Jay County Sheriff's Office

Are you at least 18 years of Age?* Yes No

Applicants for Sheriff Department: Are you at least 21 years of Age?* Yes No

Are you related to an employee currently employed by the County?* Yes No

Are you interested in:

Full-time work?* Yes No

Part-time work?* Yes No

Temporary work?* Yes No

Employment History

List all employment history and work experience during the previous 5 years, beginning with your present employer. Failure to include all past employment may be grounds for disqualification.

Company

Phone

Address

Supervisor

Title

Job Title

Starting Salary ($)

Ending Salary ($)

Responsibilities

From

Reason for wanting to leave

May we contact your current supervisor for a reference?
Yes No

Company

Phone

Address

Supervisor

Title

Job Title

Starting Salary ($)

Ending Salary ($)

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?
Yes No

Company

Phone

Address

Supervisor

Title

Job Title

Starting Salary ($)

Ending Salary ($)

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?
Yes No

Company

Phone

Address

Supervisor

Title

Job Title

Starting Salary ($)

Ending Salary ($)

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?
Yes No

If you had additional employers within the last five years, please list them here

List and explain periods of unemployment in the past five years

Education

High School

Name of School

Address

From (Date)

To (Date)

Diploma
Yes No

GED
Yes No

awards, activities (You may exclude any which indicate race, color, religion, gender, age, national origin, or disability)

College

Name of School

Address

From (Date)

To (Date)

Diploma/Degree

Major/minor course(s) of study

Other

Name of School

Address

From (Date)

To (Date)

Diploma/Degree

Major/minor course(s) of study

Activities, awards (You may exclude any which indicate race, color, religion, gender, age national origin, or disability.)

Seminars/workshops, special awards, articles you have published, other information that may be relevant to the position you are seeking

Military Service

Branch

From (Date)

To (Date)

Highest Rank Attained

Rank at Discharge

Type of Discharge

Citations/awards Received

Professional or Specialized Training

Specialized Training

Professional/special license(s) or certificate(s)

State

Issued By

Date Issued

Expiration

Type

License #

State

Issued By

Date Issued

Expiration

Type

License #

State

Issued By

Date Issued

Expiration

Type

License #

Have you had any license suspended, revoked, or terminated?
Yes No

Professional Affiliations

Name

Address

Phone

Offices/Positions

Name

Address

Phone

Offices/Positions

Name

Address

Phone

Offices/Positions

Use the following space to describe other training, education, skills, abilities, hobbies, volunteer work or other information that may be helpful in evaluating your application. (You may exclude any which indicate race, color, religion, gender, age, national origin or disability.)

Personal Information

Do you have any commiments which might interfere with or adversely affect you employment with us, such as a second job or school?*
Yes No

Have you ever been convicted of a felony?*
Yes No

List three references who are not related to you and are not former employers or supervisors:

Full Name

Number of years know

Phone

Full Name

Number of years know

Phone

Full Name

Number of years know

Phone

Are you currently required to register as a sex offender in this or any other jurisdiction?*
Yes No

Applicant Certification

Read each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each paragraph by signing your initials at the end of each paragraph. If you have any questions regarding these paragraphs, contact the employer before initially.

I understand and accept that, if I am hired, I may be hired conditional on passing any medical and/or psychological examinations that the employer deems necessary to determine the ability to perform the essential functions of the position. I understand and accept that this may include drug, alcohol, or substance abuse testing.

I understand that it may be necessary for me to approve and sign any waivers necessary in order for the employer to obtain information from my current and former employers.

I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that, if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.

I solemnly swear that all the information furnished in this employment application is true, accurate and complete to the to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that my misrepresentations or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment.

By submitting this document, I hereby agree that I shall execute the employers conditional and post-employment medical examination and drug testing consent requirements. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drug use, or alcohol abuse.

Applicant's Signature*

Date*

I understand that the employer provides sheriff services on on a seven day per week and twenty-four hour per day service, and therefore, if employed by the Sheriff's Department, I may be required to work evening shifts or night shifts, including weekends.

I understand that if I am hired as a sworn officer on the Sheriff Department, that I must successfully complete required training and courses specified and be certified by the State of Indiana Police Academy.

Employment Application

Applicant Information

Employment History

List all employment history and work experience during the previous 5 years, beginning with your present employer. Failure to include all past employment may be grounds for disqualification.

Education

High School

College

Other

Military Service

Professional or Specialized Training

Personal Information

List three references who are not related to you and are not former employers or supervisors:

Applicant Certification

Current Openings