Pbso Application Form – Fill Out and Use This PDF

APPLICANT’S CERTIFICATION / AGREEMENT / RELEASE

1.I hereby certify that all statements in this application are true correct, and complete, to the best of my knowledge.

2.I acknowledge that I am responsible for the repair or replacement of any property received from the Palm Beach County Sheriff’s Office. I agree that upon request or separation from my sponsoring organization, I will surrender any such property to said Sheriff’s Office.

3.I understand that both my person and my property are subject to search while at a detention facility. I understand that the introduction or possession of contraband at a detention facility is a Felony and agree not to participate in such an action and to properly report any such activity that I become aware of to the Sheriff’s Office.

4.I understand that a local, state, and national criminal history check, which includes fingerprinting, will be conducted as a result of the submission of this application. I further understand that, due to the type of check being performed, I am not entitled to a copy of the results and that I must independently secure such information, if desired, at my own expense.

5.I freely and voluntarily assume the risk of personal injury and property damage arising from or in any way connected to my presence at a detention facility. I hereby release the Sheriff of Palm Beach County, his/her successors, assignees, appointees, designees, employees and representatives and the County of Palm Beach from any injury, damages, loss or other expense to me or my property that may occur, result from or is in any way connected to my presence at a detention facility or for any injury, damages or loss or expense caused by a third party during my presence at a detention facility or from the gross or simple negligence of the releasee.

6.I agree that I will hold harmless and indemnify the Sheriff of Palm Beach County, his/her successors, assignees, appointees, designees, employees and representatives and the County of Palm Beach against any and all manner of actions, causes of actions, suits, debts, claims, demand for damages or liabilities for expenses of any kind and nature incurred or arising by reason of any actual or claimed negligent or wrongful act or omission of mine during my presence at a detention facility. This also includes any intentional act in which I may engage and which consequently causes injury or for any third party claims brought as a result of my intentional or negligent act.

I hereby represent that I have carefully read, understand, and agree to comply with the applicable contents of this document and sign my name below of my own free will.

Signature

Print Name

Date

ORGANIZATION:

POSITION APPLYING FOR:

ORGANIZATION ADDRESS:

SUPERVISOR / SPONSOR:

PHONE:

APPLICANT’S SUPERVISOR OR SPONSOR’S CERTIFICATE / AGREEMENT

I hereby certify that I have verified the information contained in this application as true, correct, and complete, to the best of my knowledge. I hereby witness the signature of the above individual who is known to me and/or has produced identification.

Signature

Print Name

Date

Mail or deliver completed original application to:

Security Clearance Management – SSD #3090

Corrections Administration

Palm Beach County Sheriff’s Office

3228 Gun Club Road, West Palm Beach, Florida 33406-3301

SHERIFF’S OFFICE USE ONLY

REQUESTING SUPERVISOR:

Signature

Print Name

I.D.

Date

ENTRY DAYS:

ENTRY TIMES:

FACILITIES:

ESCORT REQUIRED:

APPLICANT STATUS:

WILL RECEIVE ID CARD

WILL BE ADDED TO THE APPROVED ENTRY LIST

OTHER:

BACKGROUND CHECK:

PALMS NCIC/FCIC ID# ______________ DATE: __________________

FINGERPRINTS DATE: ___________________

IDENTIFIERS: SID # ______________________________________

FBI # _________________________________

APPROVED FOR:

1 YEAR

FOR EMPLOYMENT WITH:

OTHER: __________________________

APPROVING OFFICER:

Signature

Print Name

I.D.

Date