Roane County Sheriff's Office

Name:*

First NameLast Name

Date of Birth:*

Date

Social Security Number:*

Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Driver's License Number:*

State of Issue:*

Current Address:*

Former Address:*

Email:*

example@example.com

Position Interested In:*

Full TimePart Time

YesNo

If so, when?

If your application is considered favorably, on what date will you be available for work?*

Date

Rate of Pay Expected per week?*

Have you ever been convicted of a felony, misdemeanor, any law or ordinance (excluding traffic violations)?*

The existence of a criminal record does not constitute an automatic bar from employment.

Name of Person to be notified in case of accident or emergency:*

First NameLast Name

Relationship:*

Phone Number of Person to be notified in case of accident or emergency:*

Please enter a valid phone number.Format: (000) 000-0000.

Address of Person to be notified in case of accident or emergency:*

YesNo

If yes, which branch?

Dates of Service, Start Date:

Date

End Date:

Date

Highest level of education completed?*

List of schools attended (include any specialized courses):*

YesNo

If yes, explain:

YesNo

If yes, name the type of equipment or machines and years of experience:

All Employees and Prospective Employees:

By being an employee or a potential employee of the Roane County Sheriff's Office, you must provide personal information in order for a criminal history and/or background check to be conducted. The criminal history can be run at any time. Also, your driver's license may be run at any time if you drive of potentially drive a county vehicle.

A yes answer to any of the following questions is not automatically disqualifying. Failure to completely or truthfully answer any question many result in disqualification for employment by the Roane County Sheriff's Office. If a question does not apply, mark it with N/A. Use additional paper if necessary.

YesNo

If yes, explain:

YesNo

Where were you born?*

YesNo

List any other names and/or dates of birth that you have used (maiden name, aliases, etc.):*

List addresses for the last 10 years where you have lived at beginning with the most recent first:*

*be sure to add dates

YesNo

If you use social media which ones and under what names or log-ins?

YesNo

If yes, list below:

Date:

Agency:

Charge:

Outcome:

Date:

Agency:

Charge:

Outcome:

Date:

Agency:

Charge:

Outcome:

Date:

Agency:

Charge:

Outcome:

YesNo

If yes, list below:

Include the family members name, relationship, offense, arresting agency and date for each offense

YesNo

If yes, list the agencies, dates of employment and reason for leaving:

YesNo

If yes, list company name, supervisor, phone number and address of employer, as well as the approximate date and an explanation for each employer:

YesNo

If yes, explain below:

YesNo

If yes, explain below and include punishment received:

YesNo

If yes, explain below:

YesNo

If yes, explain below:

YesNo

If yes, detail below:

List your education from High School or GED with the most recent first:*

Include school name, address, dates, and if you graduated

Work Experience: List your significant work experience to include any military covering at a minimum the last 10 years. Start with your current or most recent job and work back. Include employing firm, dates of employment, address, supervisor, phone number, your title, salary, hours per week, specific duties and reason for leaving for each.

Employing Firm:*

Starting Date:*

Date

Ending Date:*

Address:*

Supervisor:*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Your title:*

Salary:*

Hours per week:*

Specific Duties:*

Reason for Leaving:*

Employing Firm:*

Starting Date:*

Date

Ending Date:*

Address:*

Supervisor:*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Your title:*

Salary:*

Hours per week:*

Specific Duties:*

Reason for Leaving:*

Employing Firm:*

Starting Date:*

Date

Ending Date:*

Address:*

Supervisor:*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Your title:*

Salary:*

Hours per week:*

Specific Duties:*

Reason for Leaving:*

Employing Firm:*

Starting Date:*

Date

Ending Date:*

Address:*

Supervisor:*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Your title:*

Salary:*

Hours per week:*

Specific Duties:*

Reason for Leaving:*

Reference #1 - Name:*

First NameLast Name

Reference #1 - Phone:*

Please enter a valid phone number.Format: (000) 000-0000.

