E911 and Admin Application

PERSONAL INFORMATION
Position Applying For:
Date Available to Start:

MonthDayYear
Date
First Name*
First
Middle Name
Middle
Last Name:*
Maiden: (If Applicable)
Any other names you're known by: (Include alias and nicknames)
Home Address:*

Street Address

Apt or Unit

CityState

Zip Code
Mailing Address: (If different from above)

Street Address

Apt or Unit

CityState / Province

Postal / Zip Code
Home Phone Number:*
Cell Phone Number:
Email Address*
example@example.com
Are You Currently A Certified E911 Dispatcher
Social Media Account (s)
Social Media Profile Name(s)
Date of Birth:*

MonthDayYear
Date
Social Security Number:*
xxx-xx-xxxx
Drivers License Number:*
Drivers License State*
Do you have the legal right to work in the U.S. ?*

YesNo
If yes, are you able to provide documents that are required by law to verify your eligibility to work in the U.S. if hired?

YesNo
If a specified work schedule was included in the recruitment posting, are you available to work during the days, times, and/or shifts as indicated?

YesNo
Do you have a valid South Carolina Driver's License or the willingness and ability to relocate and obtain a South Carolina Driver's License if hired?

YesNo
Do you object to wearing a uniform?

YesNo
Do you object to working overtime?

YesNo
Are you willing and able to work day shift, night shift, rotating shifts, weekends, an holidays?

YesNo
Do you have a felony conviction of any crime punishable by more than one year?*

YesNo
DRUG/ALCOHOL HISTORY
Do you currently use/sell OR have you in the past used/sold ANY of the following drugs?*

YesNo
Check all that apply

AmphetaminesSniffed PaintDilaudidSipPCPMDA/MDMAPeyoteBarbituatesLacquerDemerolSniffed GlueSniffed Freon gasPsilocybinHashishCocaineHallucinogensMescalineSchedule II-IV PillsOpiumQuaaludesHeroinMarijuanaMorphineMethamphetamineAcidNerve MedicineCBDSleeping Pills
**Any other illegal substances- If yes, please list:
**Any Controlled Substances without being properly prescribed by a licensed physician - if yes, please list:
Do you habitually use alcoholic beverages to excess?

YesNo
Within the past week, have you had any alcoholic beverages?

YesNo
In the past year, what is the most you have had to drink in one day?
Have you ever missed work due to being under the influence of alcohol or drugs?

YesNo
If yes, please explain:
Have you ever driven after drinking?

YesNo
If yes, how many drinks had you had and in what period of time before driving?
Have you ever committed or been involved in any of the following crimes or offenses?*

NoYesAssaultDUIMurderManslaughterKidnappingArsonBurglaryForgeryRobberyRapeIncestChild MolestingPeeping TomSodomyVandalismPublic Indecency
If yes, please explain
Have you ever been arrested for a felony?

YesNo
Have you ever been arrested for a misdemeanor?

YesNo
Have you ever been in jail or prison?

YesNo
Have you ever had a warrant served on you?

YesNo
If yes, please explain

List any charges you have been charged with:

	Offense Charged With	Law Enforcement Agency	State	Date of Disposition	Explanation
1
2
3

List below any traffic tickets you have received in the past five (5) years.

	Traffic Violation	Law Enforcement Agency	Date
1
2
3
4

Do you owe money to any court (s) for unpaid tickets, citations, or fines?

YesNo
If yes, please explain
Have you ever been questioned by the police for any reason?

YesNo
If yes, please explain
Have you ever illegally used another name?

YesNo
If yes, please explain
List below the last date(s) you were in court and the reason(s) you were there.

List the date (s) below you were in court and the reason (s) you were there

	Date	Reason
*
*

Has your privilege to drive ever been suspended or revoked? Type yes or no. If yes, please explain:
Do you have automobile insurance?

YesNo
Has your automobile insurance ever been canceled?

YesNo
CREDIT INFORMATION
Do you have a Judgement on File at a County Court House?

YesNo
If yes, what County?
Are you presently behind in payment on any bills?

YesNo
Has anything ever been repossessed from you?

YesNo
Have you ever declared, or are you about to declare bankruptcy, or had a judgement filed against you?

