Position You Are Applying For: *

Do you meet the basic eligibility requirements: *

Yes

No

INSTRUCTIONS:

• Unless otherwise requested, enter dates in the following format: MM/DD/YY
• Telephone numbers shall be entered in the following format: XXX-XXX-XXXX
• Standard two-character State abbreviations shall be used (i.e. IN for Indiana)
• Enter “N/A” when information is requested that is not applicable to the applicant
• Incomplete applications will not be considered
• Any misrepresentation of facts on this application will disqualify the applicant

Do not make inquiries regarding the status of the application; you may receive appropriate information concerning the application periodically via e-mail. It is important to monitor your email on a regular basis in order to receive time-sensitive information regarding the selection process.

Background Information:

To determine your eligibility for employment with Clark County Sheriff’s Office, please answer the following questions.

As a candidate for employment, I understand that all information provided will be verified by a background investigation and may include a polygraph examination. Any false information provided may cause me to be removed from further consideration for employment.

Have you used an illegal drug (other than marijuana), or abused a legal
drug within the past five (5) years? *

Yes

No

Have you use marijuana within the past 12 months? *

Yes

No

Have you ever knowingly or intentionally sold, transported or manufactured any illegal drug for profit? *

Yes

No

Do you currently abuse alcohol? *

Yes

No

How many times within the last year have you operated a motor vehicle (to include a motorboat) and felt impaired or “buzzed”, due to alcohol and/or drugs? (Enter as a whole number only: 0, 1, 2, 3...etc.) *

Have you received any of the following Military Discharges: Bad Conduct Discharge (BCD), Dishonorable Discharge (DD), or Administrative Discharge of Other Than Honorable (OTH)? *

Yes

No

Have you engaged in any form of beastiality since the age of 18? *

Yes

No

Do you have any tattoos, brands or mutilations exposed while wearing a short sleeve shirt with your arms extended downward? *

Yes

No

NOTE: Mutilation is defined under current Department policy as a purposeful, knowing, or intentional disfigurement, modification or alteration of one’s natural appearance that could bring discredit to the Department or create a non-uniform appearance which might hinder Department esprit de corps. Such mutilations may include, but are not limited to brands, ear gauges, nose gauges, facial piercings, tongue trimming, tongue splitting, tongue studs, cranium cosmetic implants or any other implant that does not project an anthropomorphic appearance.

General Information

Name *

First Middle Last

Maiden Name

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Home Phone

### - ### - ####

Business Phone

### - ### - ####

Mobile Phone *

### - ### - ####

Email Address *

REFERENCES

Reference #1 Name *

First Last

Reference #1 Phone *

### - ### - ####

Reference #1 Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Reference #2 Name *

First Last

Reference #2 Phone *

### - ### - ####

Reference #2 Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Reference #3 Name *

First Last

Reference #3 Phone *

### - ### - ####

Reference #3 Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Reference #4 Name *

First Last

Reference #4 Phone *

### - ### - ####

Reference #4 Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

RELATIVE DISCLOSURE INFORMATION:

In an effort to avoid nepotism during the interview process, it is necessary that you notify the Department of all relatives who have or currently work for the Clark County Sheriff’s Office in the spaces provided below. For purposes of this procedure, “relative” means father, mother, brother, sister, uncle, aunt, husband, wife, son, daughter, son-in-law, daughter-in-law, niece or nephew.

Do you currently have or ever had relatives employed by the Clark County Sheriff’s Office?

Yes

No

If “Yes”, enter their information below:

Their Name

First Last

Position They Held

Your Relationship To Them

Initial Requirement Data

Date of Birth *

MM / DD / YYYY

Your Age *

Race

Sex

Marital Status

Are you a US Citizen? *

Yes

No

Education Data

Highest Grade of School Completed

Diploma

GED

Highest Level of College Completed

Degree(s) Obtained

Name of School

Number of Hours Completed

GPA on 4.0 Scale

Did you graduate?

Yes

No

Name of School

Number of Hours Completed

GPA on 4.0 Scale

Did you graduate?

Yes

No

Name of School

Number of Hours Completed

GPA on 4.0 Scale

Did you graduate?

Yes

No

Prior Law Enforcement Data

Do you have full-time paid law enforcement experience as a police
officer?

Yes

No

If yes, please complete the following:

Did you complete a state accredited law enforcement academy?

Yes

No

If “Yes”, what academy/facility did you attend?

Did you receive a certificate upon completion of this training?

Yes

No

What month and year was this training completed? (MM/YY)

Total number of academy training hours.

Below, list ALL law enforcement experience, beginning with the most recent:

Agency Name

Start Date

MM / YYYY

End Date

MM / YYYY

Status

Full Time

Reserve

Had you been disciplined?

Yes

No

Reason for leaving

Eligible for rehire?

Yes

No

Agency Name

Start Date

MM / YYYY

End Date

MM / YYYY

Status

Full Time

Reserve

Had you been disciplined?

Yes

No

Reason for leaving

Eligible for rehire?

Yes

No

Agency Name

Start Date

MM / YYYY

End Date

MM / YYYY

Status

Full Time

Reserve

Had you been disciplined?

Yes

No

Reason for leaving

Eligible for rehire?

Yes

No

Agency Name

Start Date

MM / YYYY

End Date

MM / YYYY

Status

Full Time

Reserve

Had you been disciplined?

Yes

No

Reason for leaving

Eligible for rehire?

Yes

No

MILITARY HISTORY AND STATUS:

Include active duty service with the National Guard and Reserve Components.

Have you ever served in the United States military on active duty (including basic training)?

Yes

No

If “Yes”, how many total years of active duty?

If “Yes”, complete the information below for each branch of service, beginning with the most recent:

Military Branch

Start Date

MM / YYYY

ETS

MM / YYYY

Rank at Separation

Current Status

Had you been disciplined?

Yes

No

Military Branch

Start Date

MM / YYYY

ETS

MM / YYYY

Rank at Separation

Current Status

Had you been disciplined?

Yes

No

EMPLOYMENT HISTORY:

List current employment, beginning with the most recent (include part-time):

Name of Employer *

Address of Employer *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Telephone Number *

### - ### - ####

Position or Professional Title for Employer #1 *

Start Date *

MM / YYYY

End Date *

MM / YYYY

Had you been disciplined? *

Yes

No

Name of Employer *

Address of Employer *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Telephone Number *

### - ### - ####

Position or Professional Title for Employer #2 *

Start Date *

MM / YYYY

End Date *

MM / YYYY

Had you been disciplined? *

Yes

No

Name of Employer *

Address of Employer *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Telephone Number *

### - ### - ####

Position or Professional Title for Employer #3 *

Start Date *

MM / YYYY

End Date *

MM / YYYY

Had you been disciplined? *

Yes

No

Name of Employer

Address of Employer

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Telephone Number

### - ### - ####

Position or Professional Title for Employer #4

Start Date

MM / YYYY

End Date

MM / YYYY

Had you been disciplined?

Yes

No

DRIVER’S LICENSE INFORMATION:

Do you currently possess a valid driver’s license? *

Yes

No

Driver's License Number *

State of Issue *

Expiration Date *

MM / YYYY

Has your driver’s license ever been suspended or revoked?

Yes

No

If “Yes”, what state(s)?

VEHICLE CRASH AND TRAFFIC TICKET INFORMATION:

Have you ever been involved in a vehicle crash?

Yes

No

If “Yes”, what is the number of crashes you have been involved in?

Have you ever received a ticket for a traffic offense?

Yes

No

If “Yes”, what is the number of tickets you have received?

CRIMINAL ARREST INFORMATION:

Have you ever been arrested or ticketed for a misdemeanor that has not been expunged by a court, even if charges were later dropped or dismissed?

Yes

No

If “Yes”, complete the information requested below for each offense, beginning with the most recent:

Date

MM / YYYY

Arresting Agency

Charge/Offense

Disposition of Case

Date

MM / YYYY

Arresting Agency

Charge/Offense

Disposition of Case

Date

MM / YYYY

Arresting Agency

Charge/Offense

Disposition of Case

Have you ever been arrested or ticketed for a felony that has not been expunged by a court, even if charges were later dropped or dismissed?

Yes

No

If “Yes”, what offense were you convicted of?

Have you ever been arrested for an act as a juvenile that would have been a crime had it been committed by an adult?

Yes

No

If “Yes”, what offense were you convicted of?

Have you ever been, or are you currently involved as a plaintiff, defendant, petitioner or respondent in any civil court case?

Yes

No

MISCELLANEOUS INFORMATION:

Do you currently possess a personal protection handgun permit?

Yes

No

Have you ever been denied a personal protection handgun permit?

Yes

No

Have you ever had a personal protection handgun permit that was suspended or revoked?

Yes

No

Number of your dependents?

Are you legally required to make child support payments?

Yes

No

If “Yes” are your child support payments current?

Yes

No

Do you speak a foreign language?

Yes

No

If “Yes”, what language(s)?

If “Yes”, what language(s) do you speak fluently?

If “Yes”, what language(s) do you read and understand?

The Clark County Sheriff’s Office may require, at a later time, the following documentation. You will be notified when it will be necessary to provide this documentation.

• Birth Certificate
• High School transcripts (Copy)
• Official College/University transcripts (if applicable)
• Military DD214 (if applicable)
• If active duty, a letter of endorsement from a military commander is required
• Copies of specialized training certificates and awards
• Previous law enforcement documentation:
-Copy of State accredited law enforcement academy certificate and curriculum
-Copies of commendations and awards

By placing my name in the box below, I swear or affirm under the penalty of perjury, all information contained in this application is true, accurate and complete to the best of my knowledge. I understand any false information provided may cause me to be removed from further consideration of employment.

Name

First Middle Last

Date Completed

MM / DD / YYYY

PLEASE READ BEFORE CLICKING SUBMIT:

PLEASE ONLY CLICK SUBMIT ONCE AND ALLOW UP TO 30 SECONDS FOR YOUR APPLICATION TO BE SUBMITTED.

Application for Employment

BASIC ELIGIBILITY REQUIREMENTS FOR MERIT DEPUTY:

BASIC ELIGIBILITY REQUIREMENTS FOR CORRECTIONS OFFICERS/CIVILIAN STAFF:

INSTRUCTIONS:

Background Information:

General Information

REFERENCES

RELATIVE DISCLOSURE INFORMATION:

If “Yes”, enter their information below:

Initial Requirement Data

Education Data

Prior Law Enforcement Data

MILITARY HISTORY AND STATUS:

EMPLOYMENT HISTORY:

DRIVER’S LICENSE INFORMATION:

VEHICLE CRASH AND TRAFFIC TICKET INFORMATION:

CRIMINAL ARREST INFORMATION:

MISCELLANEOUS INFORMATION:

The Clark County Sheriff’s Office may require, at a later time, the following documentation. You will be notified when it will be necessary to provide this documentation.

PLEASE READ BEFORE CLICKING SUBMIT:

BASIC ELIGIBILITY REQUIREMENTS FOR CORRECTIONS OFFICERS/CIVILIAN
STAFF: