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POLK COUNTY SHERIFF’S OFFICE

1891 Jim Keene Boulevard

Winter Haven, FL 33880

EMPLOYMENT APPLICATION

			Toll Free: (877) 477-7276
E-mail: hr@polksheriff.org			Fax: (863)	298-6460
Website: http://www.polksheriff.org		Human Resources: (863)		298-6440
POSITION DESIRED 1st Choice		DATE
2nd Choice	3rd Choice

INSTRUCTIONS

Application must be typewritten or printed legibly in ink. All questions must be answered. If the space provided is not sufficient for

complete answers or you wish to furnish additional information, attach sheets of the same size as this application and number answers to correspond with questions. If you require special disability accommodations, notify the agency’s hiring authority in

advance.

PERSONAL HISTORY

1.	Full Name:

	Last Name				First	Middle	Nickname

	Residence Address				Apt. No.	Mailing Address	Apt. No.

	City			County		State	Zip Code
	(	)		(	)
	Telephone Number (Home)			Work/Other
						(	)
	E-mail Addresses						Cell
2.	Social Security Number:		-	-
	Driver License Number:					State Issued:
3.	Place of Birth:

	City			County		State	Country (if not the United States)

4.Other: List all other names you have used including circumstances and time periods you used them. For example: former name(s), alias(es), and nickname(s).

Name

Circumstance

Dates From - Mo./Yr.

Dates To - Mo./Yr.

The Polk County Sheriff's Office is an Equal Employment Opportunity Employer. We consider applicants for all positions without regard to race, color, national origin, sex, age, handicap, marital status, religion or any other legally protected status.

PCSO FORM 188 (REV 11/25/15)

5.	Have you ever filed an application with us before?	Yes	No	Dates
6.	Have you ever been employed by us before?	Yes	No	Dates
7.	Are you related to anyone who has worked in law enforcement?			Yes	No
	If yes, provide name and relationship:
8.	Have you ever had a relative work for the Polk County Sheriff's Office?				Yes	No
	If yes, provide name (and member number, if known):

EDUCATION/TRAINING

High School

Name/Address

Dates Attended - Mo./Yr.

From To

Years	Did You
Completed	Graduate?

Type of Diploma

College/University

Name/Address

Dates Attended - Mo./Yr. Credit Hours Earned
From	To	Qtr.	Sem.

Did You

Graduate?

Type of Degree

MajorMinor

3. Other Schools (Trade, Vocational, Business, Police Academies or Military):

Name/Address

Dates Attended - Mo./Yr.

From To

Credit Hours

earned

Area of Study

Did You

Graduate?

Type of Degree

or Certificate

4.Describe any awards, honors, citations or other special recognition you received while attending school and positions held in school organizations:

5.Indicate any law enforcement education/training:

6. Did you receive a certificate for this training?

Yes

No	(If yes, attach a copy)

Page -2-

7.Indicate any special skills you possess and equipment you can use which may be related to the position for which you are applying (i.e., breathalyzer, speed detection equipment, firearms, and computers):

8.Describe any word processing or computer skills and list all software used:

9. State approximate number of words per minute:

Typing

Shorthand

10. On what date are you available for work?

11. Are you available to work?

Full-Time

Part-Time

12. Are you available to work rotating shifts?

Yes

EMPLOYMENT HISTORY

1.List chronologically all employment including current employment, including summer and part-time employment while attending school. All time must be accounted for. If unemployed for any length of time, indicate dates of unemployment. Please attach a separate sheet of paper for additional employment history if necessary.

Name of present or last employer:

Part-Time

Full-Time

Address:

Your Job Title:

Phone Number:

(

)

FROM:

TO:

Supervisor's Name:

Duties and Responsibilities:

Reason for Leaving:

Name of employer:

Part-Time

Full-Time

Address:

Your Job Title:

Phone Number:

(

)

FROM:

TO:

Supervisor's Name:

Duties and Responsibilities:

Reason for Leaving:

Page -3-

Name of employer:

Part-Time

Full-Time

Address:

Your Job Title:

Phone Number:

(

)

FROM:

TO:

Supervisor's Name:

Duties and Responsibilities:

Reason for Leaving:

Name of employer:

Part-Time

Full-Time

Address:

Your Job Title:

Phone Number:

(

)

FROM:

TO:

Supervisor's Name:

Duties and Responsibilities:

Reason for Leaving:

Name of employer:

Part-Time

Full-Time

Address:

Your Job Title:

Phone Number:

(

)

FROM:

TO:

Supervisor's Name:

Duties and Responsibilities:

Reason for Leaving:

2.May we contact your present employer? Yes

3.Have you ever been dismissed or asked to resign?

Yes

No If yes, please explain:

4.Have you had any disciplinary action, to include verbal, written warnings, reprimands, suspensions and counsellings, taken against you from any employment or position you have held?

Yes

No If yes, please provide details.

5.Have you resigned, or left a job by mutual agreement, for any reason?

Yes

No If yes, please provide details.

Page -4-

6. Have you ever applied or worked with any law enforcement agencies?		Yes		No If yes, please provide the
following.
Agency and/or Department			Date Applied
Address (Street, City, State, Zip)
Position applied for:	Status:

Agency and/or Department			Date Applied
Address (Street, City, State, Zip)
Position applied for:	Status:

Agency and/or Department			Date Applied
Address (Street, City, State, Zip)
Position applied for:	Status:

Agency and/or Department			Date Applied
Address (Street, City, State, Zip
Position applied for:	Status:

7.Do you own a business, or are you a partner or corporate officer in any business or organization not listed previously as a

current or former employer?	Yes	No	If yes, please provide name and address of business, corporation
or organization and describe your relationship or position.

8.Have you ever performed paid or unpaid services for a law enforcement agency not listed as an employer to include extra-

duty details and auxiliary?	Yes	No	If yes, please provide name and address of business, corporation
or organization and describe your relationship or position.

RESIDENCES

1.Actual places of residence for past 15 years - list chronologically all addresses, including residences while at school and in the military. For college or campus residences, give dormitory name, city and state. If residences in military service cannot be shown as a street address, indicate complete military unit designation and location by city and state. If a post office box, give location of post office. If any addresses listed were an apartment complex, please provide the complex name, name of manager, and phone number below. Attach a separate sheet of paper for additional residences and landlords, if necessary.

Dates - Mo./Yr.

From To

Apt. No.

Street Address

City

County

State

Zip

LANDLORDS

Dates - Mo./Yr.

From To

Apt. No.

Name of Complex

Manager Name

Phone Number

Page -5-

ARREST HISTORY/COURT DATA

1.Have you ever been arrested, charged or received a notice or summons to appear for any criminal violations?

Yes No

2. Have you ever been convicted of a felony or a misdemeanor?

Yes

3. To your knowledge, has any member of your family ever been arrested for other than traffic violations?

Yes

4.If yes to question #1, #2, or #3, list all such matters even if not formally charged, or no court appearance, or found not guilty, or nolo contendere to any charge for which adjudication was withheld, or the matter was settled by payment of fine or forfeiture of collateral. (Include your juvenile charges and charges which have been sealed, if any.)

Applicant	Place & Department	Charge	Court & Place	Date of Charge	Disposition




Relative's Name/	Place & Department	Charge	Court & Place	Date of Charge	Disposition
Relationship	Place & Department	Charge	Court & Place	Date of Charge	Disposition
Relationship

5. Have you or your spouse ever been a plaintiff or defendant in a court action?

Yes

6. Have you ever been detained by any law enforcement officer for investigative purposes OR have you ever been the

subject of OR a suspect in any criminal investigation?

Yes

7.Have you ever been fingerprinted for any reason (arrest, job application, military, etc.)? If yes to question #5 or #6, please provide details.

Yes

DRIVING HISTORY

1.Do you have a Florida driver license? Date of Expiration:

Yes

No	License No.:

Restrictions:

2. Do you hold or have you ever held an operator or chauffeur license in another state?

Yes

No If yes, please

provide state(s), name used, driver license(s) number and approximate dates license(s) was/were held.

3.Have you ever received a ticket or been charged with a traffic violation? and disposition.

Yes

No If yes, list charge, date,

4.Have you ever been denied issuance of a license or have you ever had a license suspended or revoked?

Yes

No	If yes, please provide complete details including reason and place.

Page -6-

MILITARY HISTORY

1. Have you ever served on active duty in the Armed Forces of the United States? Yes

Branch of Service:

Highest Rank:

Service #:	Duty Dates: From:	To:	From:	To:
	From:	To:	From:	To:
Discharge Type:
2. Are you now or have you ever been a member of the Reserve Unit or the National Guard?			Yes	No

If yes, state the branch of service, name and location of your unit and whether you attend drills, meetings, or camps.

3.Have you ever been tried on charges, or were you the subject of a summary court, court martial, deck court, Captain's Mast, company punishment, or any other type of disciplinary action while a member of the armed forces?

Yes

Date:

No	If yes, please provide details:

Place:

Nature of Offense:

Action Taken:

4.VETERANS' PREFERENCE: Documentation for eligibility of veterans' preference will be required at the time of application if you are claiming veterans' preference under the following circumstances:

1. Disabled veterans who have served on active duty in any branch of the Armed Forces and who presently have an existing service-connected disability which is compensable under public laws administed by the DVA or are receiving compensation, disability retirement benefits, or pension by reason of public laws administered by the DVA and the Department of Defense.

2. The spouse of a veteran: (a) who has a total and permanent service-connected disability and who, because of this disability, cannot qualify for employment; or (b) who is missing in acrion, captured in the line of duty by a hostile force or detained or interned in the line of duty by a foreign government or power.

3 A veteran of any war, who has served at least one day during that war time period as defined in Section 1.01(14), F.S., or who has been awarded a campaign or expeditionary medal. Active duty training shall not be allowed for eligibility under this paragraph.

4. The unremarried widow or widower of a veteran who died of a service-connected disability.

5. The mother, father, legal guardian, or unremarried widow or widower of a service member who died as a result of military service under combat-related conditions as verified by the U.S. Department of Defense.

6. A veteran as defined in Section 1.01(14), F.S. "Active Duty for Training" may not be allowed under this paragraph. The term "veteran" is defined as a person who served in the active military, naval, or air service and who was discharged or released under honorable conditions only or who later received an upgraded discharge under honorable conditions.

7. A current member of any reserve component of the U.S. Armed Forces or the Florida National Guard.

Have you claimed and been employed using veterans' preference since October 1, 1987?

If "yes", please give name of employer:

Yes

NOTE: Under Florida law, preference in employment may be given only to eligible persons described in categories 1 through 7 listed above. An applicant for veterans' preference who believes he or she was not afforded employment preference may file a complaint with the Florida Department of Veterans' Affairs, Division of Benefits and Assisance, Post Office Box 31001, St. Petersburg, FL 33731.

Page -7-

If yes to question #2 or #3, answer question #4 and #5 also.

ORGANIZATION MEMBERSHIP

1.List all clubs and societies of which you are or have been a member.

Name

City & State

Former

Member

Present Member

List position held (describe activity)

2.Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group or

combination of persons which has adopted, or shows a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States, or which seeks to alter the form of

government of the United States by unconstitutional means?

Yes

3.Have you ever made a financial or other material contribution to any organization of the type described in question #2 above?

Yes No

4.At the time of your membership, participation, or contribution, did you know of any unlawful aims of the organization?

Yes No

5. Did you intend to promote any unlawful aims of the organization?

Yes

If yes to questions #2, #3, #4, or #5, explain, including name of organization and location.

BUSINESS INTERESTS & LICENSES

1.Do you or have you ever owned any stock or interest in any firm, partnership or corporation dealing wholly or partly in the

sale or distribution of alcoholic beverages?

Yes

2. Are you now issued or have you ever been issued a license to engage in a business or profession?

Yes

3. Was license ever canceled, suspended or revoked?

Yes

If yes to question #1, #2, or #3, please provide details including the type of license or certificate, the agency that issued the license, effective date of the license, and license number.

Page -8-

PERSONAL REFERENCES & ACQUAINTANCES

1.Personal References: Give three (3) references (not relatives, former or present employer, fellow employees, or school teachers) who are responsible adults of reputable standing in their communities, such as property owners, business or professional men or women, who have known you well for the past five (5) years. If retired, list their former occupation.

Provide complete mailing addresses and phone numbers.

Complete Name (and relationship to the applicant)		Home Address:
		Home Address:
		City, State & Zip:
	(Last, First, Middle)	Home Phone:	(	)
Yrs. Acq.	Occupation	Business Address:
		City, State & Zip:

Complete Name		Home Address:
		Home Address:
		City, State & Zip:
	(Last, First, Middle)	Home Phone:	(	)
Yrs. Acq.	Occupation	Business Address:
		City, State & Zip:

Complete Name		Home Address:
		Home Address:
		City, State & Zip:
	(Last, First, Middle)	Home Phone:	(	)
Yrs. Acq.	Occupation	Business Address:
		City. State & Zip:

POLYGRAPH EXAMINATION

Prior to final approval for hiring, you will be required to undergo a polygraph examination regarding your background and other aspects of your character.

The following is a list of subject areas from which polygraph questions will be drawn:

i.FINANCIAL STATUS

ii.WORK RECORD

iii.HONESTY

iv.USE OF ALCOHOL

v.DRIVING RECORD

vi.ARRESTS AND CONVICTIONS

vii.DRUGS, NARCOTICS, AND MARIJUANA

viiiGAMBLING

ix.BLACKMAIL

x.FRIENDS, RELATIVES AND ASSOCIATES

xi.LOYALTY TO THE UNITED STATES

Page -9-

APPLICANT CERTIFICATION

I understand that, in submitting this application for employment or appointment, I agree to abide by the following terms and conditions:

My appointment or employment will be contingent upon the results of a complete background investigation. Any omission, falsification, misstatement or misrepresentation may disqualify me as an applicant or cause my dismissal from the Polk County Sheriff's Office. All statements made by me on this application are true, correct and complete, to the best of my knowledge.

I consent to a polygraph examination concerning the veracity of this information or that which is discovered as a result of the background investigation or any physical examination or drug test. My employment or appointment will be contingent upon the results of a complete drug test. I may be required to take drug tests during the term of my employment or appointment with the Polk County Sheriff's Office. I authorize all persons and organizations referenced in this application to furnish the Polk County Sheriff's Office information, personal or otherwise, regarding my ability and fitness for employment or appointment. I relieve all such parties from any and all liability for any damage that might result from furnishing such information to the Polk County Sheriff's Office.

I understand that this employment application shall become the property of the Polk County Sheriff's Office. The application and information received in response to the background investigation are public records.

If employed by, or appointed to, the Polk County Sheriff's Office, I accept and agree to abide by the following conditions:

I will agree to work shift work, my position may be relocated. I will obey and abide by all directives, procedures, rules, regulations and General Orders issued by the Polk County Sheriff's Office and its official representatives. I understand my position will require use of agency supplied equipment and/or uniform(s).

I will maintain active telephone and/or cellular service at my residence during my period of employment with the Polk County Sheriff's Office. I will establish my domicile within the boundaries of Polk County, Florida within 180 calendar days of my employment or appointment date and maintain such residence during the course of my employment (Deputy Sheriff and Civilian applicants). Detention Deputy and Detention Support Specialist applicants are excluded from the residence requirements.

In the event that I am eligible for, and accumulate, overtime work hours, the Polk County Sheriff's Office may, at its option, adjust my work schedule, grant me compensatory time or reimburse me monetarily.

Any property or equipment issued or loaned to me by the Polk County Sheriff's Office shall be maintained in good repair at all times. I will report any discrepancies to my supervisor immediately. I may be required to reimburse the Polk County Sheriff's Office for any property or equipment that is damaged or lost through my own negligence or misconduct. If funds from the damage or loss of such property are due and owing at the termination of my employment, I agree that said funds may be deducted from my final paycheck in accordance with state and federal wage and hour laws. Holiday pay utilized in advance of the date earned will be deducted from my final paycheck.

I acknowledge that all property belonging to the Polk County Sheriff's Office, or utilized by me in the course and scope of my employment, is subject to search or inspection at any time without notice. I also agree to, and fully realize that, I have no expectation of privacy, whether subjective or objective, in the use of such property.

I acknowledge that, in accordance with Florida Statute 943.16, if I should voluntarily leave the Polk County Sheriff's Office within one (1) year of entering or completing (whichever is later) an approved Criminal Justice Standards and Training Program, the tuition and any related educational costs paid by the agency will be deducted from my final paycheck.

I understand that, if employed, I shall be required to have direct deposit into a checking or savings account.

AFFIDAVIT (Must be notarized)

Applicant's Signature

The foregoing was acknowledged before me this by

Date

day of

Yr.

,who is personally known to me or who has produced as identification.

Signature of person taking acknowledgement

Printed Name

Title or Rank

Page -10-

PERSONAL INQUIRY WAIVER

Authority for Release of Information

TO: Concerned Person or Authorized Representative of Any Organization, Institution or Repository of Records

APPLICANT'S NAME:

DATE OF BIRTH:

SOCIAL SECURITY NO.:

I respectfully request and authorize you to furnish the Polk County Sheriff's Office any and all information that you may have concerning my work record, school record, military record, reputation, criminal history, and financial and credit status. Please include any and all medical, physical and mental records or reports including all information of a confidential or privileged nature, and photostats of same, if requested. This information is to be used to assist in determining my qualifications and fitness for the position I am seeking with the Polk County Sheriff's Office.

I hereby release you, your organization or others from any liability or damage which may result from furnishing the information requested above.

Applicant's Signature			Date

Address		Apt. No.

City	State	Zip Code

AFFIDAVIT

(Must be notarized)

STATE OF FLORIDA

COUNTY OF POLK

The foregoing was acknowledged before me this				day of		Yr.
by			, who is personally known to me or who has produced

as identification and who did (did not) take an oath.

Signature of person taking acknowledgement

Printed Name

Title or Rank

Page -11-

Mission Statement:

We, the members of the Polk County Sheriff's Office, are committed to excellence in providing law enforcement, detention, and public safety services. In partnership with our community, we will serve with integrity, compassion, accountability, and professionalism.

Vision Statement:

Our vision is to maintain a staff of well-equipped, highly- trained, professional members to provide the highest level of customer service with a sense of urgency. While providing comprehensive services, we will be transparent in our actions. Utilizing cutting edge technology, we will continue to proactively reduce crime and enhance the quality of life to ensure Polk County is a safe and attractive place to live, work, and visit.

To join us,GradypleaseJuddcontact:

Human Resources Division Polk County Sheriff's Office 1891 Jim Keene Boulevard Winter Haven, FL 33880 Toll Free: (877) 477-7276 Office: (863) 298-6440 Fax: (863) 298-6460 e-mail: hr@polksheriff.org website: www.polksheriff.org

Equal Employment Opportunity Employer M/F/D/V

Page -12-

Question	Answer
Form Name	Pcso Form 188
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	pcso medical assistance form, pcso financial assistance form, pcso imap application form, pcso online application requirements

Pcso Form 188 – Fill Out and Use This PDF

Pcso Form 188 PDF Details

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Pcso Form 188 – Fill Out and Use This PDF

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