Deputy Sheriff Application

Personal Information

Full Name

1. Last Name
2. Middle Name
3. First Name
4. Alias(s), maiden, nicknames, any other names used

Present Address

5. Address
6. City
7. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
8. Zip
9. How long have you lived at this address?
10. Are you a resident of the State of Iowa? Please Select Yes No

Other Information

11. Are you 18 years of age or older? Please Select Yes No
12. Are you a U.S. Citizen? Please Select Yes No
13. Place of Birth City
14. Place of Birth State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
15. Driver's License No
16. State of Issuance Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
17. Expiration Date
18. Home Phone
19. Cell Phone
20. Email
21. Are you a certified peace officer in the State of Iowa? Please Select Yes No
Route to Certification Please Select Iowa Law Enforcement Academy CTE (Certification through Examination)
Level I Regional Academy Please Select Des Moines Police Academy Dept of Public Safety Academy Cedar Rapids Police Academy Other
If other, where?
Level II Regional Academy Please Select Hawkeye Community College Western Iowa Tech Community College Other
If other, where?
22. Have you ever applied with the Jackson County Sheriff's Department before? Please Select Yes No
If yes, approximately when? (month and year)
23. How did you hear about this opening? Please Select Maquoketa Sentinel Press Bellevue Herald Leader Preston Times Buyers Guide KMAQ The DeWitt Observer Telegraph Herald The Des Moines Register Facebook Iowa Sheriff Association Iowa State Association of Counties Iowa Works National Association of Counties Friend or Relative Online Job Ad Other
Other

Education

24. Education Level Please Select High School Diploma/GED Associate's Degree in Criminal Justice or Police Science Bachelor's Degree in Criminal Justice or Police Science A.A. B.A. B.S. Master's Degree

High School

1. School Name/Location
2. Area of Concentration/Course of Study
3. Diploma/Degree(s), Certificates, Licenses, Endorsements

Undergraduate College/University

1. School Name/Location
2. Area of Concentration/Course of Study
3. Diploma/degree(s), certificates, licenses, endorsements

Graduate/Professional

1. School Name/Location
2. Area of Concentration/Course of Study
3. Diploma/degree(s), certificates, licenses, endorsements

Military Service

25. Are you a U.S. Veteran, member of the Reserves or National Guard? Please Select Yes No
Branch
Location Served
Dates of Service
Specialty
Type of Discharge
Those wishing to claim Veteran’s Preference must submit DD214 with this application.
Upload DD214 Form
only PDF files are allowed

References

Reference 1

1. Name
2. Address
3. City
4. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip
6. Phone
7. Relationship

Reference 2

1. Name
2. Address
3. City
4. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip
6. Phone
7. Relationship

Reference 3

1. Name
2. Address
3. City
4. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip
6. Phone
7. Relationship

Reference 4

1. Name
2. Address
3. City
4. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip
6. Phone
7. Relationship

Employment History

Provide your employment history for the past 10 years, starting with the most recent. Include reasons for any period of unemployment.

Employer 1

1. Employer
2. Position Held
3. Address
4. City
5. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. Zip
7. Phone
8. Supervisor
9. Start Date
10. End Date
    Leave blank if this is a current position
11. Duties/Responsibilities
12. Reason For Leaving
13. May we contact current employer? Please Select Yes No
If no, why?
Add Employer

Employer 2

1. Employer
2. Position Held
3. Address
4. City
5. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. Zip
7. Phone
8. Supervisor
9. Start Date
10. End Date
11. Duties/Responsibilities
12. Reason For Leaving
13. May we contact this employer? Please Select Yes No
If no, why?
Add Employer

Previous Certifications

1. Have you ever been certified in another state? Please Select Yes No
If yes, which state?
2. Have you ever been decertified as a police officer in any state or territory? Please Select Yes No
If yes, which state or territory?
If yes, please provide the date, circumstances and supporting documentation of that decertification
Upload Documentation
only PDF files are allowed


3. Have you ever committed acts of serious misconduct as defined by Iowa Code 80B. 11F? (Including felony conviction, fabrication of evidence, repeated use of excessive force, acceptance of a bribe or the commission of fraud) Please Select Yes No

Criminal History

4. Have you ever been convicted of any offense other that a simple misdemeanor traffic violation? Please Select Yes No

Traffic Citation 1

List all Traffic Citations

1. Date
2. Violation/Specific Charge
3. City
4. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Disposition
6. Police Agency
Add Traffic Citation

1. Has your driver's license ever been suspended, revoked, or restricted? Please Select Yes No
If yes, please explain
2. Has your automobile insurance ever been refused or cancelled? Please Select Yes No
If yes, please explain

Arrest 1

List ALL ARRESTS, including juvenile arrests regardless of whether or not you were convicted

1. Date
2. Violation/Specific Charge
3. City
4. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Disposition
6. Police Agency
Add Arrest

1. Please use this space to provide further explanation to any of the above

Personal Questionnaire

1. Describe your lifestyle, personal interests, goals in life
2. Describe your current/previous experience in law enforcement
3. What motivated you to apply for the position of Deputy Sheriff with Jackson County?

Applicant's Statement

Under penalty of perjury, I solemnly affirm or swear that the foregoing statements in answers to the questions on the Application for Jackson County, Iowa Deputy Sheriff (including any attachments provided hereto) are full, true and correct in every regard. I understand all statements contained in this application may be investigated further by Jackson County.

I further understand and agree that I must meet minimum qualifications for an Iowa Peace Officer as required under the provisions of Iowa Code Chapter 80B and rules and regulations promulgated thereunder by the Iowa Law Enforcement Commission.

1. Signature of Applicant Please type your full name to serve as an electronic signature.
2. Date

General requirements for Law Enforcement Officers can be found in: IAC 501, Chapter 2 & Iowa Code 80B.11 & 400.17

Applicant Investigation Section

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I hereby authorize the release, review, and full disclosure of, all records concerning myself to a duly authorized agent of Jackson County, Iowa or the Jackson County Sheriff’s Office, whether the said records are of a public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of the records of any:

• Educational institution
• Utility company
• Financial or credit institution, to include records of any depository checking or savings account
• Medical, psychological and psychiatric reports of consultation, treatment and evaluation at or by any hospital, clinic, private practitioner and the US Department of Veteran’s Affairs
• Employment and pre-employment records, to include salary records, background reports, polygraph examination reports and polygraph questions, pre-employment and promotional examination results, efficiency ratings, disciplinary actions, complaints or grievances filed by or against me, and internal affairs investigation reports
• Real and personal property tax statements and records, as well as other financial statements or records wherever filed
• Records of complaints, arrests, trials and convictions for alleged or actual law violations, including criminal or traffic records
• Records of civil complaints made by or against me, wherever located, to include the records and recollections of attorneys at law or other counsel, whether representing me or another person, in any case which I have ever been a party or had an interest

It is my specific intent to provide access to personal information and to release copies and abstracts, however personal or confidential they may appear to be, and the sources of information specifically enumerated are not to deny access to any records that may not be specifically identified herein.

The reason for this authorization is to provide full and free access to the background and history of my personal life for the specific purpose of conducting a background investigation that may provide pertinent information for the Jackson County Sheriff’s Office to consider in determining my suitability for employment.

This release form and any photocopy/fax of this release form, even though the said photocopy/fax does not contain an original writing of my signature, will be valid and should be honored for a period of two -years from the date of my signature.

I have read and fully understand the contents of the “Authorization of Personal Information.”

1. Signature Please type your full name to serve as an electronic signature.
2. Date