Reference #1 - Address:*

Reference #1 - Relationship:*

Reference #1 - Email:*

example@example.com

Reference #2 - Name:*

First NameLast Name

Reference #2 - Phone:*

Please enter a valid phone number.Format: (000) 000-0000.

Reference #2 - Address:*

Reference #2 - Relationship:*

Reference #2 - Email:*

example@example.com

Reference #3 - Name:

First NameLast Name

Reference #3 - Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Reference #3 - Address:

Reference #3 - Relationship:

Reference #3 - Email:

example@example.com

Signature*

Date*

Date

The facts set forth in my application for employment are true and complete to the best of my knowledge and are made in good faith. I understand that any misstatement of material fact containined in this application may cause rejection of this application and if employed will be considered sufficient cause for dismissal.

You are hereby authorized to contact the persons I have listed as references and to make any investigation of my personal financial and credit record you deem necessary.

This application will be kept on file for twelve (12) months from date of filing. If you are hired, provided the following information:

Height*

Weight*

Eye Color*

Hair Color*

Place of Birth*

Pant Size*

Shirt Size*

Hat Size*

Jacket Size*

If married, spouses name:*

Spouses Birthdate:*

Date

Number of children or dependents:*

Drivers License Number:*

Driver's License Number:*

State of Issue:*

This information will be provided to sheriff's designee in order to process the information and then be locked in your personal records.

WAIVER AND AUTHORIZATION TO RELEASE CONFIDENTIAL PRE-EMPLOYMENT BACKGROUND INFORMATION.

TO WHOM IT MAY CONCERN:

I am an applicant for a position with the Roane County Sheriff's Office (RCSO). As part of my application, the RCSO needs to thoroughly investigate my work record, and reputation to evaluate my qualifications and fitness for the position I am seeking. It is in the publics best interest that you provide this information to the Department. The RCSO will discontinue processing my application if you refuse to provide the information requested.

I hereby authorize RCSO and any agent of the RCSO bearing this release to obtain any and all information described below.
I consent to and authorize your release of any and all public and private information that you may have concerning me, such as my work record, background, reputation, my military service record, educational records, criminal history records, including any arrest records, any information in investigatory files, efficiency ratings, complaints or grievances filed by or against me, attendance records, records or recollections or attorneys at law, polygraph examinations, and internal affairs investigations and discipline, including any files which are or may be confidential or sealed.
My intent is to provide full and complete disclosure of any information about me, however personal or confidential it may appear to be.
I hereby release to you, your organization and any other from any liability or damage that may result from furnishing the information requested, whether to you, your agents and employees or to me, my heirs, successors and assigns.
I understand that all information obtained by the RCSO is confidential and will not be disclosed to me and will be used by the RCSO solely for the purpose of determining qualifications and fitness for the position I am seeking. However, I understand that should information of a serious criminal nature be discovered, the information may be turned over to the proper authorities by the RCSO.
I hereby agree to hold the Roane County Government and the RCSO, and their elected and appointed officials, agents and employees and assigns harmless from and against any and all claims and liability associated with this investigation about me, their use of the information obtained about me pursuant to this document, and their refusal to disclose any of the information to me.
This waiver is valid for a period of 120 days from the date first written above.
I have been advised and given the opportunity to consult with an attorney of my own choosing prior to signing this waiver. I sign the waiver voluntarily, of my own free will, under no duress and without coercion.
I agree to pay any and all charges or fees concerning this request that you bill me directly at my address as written on the application.
A photocopy or fax copy of this waiver shall be for all intents and purposes as valid as the original. You may retain this form for your files.

Applicants Name*

First NameLast Name

Applicants Address*

Date*

Date

Applicants Service Number (if applicable)

Applicants Signature*

Roane County Sheriff's Office

Personal Information

Education and other Formal Training

Employment History

Personal References

WAIVER AND AUTHORIZATION TO RELEASE CONFIDENTIAL PRE-EMPLOYMENT BACKGROUND INFORMATION.

TO WHOM IT MAY CONCERN: