PINELLAS COUNTY SHERIFF'S OFFICE VIP Program PRE ...
o
PINELLAS COUNTY SHERIFF'S OFFICE VIP Program PRE-APPLICATION QUESTIONNAIRE
NAMc:
___
ADDRESS:
_
DATE:
___
SSN:
___
CITY/STATE/ZIP: RACE:
0
_
White (not Hispanic or Latino) (1)
o o
American Indian/Alaskan
o Hispanic or Latino (4) Asian (5) o Two or more Races (not Hispanic or Latino) (7) DATE OF BIRTH:
SEX:
o
TELEPHONE: Home (
EMAIL ADDRESS
Native (2)
Pager (
o
Black (not Hispanic or Latino) (3)
Native Hawaiian/Pacific Islander (6)
_________ _____
Work (
)
Cell (
_ )
_
POSITION(S) APPLIED FOR:
_
ARE YOU AVAILABLE FOR SHIFT WORK?
o NO
DYES
REFERRED BY:
___
READ AND ANSWER EVERY QUESTION. Any candidate who intentionally misrepresents, falsifies, omits or conceals any material fact, or attempts deception or fraud in the completion of this questionnaire or any other application, examination, or employment procedure will be subject to disqualification, and may subject the applicant to discharge if discovered subsequent to employment. All information on this form will be subject to review for truthfulness and integrity during a 01 ra h examination. CIRCLE YES OR NO TO THE FOLLOWING QUESTIONS 1.
Have you EVER been convicted of a felony, regardless of whether the sentence was suspended, adjudication was withheld, you pled no contest, or the conviction was sealed or expunged?
YES
NO
2.
Have you EVER been convicted of a misdemeanor, regardless of whether the sentence was suspended, adjudication was withheld, you pled no contest, or the conviction was sealed or expunged?
YES
NO
3.
Have you EVER been convicted of any felony or misdemeanor involving perjury or a false statement, regardless of whether the sentence was suspended, adjudication was withheld, you pled no contest, or the conviction was sealed or expunged?
YES
NO
4.
Have you EVER received a Dishonorable, an Undesirable, or a General Discharge from the Armed Forces?
YES
NO
5.
Within the last twelve (12) months, have you possessed or used Marijuana, Hash, Hash Oil, THC, or any other of its derivatives?
YES
NO
6.
Have you EVER influenced, persuaded, or attempted to influence or persuade another person to use illegal drugs?
YES
NO
7.
Have you EVER sold, purchased or offered for sale any illegal drug?
YES
NO
8.
A T ANY TIME within the last six (6) months, have you used any tobacco products, including cigarettes, cigars, chewing tobacco, or snuff?
YES
NO
1
If you answered YES to any of the above questions, you must provide a brief explanation on page 3. Attach additional pages or supportive documentation if necessary.
DRUG
CHECK ONE
SLANG
YES
Marijuana
Pot, Grass, Weed, Green, Hashish, Hash, THC
Cocaine, Crack, or any type of Cocaine derivative
Coke, Snow, Powder, Nose Candy, Tool, Blow, Rock, Girl, Soft (powder), Hard (crack)
Ecstasy (MDMA)
XTC, X, E, Doctor, Adam, Doves, Love Drug, Roll
LSD
Acid, Gel-tabs, Blotter, Dot
Amphetamines
Phennies, Dexies, Speed, Ups/Uppers, White Crosses
Steroids
Roids, Juice, Gym Candy
GHB
G
PCP
Tea, Crystal Tea, Angel Dust
NO
TIMES POSSESSED
LAST TIME
Inhalants: glue, paint, and others Ketamine
K, Special K, Super K, Kit-Kat, Cat Valium, Vitamin K
Barbituates
Barbs, Yellow Jackets, Bennies
Rohypnol
Roofies, Date Rape
Methamphetamine
Crank, Meth, Crystal Meth, Ice
Mushrooms (Psilocybin)
Shrooms, Magic Mushrooms
Opium, Opiate based drugs
Morphine, Oxycontin (Hillbilly Heroin)
Heroin
Smack, Horse, Black Tar, White, Brown, Boy
Other: 9.
Have you EVER used or had in your possession, care, custody or control, ANY of the following drugs, OTHER THAN: (1) those prescribed for you while under the care of a licensed physician; or (2) while in the course of employment as a medical professional; or (3) during an official investigation while employed as a law enforcement officer.
2
IF YOU HAVE ANSWERED 'YES' TO ANY OF THE PRECEDING QUESTIONS, #1 - #9, EXPLAIN YOUR ANSWER(S) BELOW:
I hereby certify the answers given in this pre-employment questionnaire are true and complete to the best of my knowledge. You are hereby authorized to make any investigation of my personal history.
Signature of Candidate:
_
STATE OF FLORIDA COUNTY OF PINELLAS
The foregoing instrument was acknowledged before me this
day of
by
, who is personally known to me or who has produced
________________________
Signature Notary Public
as identification and who did (did not) take an oath.
Name Title
3
_
1.
NAME:
__
2.
POSITION(S) APPLIED FOR:
_
3.
EDUCATION:
HIGH SCHOOL DIPLOMA: GED:
D
DYES DYES
D
NO NO
OTHER:
___
4.
WORK EXPERIENCE:
_
5.
MILITARY:
_
6.
REFERRED BY A MEMBER OF THE SHERIFF'S OFFICE?
DYES
D
NO
IF YES, PLEASE PRINT MEMBER'S NAME CLEARLY:
_
IF YOU WERE NOT REFERRED BY A MEMBER OF THE SHERIFF'S OFFICE, BY WHOM OR WHAT MEANS DID YOU LEARN OF THE EMPLOYMENT OPPORTUNITIES AVAILABLE AT THE SHERIFF'S OFFICE?
THE PINELLAS COUNTY SHERIFF'S OFFICE IS COMMITTED TO A DRUG FREE WORKPLACE. ****************************
All applicants receive consideration for employment without regard to race, age, ancestry, color, marital status, religion, national origin, medical condition, or handicap.
4
CANDIDATE QUESTIONNAIRE
CANDIDATE INFORMATION: NAME:
_
SOCIAL SECURITY NUMBER:
_
POSITION APPLIED FOR:
_
CANDIDATE INSTRUCTIONS: As part of the interview process for the position listed above you will be provided with a copy of the job duties which describes the requirements of that position. You are asked to review the information and complete this questionnaire by checking the appropriate option box and signing in the space provided. The Human Resource Division of the Pinellas County Sheriff's Office is using this procedure to ensure compliance with the Americans with Disabilities Act of 1990. I have read (or had read to me) the job duties/functions for this position and I am capable of performing the duties of the job as described with or without a reasonable accommodation. YES
D
NO
D
I hereby certify that my answers are true and correct to the best of my knowledge.
SIGNATURE
DATE
5
EEOC Information ~ The Pinellas County Sheriff's Office Guidelines on Employee Selection Procedures requires records to be kept by gender and race/ethnic categories defined by the Equal Employment Opportunity Commission (EEOC). The Sheriff's Office Guidelines on employee Selection Procedures have been adopted as final rules by the EEOC, the Office of Personnel Management, the Justice Department, and the Department of Labor. ~ Pinellas County Sheriff's Office is subject to certain government record keeping and reporting requirements for the administration of civil rights laws and regulation. In order to comply with these laws, we invite you to voluntarily self-identify your race or ethnicity. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. ~ The information obtained is considered confidential and will only be used in accordance with the provision of applicable laws, executive orders, and regulation, including those that required the information be summarized and reported to the federal government for civil rights enforcement. The Human Resources Division has adapted safeguards to insure that the records required are used for the a ppropriate purposes within the Division such as determining adverse impact, or for monitoring our affirmative action program. ~ The concept of race used by the EEOC does not denote clear-cut scientific definitions of anthropological origins. Applicants may be included in groups to which he/she appears to belong, identifies with, or is regarded in the community as belonging. PLEASE RETURN TO: PINELLAS COUNTY SHERIFF'S OFFICE COMMUNITY PROGRAMS E-MAIL [email protected]
MAIL P.O. Drawer 2500 Largo, FL 33779
6
PINELLAS COUNTY SHERIFF'S OFFICE VIP Program PRE-APPLICATION QUESTIONNAIRE
NAMc:
___
ADDRESS:
_
DATE:
___
SSN:
___
CITY/STATE/ZIP: RACE:
0
_
White (not Hispanic or Latino) (1)
o o
American Indian/Alaskan
o Hispanic or Latino (4) Asian (5) o Two or more Races (not Hispanic or Latino) (7) DATE OF BIRTH:
SEX:
o
TELEPHONE: Home (
EMAIL ADDRESS
Native (2)
Pager (
o
Black (not Hispanic or Latino) (3)
Native Hawaiian/Pacific Islander (6)
_________ _____
Work (
)
Cell (
_ )
_
POSITION(S) APPLIED FOR:
_
ARE YOU AVAILABLE FOR SHIFT WORK?
o NO
DYES
REFERRED BY:
___
READ AND ANSWER EVERY QUESTION. Any candidate who intentionally misrepresents, falsifies, omits or conceals any material fact, or attempts deception or fraud in the completion of this questionnaire or any other application, examination, or employment procedure will be subject to disqualification, and may subject the applicant to discharge if discovered subsequent to employment. All information on this form will be subject to review for truthfulness and integrity during a 01 ra h examination. CIRCLE YES OR NO TO THE FOLLOWING QUESTIONS 1.
Have you EVER been convicted of a felony, regardless of whether the sentence was suspended, adjudication was withheld, you pled no contest, or the conviction was sealed or expunged?
YES
NO
2.
Have you EVER been convicted of a misdemeanor, regardless of whether the sentence was suspended, adjudication was withheld, you pled no contest, or the conviction was sealed or expunged?
YES
NO
3.
Have you EVER been convicted of any felony or misdemeanor involving perjury or a false statement, regardless of whether the sentence was suspended, adjudication was withheld, you pled no contest, or the conviction was sealed or expunged?
YES
NO
4.
Have you EVER received a Dishonorable, an Undesirable, or a General Discharge from the Armed Forces?
YES
NO
5.
Within the last twelve (12) months, have you possessed or used Marijuana, Hash, Hash Oil, THC, or any other of its derivatives?
YES
NO
6.
Have you EVER influenced, persuaded, or attempted to influence or persuade another person to use illegal drugs?
YES
NO
7.
Have you EVER sold, purchased or offered for sale any illegal drug?
YES
NO
8.
A T ANY TIME within the last six (6) months, have you used any tobacco products, including cigarettes, cigars, chewing tobacco, or snuff?
YES
NO
1
If you answered YES to any of the above questions, you must provide a brief explanation on page 3. Attach additional pages or supportive documentation if necessary.
DRUG
CHECK ONE
SLANG
YES
Marijuana
Pot, Grass, Weed, Green, Hashish, Hash, THC
Cocaine, Crack, or any type of Cocaine derivative
Coke, Snow, Powder, Nose Candy, Tool, Blow, Rock, Girl, Soft (powder), Hard (crack)
Ecstasy (MDMA)
XTC, X, E, Doctor, Adam, Doves, Love Drug, Roll
LSD
Acid, Gel-tabs, Blotter, Dot
Amphetamines
Phennies, Dexies, Speed, Ups/Uppers, White Crosses
Steroids
Roids, Juice, Gym Candy
GHB
G
PCP
Tea, Crystal Tea, Angel Dust
NO
TIMES POSSESSED
LAST TIME
Inhalants: glue, paint, and others Ketamine
K, Special K, Super K, Kit-Kat, Cat Valium, Vitamin K
Barbituates
Barbs, Yellow Jackets, Bennies
Rohypnol
Roofies, Date Rape
Methamphetamine
Crank, Meth, Crystal Meth, Ice
Mushrooms (Psilocybin)
Shrooms, Magic Mushrooms
Opium, Opiate based drugs
Morphine, Oxycontin (Hillbilly Heroin)
Heroin
Smack, Horse, Black Tar, White, Brown, Boy
Other: 9.
