Hendry County Sheriff’s Office

Date:*

MonthDayYear

Position Applying for:*

Name:*

First NameLast NameSuffix

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Last 4 of SSN:*

DOB:*

MonthDayYear

E-mail:*

example@example.com

Cell Phone Number:*

Cell Phone

Home Phone Number:

Home Phone

PRESCREEN QUESTIONNAIRE

A thorough background investigation is a part of the screening process the Hendry County Sheriff’s Office uses to ensure that the individuals it hires is worth of the trust and authority vested in them. This prescreen questionnaire is a part of that process. Please read the following questions carefully and answer them as fully and accurately as you can. The information you provide will be checked with other sources and with other employers to whom you have applied for jobs.

If it is determined that the information you have supplied is inaccurate or incomplete, you may be disqualified for the subject issues and for dishonesty during the background investigation. This is a serious matter to the Hendry County Sheriff’s Office because honesty is imperative to this agency.

1. Will you consent to a thorough background investigation of your character?*

YesNo

Please Explain:

2. Have you ever applied with the Hendry County Sheriff’s Office?*

YesNo

3. Are you a citizen of the United States? (If no, go to question 3a)*

YesNo

3a. Are you a Resident Alien, or do you possess a United States Work Permit?

YesNo

4. Do you possess a High School Diploma or GED?*

YesNo

5. Do you possess a College degree? (Associates, Bachelors, Masters of Doctorate)*

YesNo

6. Have you ever been denied employment, for any reason, by a law enforcement agency?*

YesNo

Please Explain:

7. Have you ever been terminated by any law enforcement agency?*

YesNo

Please Explain:

8. Have you ever been terminated or asked to resign from ANY job?*

YesNo

Please Explain:

9. Have you ever been physically arrested or given a Notice to Appear (copy of charges)for violation of any city, county, state or federal law?*

YesNo

Please Explain:

10. Have you ever appeared in any County (including juvenile) as a defendant to answer any city, county, state or Federal charges?*

YesNo

Please Explain:

11. Have you ever been detained or stopped by any law enforcement representative, been the subject of any criminal investigation, or been named as the accused on an indictment or warrant?*

YesNo

Please Explain:

12. Have any of your immediate relatives, (spouse, parent, child) been convicted of a felony?*

YesNo

Please Explain:

13. Have you ever done anything, which if uncovered by law enforcement, would have led to your arrest?*

YesNo

Please Explain:

14. Have you ever taken anything that did not belong to you?*

YesNo

Please Explain:

15. With the exception of pens and pencils, have you ever taken any property from your employer for your personal use?*

YesNo

Please Explain:

16. Have you ever been named in or served with an Injunction for Protection Against Domestic Violence*

YesNo

Please Explain:

17. Have you ever viewed or downloaded any child pornography?*

YesNo

Please Explain:

18. Have you ever been arrested for DUI (Driving Under the Influence)?*

YesNo

Please Explain:

19. Have you ever been arrested for any crime of moral turpitude?*

YesNo

Please Explain:

20. Have you ever received any tickets for traffic violations on any license that you have held since you began driving?*

YesNo

Please Explain:

21. Have you ever driven under the influence of alcohol or any other drugs?(for purposes of this question, “under the influence” means that you may have been Arrested by law enforcement if you have been stopped)*

YesNo

Please Explain:

22. During the past five (5) years, have you been involved in more than two (2) traffic stops?*

YesNo

Please Explain:

23. Have you ever signed up for, joined, or served in any US Military branch?(i.e. Army, Navy, Air Force, Marines, Coast Guard or National Guard)*

YesNo

Please Explain:

24. If you have served in the US Military, were you ever disciplined while in the armed forces?*

YesNo

Please Explain:

25. If you served in the US Military, did you receive a discharge other than Honorable?*

YesNo

Please Explain:

26. Have you ever used, tried, ingested or experimented with marijuana? (including as a juvenile)*

YesNo

Please Explain:

27. Have you ever used, tried, ingested, inhaled, injected or experimented with ANY other type of Illegal narcotics or other illegal drugs (i.e. cocaine, crack cocaine, heroin, hashish, speed, LSD, anabolic steroids, etc.)?*

YesNo

Please Explain:

28. Have you ever sold any type of illegal drugs, delivered illegal drugs, sharedperson, drugs with another held drugs for another person, or directed another person where to buy drugs?*

YesNo

Please Explain:

29. Have you ever used prescription drugs other than your own?*

YesNo

Please Explain:

30. Are you delinquent in any payments, you owe credit cards, car loans, home loans, personal loans, child support, spousal support, utility bills, taxes, or other debts?*

YesNo

Please Explain:

31. Have you ever filed for bankruptcy, had any judgements against you, had property repossessed, had a foreclosure against any property you owned, or had an account turned over for collection?*

YesNo

Please Explain:

32. Do you know of anything that might prevent you from obtaining the position that you have applied for?*

YesNo

Please Explain:

33. Have you purposely omitted any information from this prescreen questionnaire?*

YesNo

Please Explain:

34. Have you applied at any other law enforcement agencies?*

YesNo

Which Agencies?

35. Were you able to understand all of the questions in this application?*

YesNo

THE FOLLOWING QUESTIONS TO BE COMPLETED ONLY BY APPLICANTS WHO ARE CURRENTLY CERTIFIED ENFORCEMENT OR CORRECTION OFFICERS.

If NO is selected questions 38-45 will not be visable for selection.

36. Are you a certified law enforcement officer?*

YesNo

37. Are you a certified corrections officer?*

YesNo

38. Have you ever been the focus of or a witness in any internal investigation?*

YesNo

Please Explain:

39. Have you ever been under investigation by your agency or any other government agency?*

YesNo

Please Explain:

40. Have you ever been terminated or asked to resign from any law enforcement agency?*

YesNo

Please Explain:

41. Did you ever take a pre-employment polygraph or voice stress exam prior to being hired into law enforcement or corrections?*

YesNo

Please Explain:

42. Have you ever been sued or caused any law enforcement agency to be sued as a result of your actions or lack of actions?*

YesNo

Please Explain:

43. Have you ever been found to be at fault in any vehicle crash while on duty?*

YesNo

Please Explain:

44. Have you ever been demoted as a result of any discipline?*

YesNo

Please Explain:

45. What law enforcement agencies have you worked for?*

Have you ever used:*

	Yes	No	This Past Year	1-5 Years Ago	5 or More Years
Marijuana
Cocaine
Steroids
Quaaludes
Hashish
Ecstasy (MDMA)
Rohypnol (Roofies)
P.C.P.
Heroin (Other Opiates)
Crack Cocaine
LSD or Other Hallucinogens
PCP (Angel Dust)
Barbiturates (Downers)
Amphetamines (Uppers)
Methamphetamines
Fraudulent use of Prescription Drugs

I do solemnly swear and affirm that I have read and understand these questions and that the information Provided above is true and correct to the best of my knowledge.

Your signature must have an HCSO employee witness

Applicant Signature:*

Date:*

MonthDayYear

Signature Date

Please verify that you are human*

Hendry County Sheriff’s Office

Drug Use Questionnaire