Download Malheur County Sheriff`s Office Background Check

MALHEUR COUNTY SHERIFF'S OFFICE
BACKGROUND INVESTIGATION APPLICATION AND RELEASE
PLEASE TYPE OR PRINT (In Black Ink)
Date :
1.
/
/
Social Security Number :
Name:
/
Last
/
/
First
Middle
Race
Sex
/
Date of Birth
Present Address:
Number and Street
City
State
Zip Code
Permanent Address:
Number and Street
City
State
Zip Code
Telephone:
Home
Work
Permanent
Employment:
2.
Work Number:
List any other name(s) which you have used or by which you have been known. Explain fully why it was used, where and when
(Include nicknames, Aliases, and Maiden name).
A.
B.
C.
3.
CITIZENSHIP
Are you a U.S. Citizen?
Yes
No
Naturalized?
Yes
No
If naturalized, give date, place and court of naturalization:
Place of Birth:
Height:
Weight:
Eye Color:
Hair Color:
Distinguishing Marks or Features:
4.
DRIVER LICENSE
Are you licensed to operate a motor vehicle?
Yes
No
Drivers License Number:
State:
Has your Driver's License ever been suspended or Revoked?
Yes
No
If yes, explain fully:
5.
PERSONAL HISTORY
If the answer to any of these questions is yes, provide an explanation on a separate page and attach (append) to this application,
listing the date, circumstances, and frequency.
A. Have you ever used an illegal drug?
Yes
No
B. Have you ever used a controlled substance other than those prescribed by a doctor?
C. Have you ever manufactured, sold or delivered a controlled substance or illegal drug?
Yes
Yes
No
No
D. Have you ever been discharged from any position for failing a probation period?
Yes
No
E. Have you ever resigned to avoid discharge or resigned while under suspension or resigned while dismissal proceedings were
pending?
Yes
No
F. Have you ever resigned under pressure or unfavorable circumstances?
G. Have you ever sued anyone or been sued by anyone?
Yes
H. Have you ever applied for a permit to carry a concealed weapon?
If yes, was permit granted?
Yes
Name of Police Agency:
Yes
No
No
Yes
No
No
Reason for Permit:
I. Have you ever been terminated or removed from a volunteer/instructor position in a jail facility?
6.
Yes
No
APPLICANT'S CERTIFICATION AND RELEASE
A. I hereby certify that all statements made in this application or appended to it are true and correct to the best of my knowledge.
I am aware that withholding pertinent information found to be materially (grossly) inaccurate will be cause for refusing
further consideration of my application, or will constitute grounds for my termination if I am employed. I understand this is
not to be considered as an indication of probable appointment by the department, but a part of the selection process only. I
understand that failure on my part to notify the Malheur County Sheriff's Office of a change of address within thirty (30) days
may subject my file to being closed
B. AUTHORITY, CHARACTER AND PERSONAL HISTORY INFORMATION
Having made application with the Malheur County Sheriff's Office, I hereby authorize a complete investigation of my records
including personal history, job performance, and criminal convictions by the Malheur County Sheriff's Office, or another
police agency authorized to conduct their applicant investigations, to ascertain any and all information which may concern
my credit and character, whether same is of record or not, and release your organization and all persons, who ever, from any
charge because of furnishing said information. I hereby acknowledge that I am aware the results of this investigation are
confidential for the Malheur County Sheriff's Office use only and will not be disclosed to myself or any other person without
proper authorization.
Name (Print or Type):
Signature: ____________________________________________________________ Date: __________________________