Have you EVER used or had in your possession, care, custody or control, ANY of the following drugs, OTHER THAN: (1) those prescribed for you while under the care of a licensed physician; or (2) while in the course of employment as a medical professional; or (3) during an official investigation while employed as a law enforcement officer.
2
IF YOU HAVE ANSWERED 'YES' TO ANY OF THE PRECEDING QUESTIONS, #1 - #9, EXPLAIN YOUR ANSWER(S) BELOW:
I hereby certify the answers given in this pre-employment questionnaire are true and complete to the best of my knowledge. You are hereby authorized to make any investigation of my personal history.
Signature of Candidate:
_
STATE OF FLORIDA COUNTY OF PINELLAS
The foregoing instrument was acknowledged before me this
day of
by
, who is personally known to me or who has produced
________________________
Signature Notary Public
as identification and who did (did not) take an oath.
Name Title
3
_
1.
NAME:
__
2.
POSITION(S) APPLIED FOR:
_
3.
EDUCATION:
HIGH SCHOOL DIPLOMA: GED:
D
DYES DYES
D
NO NO
OTHER:
___
4.
WORK EXPERIENCE:
_
5.
MILITARY:
_
6.
REFERRED BY A MEMBER OF THE SHERIFF'S OFFICE?
DYES
D
NO
IF YES, PLEASE PRINT MEMBER'S NAME CLEARLY:
_
IF YOU WERE NOT REFERRED BY A MEMBER OF THE SHERIFF'S OFFICE, BY WHOM OR WHAT MEANS DID YOU LEARN OF THE EMPLOYMENT OPPORTUNITIES AVAILABLE AT THE SHERIFF'S OFFICE?
THE PINELLAS COUNTY SHERIFF'S OFFICE IS COMMITTED TO A DRUG FREE WORKPLACE. ****************************
All applicants receive consideration for employment without regard to race, age, ancestry, color, marital status, religion, national origin, medical condition, or handicap.
4
CANDIDATE QUESTIONNAIRE
CANDIDATE INFORMATION: NAME:
_
SOCIAL SECURITY NUMBER:
_
POSITION APPLIED FOR:
_
CANDIDATE INSTRUCTIONS: As part of the interview process for the position listed above you will be provided with a copy of the job duties which describes the requirements of that position. You are asked to review the information and complete this questionnaire by checking the appropriate option box and signing in the space provided. The Human Resource Division of the Pinellas County Sheriff's Office is using this procedure to ensure compliance with the Americans with Disabilities Act of 1990. I have read (or had read to me) the job duties/functions for this position and I am capable of performing the duties of the job as described with or without a reasonable accommodation. YES
D
NO
D
I hereby certify that my answers are true and correct to the best of my knowledge.
SIGNATURE
DATE
5
EEOC Information ~ The Pinellas County Sheriff's Office Guidelines on Employee Selection Procedures requires records to be kept by gender and race/ethnic categories defined by the Equal Employment Opportunity Commission (EEOC). The Sheriff's Office Guidelines on employee Selection Procedures have been adopted as final rules by the EEOC, the Office of Personnel Management, the Justice Department, and the Department of Labor. ~ Pinellas County Sheriff's Office is subject to certain government record keeping and reporting requirements for the administration of civil rights laws and regulation. In order to comply with these laws, we invite you to voluntarily self-identify your race or ethnicity. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. ~ The information obtained is considered confidential and will only be used in accordance with the provision of applicable laws, executive orders, and regulation, including those that required the information be summarized and reported to the federal government for civil rights enforcement. The Human Resources Division has adapted safeguards to insure that the records required are used for the a ppropriate purposes within the Division such as determining adverse impact, or for monitoring our affirmative action program. ~ The concept of race used by the EEOC does not denote clear-cut scientific definitions of anthropological origins. Applicants may be included in groups to which he/she appears to belong, identifies with, or is regarded in the community as belonging. PLEASE RETURN TO: PINELLAS COUNTY SHERIFF'S OFFICE COMMUNITY PROGRAMS E-MAIL [email protected]
MAIL P.O. Drawer 2500 Largo, FL 33779
6