YesNo
If yes, please explain:
Has any debt owned by you been turned over to a collection agency?

YesNo
If yes, please explain:
MILITARY SERVICE
Did you serve in the military? If yes, which branch?
How many years were you in the military? blanks
From (year) blank to
What was your highest military rank?
What type of discharge did you receive?
What was your rank upon discharge?
Upon what conditions was your discharge?
Were you ever court-martialed while in service?

YesNo
If yes, please explain:
**Applicants must also be able to provide a copy of your DD form 214, Certificate of Release or Discharge from Active Duty by military services**
Employment
Have you ever been fired from a job?*

YesNo
Have you ever been forced to resign from a job?

YesNo
Have you ever been or are you now the subject of any investigation concerning illegal or improper activities with your present or previous employer??

YesNo
If yes, please explain:
Have you ever been employed with Chester County Sheriff's Office in the past?*

YesNo
If yes, when and where
Are you related to any employee currently employed with the Chester County Sheriff's Office?

YesNo
Note: This includes immediate family members or family members related to you by marriage.

If you are related to any employee in the detention side of the Chester County Sheriff's Office, please list their name and your relationship to them

	Employee Name	Relationship
1
2
3

If you are related to any employee in the detention side of the Chester County Sheriff's Office, please list their name and your relationship to them

	Employee Name	Relationship	Position
1
2
3
4

References - Please list three (3) personal references below. (Do not use former employers or relatives.)

	Name (First and Last	Occupation	Address	Telephone	Email	Years Known
1
2
3

Education
Did you graduate High School?

YesNo
High School

School Name

Address

CityState / Province

Postal / Zip Code
Attended from: blanks to blank .
Degree(s) Earned
Did you graduate Technical School?

YesNo
Technical School

School Name

Address

CityState / Province

Postal / Zip Code
Attended from: blanks to blank
Degree(s) Earned
Did you graduate from a college or university?

YesNo
College or University

School Name

Address

CityState / Province

Postal / Zip Code
Attended From: blanks to
Degree(s) Earned
Did you graduate from any other type education program?

YesNo
Other Education Program

School Name

Address

CityState / Province

Postal / Zip Code
Attended From: blanks to blank
Degree(s) Earned:
Are there any experiences, skills, training, or qualifications which you feel would especially prepare you to work with the Chester County Sheriff's Office?
Employment History
Please list below your last 10-year history of employment, beginning with your most recent.
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
Employment Dates - From blanks to blank
Ending Salary (Bi-Weekly)$
Company Name:
Phone:
Address:   Street Address      City   State   ZipJob Title:
Job Duties:
Supervisor(s) Name:
Reason for Leaving:
May we contact the employers listed above?
If not, indicate which one(s) you do not wish CCSO to contact?
If you are employed, why do you wish to change employment?
Family Information
Father's Full Name (No Initals)

First NameLast Name
Father's Nickname or Alias:
Father Living or Deceased?
Father's Address

Street Address

CityState / Province

Postal / Zip Code
Father's Occupation
Father's Employer and Employer Address
Father's Military Branch (If applicable)
Father's Military Rank (If applicable)
Father's Military Begin Date (If applicable)
Father's Military End Date (If applicable)
Mother's Full Name (No Initals)

First NameLast Name
Mother's Nickname or Alias
Mother Living or Deceased?
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Occupation
Mother's Employer and Address
Mother's Military Branch ((If Applicable)
Mother's Military Rank (If Applicable)
Mother's Military Begin Date (If Applicable)
Mother's Military End Date (If Applicable)
Spouse's Name (If Applicable)

First NameLast Name
Spouse's Nickname or Alias
Spouse Living or Deceased?
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Occupation
Spouse's Employer and Address
Spouse's Military Branch
Spouse's Military Rank
Spouses Military Begin Date (If Applicable)
Spouses Military End Date (If Applicable)
Brother/Sister Full Name
No Initials
Brother/Sister Full Name
No Initials
Brother/Sister Full Name
No Initials
Brother/Sister Full Name
No Initials
Brother/Sister Full Name
No Initials
Brother/Sister Full Name
No Initials
Applicant Waiver, Consent, and Certification
Applicant Name
Social Security Number
Telephone
Date

MonthDayYear
Date
The Chester County Sheriff's Office is an equal employment opportunity employer. We adherer to a policy of making employment decisions without regard to race, color, religion, sex, gender, national origin, age, or disability. Your opportunity for employment with the Chester County Sheriff's Office depends solely on your qualifications.

TO WHOM IT MAY CONCERN: I am applying for employment with the Chester County Sheriff's Office (CCSO). The Chester County Sheriff's Office must thoroughly investigate my academic, employment, and personal histories to evaluate suitability for employment.

I hereby authorize any CCSO representative bearing this release (or a facsimile thereof) to obtain any information regarding me in your files and hereby direct you to release such information as soon as practicable upon the request of the bearer. I hereby authorize a review of, and full disclosure of, all records and any part thereof whether said records are public, private, or confidential. This information may include (but is not limited to) military service records, education records, financial records, credit reporting information, criminal history records, driving records, employment files (to include investigatory files), complaints, efficiency/personnel evaluations, and/orcomplaints/grievances filed by or against me.

I hereby release you, your organization, and all others liability or damages which may result from providing the information requested, to include damages or remedies for by State or Federal law. Regardless of any agreement, I may have made earlier. I hereby release your organization (including its officers, employees, and related personnel) from all liability for damages of whatever kind which may result in regard to me or my heirs, family, and/or assigns.

For and in considerations of the Chester County Sheriff's Office acceptance, review, and processing of my application material, I agree to hold CCSO and all of its employees or agents harmless from any claims liability associated with my application for employment or in any way connected with a decision not to employ me. I understand that if CCSO's pre-employment background investigation reveals criminal activity, that information will be forwarded to the appropriate law enforcement authority.

I understand my rights pursuant to §5 USC 552A (Privacy Act of 1974) with regard to access and disclosure of records, and I waive those rights with the understanding that information furnished will be used by the Chester County Sheriff's Office in conjunction with the pre-employment application process. A photocopy and facsimile of this release shall be valid as an original thereof, even though the copy may not contain an original writing of my signature. This release and waiver shall remain valid and in force for a period of 60 days from the date upon which I signed.
Applicant Signature*

Clear
PLEASE READ THE FOLLOWING STATEMENTS AND SIGN BELOW

Student Loans: SC State Law (§59-111-50) prohibits employment with the State or its political subdivisions to persons who have defaulted on certain student loans unless they can prove that satisfactory arrangements have been made for repayment. I certify by my signature below that I am not currently in default on a student loan.

Physical Examination: The CCSO hiring process may include a physical examination. If required, a physician provided by Chester County will provide the examination to me at no expense. The examination will include a test for drug dependency or use, and by my signature below, I consent to such an examination and test.

Terms of Employment: Neither this application, and attendant forms, or any of the language used herein implies or creates any types of an employment contract between the Chester County Sheriff's Office and the applicant/employee, nor do they create any contractual rights or entitlements. No promises or assurances (whether written or oral) which are contrary to or inconsistent with this paragraph create any contract of employment. If I am eventually employed, I understand that such employment is at-will and may be terminated by either party with or without notice at any time, for any reason or no reason. No one other than the Sheriff possesses any authority to enter into any agreement for employment for any specified period of time, or many any agreement contrary to the foregoing.

Veracity: I understand that the Chester County Sheriff's Office may verify the information I have provided within this application and/or in personal interviews. By my signature below, I affirm, agree, and understand all statements made within this application to be true and accurate. I further understand that any misrepresentation, falsification, or material omission of information or data may result in exclusion from further consideration, or (if hired) termination of employment. My signature below also certifies that I understand any offer of employment to be conditional upon successful completion of the CCSO pre-employment background investigation.
Applicant Signature*

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Resume Upload

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Applicant Full Body Photo

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Driver's License Copy

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DD-214

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Birth Certificate

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Hand Written Statement of Interest

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Should be Empty:

PERSONAL INFORMATION

DRUG/ALCOHOL HISTORY

CREDIT INFORMATION

MILITARY SERVICE

Employment

Education

Employment History

Family Information

Applicant Waiver, Consent, and Certification