Application All fields marked with * are mandatory. Please click the headers marked ">" for additional fields. > Administrative Use Only Personal Identification Name * First MIddle Middle Last * Last Email * Home Phone Mobile Phone Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Date of Birth Age Sex Male Female Social Security Number Driver's License Number Driver's License State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Other Names You Have Gone Under: First Middle Last Date of Birth Add Row Photo Upload Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 8.39MB Please attach a recent photo of yourself. Photo requirements: Taken within the last 6 months to reflect your current appearance Taken in full-face view directly facing the camera With a neutral facial expression and both eyes open File size less than 5mb in .jpg .bmp or .png format > Waiver I do hereby authorize a review and full disclosure of all records, or any part thereof, concerning myself to any duly authorized agent of the Madison County Sheriff s Office, or any agency assisting them, whether the said records are public or private, and including those which may be deemed to be a privileged or confidential nature. The intention of this authorization is to provide information which will be utilized for investigative resource material. I authorize the full and complete disclosure of the records of educational institutions; financial or credit institutions; commercial or retail mercantile establishments and retail credit agencies; results of polygraph examinations, efficiency ratings, complaints or grievances filed by or against me; records of complaints of a civil nature made by or against me and including but not limited to the records and recollections of attorneys at law, or other counsel representing or having represented me; and any records of any type whatsoever which concern any criminal charges involving me. I further authorize the release of information concerning all of the above mentioned areas, or any other information which has a bearing on my fitness or ability to become an employee of the Madison County Sheriff s Office, even though such information is not contained in written records and regardless of whether such information is considered privileged or confidential in nature. A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature. Signature: (Please type your full name signifying your agreement to this waiver)* * * Date Signed * > Employment Desired Employment Desired * Full-time Part-time Full- or Part- time Position Applied For: Clerk/Administrative Assistant Correctional Officer Deputy Sheriff - Corrections Deputy Sheriff - Road Dispatcher Door Control Other Click all that apply Position Applied For (Other:) Date available to work Explain Have you worked for the County of Madison before? * Yes No What department or office? Have you applied or tested for any other law enforcement or public service positions in the last twelve months? * Yes No If yes, please provide details below. Other applications * Where applied Position applied for Result of application Add Row One line per application > Military History Military Veteran * No Yes Military Branch * Dates Served * Attach DD-214 Drop a file here or click to upload Choose File Maximum upload size: 8.39MB Military preference will NOT be given without a valid DD-214 > Law Enforcement Certification Law Enforcement Certified * No Yes Date Certified * State Certified * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Military Federal Certification Status * Active Inactive Expired Suspended Revoked Reason * > Personal History Work History Business Name Business Address Business Phone Dates Employed Supervisor Duties Reason for leaving Add Employment Starting with your CURRENT employer, list complete employment history for the last 10 years Residence History Address City State Zip Code Own/Rent If rented - Landlord Date began at this residence Date ended at this residence AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Own Rent Add Address List all residences for the last 10 years Education Name and Location of School Course of Study # of Years Did you graduate? Degree/Diploma? Yes No Add School Starting with high school, list all education and/or experience relating to the position applied for: Other education/experience References Name Address Phone Relationship What does this person know about you? Add Reference List at least two persons who have knowledge of your character, work history, etc. May we contact your references? * Yes No May we contact your present employer? * Yes No Contact person at your present employer Attach Resume Drop a file here or click to upload Choose File Maximum upload size: 8.39MB All the information listed by me on this application is true and correct to the best of my knowledge. I understand fully that any false and misleading statements may be cause for rejection of my application and/or if employed may be just cause for subsequent dismissal. Signature: (Please type your full name signifying your agreement to this statement)* * * Date * > Character Affidavit THE APPLICANT, AFFIRMING THAT EACH STATEMENT IS TRUE AND CORRECT, MUST INITIAL EACH OF THE FOLLOWING STATEMENTS in the following sections. If statement cannot be answered in the affirmative, your must give full details in the box below. Character Affidavita * Initials 1. I have NOT used marijuana for any purpose in the last two years preceding this application. 2. I have NOT used illegal drugs or narcotics other than marijuana in the five years preceding this application for admission. 3. I have NOT been convicted of a felony or any crime which carried a possible penalty of one year or more imprisonment or any crime which would have carried such a penalty if committed in Nebraska (Class I Misdemeanor) 4. I have NOT been convicted of Driving Under the Influence / Driving While Intoxicated in the four years immediately preceding this application 5. I have NOT been convicted of either a federal or state misdemeanor which has, as an element, the use or attempted use of physical force, or the threatened use of a deadly weapon, committed against a current or former spouse, parent, or guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse, parent, or guardian, or by a person similarly situated to a spouse, parent, or guardian of the victim. 6. I have NOT received a punitive discharge from the United States Armed Forces. Punitive discharges are discharges classified as Dishonorable or Bad Conduct 7. I have NOT been denied law enforcement certification status, or had my certification revoked or currently suspended in the state or another jurisdiction. 8. I have NOT been convicted of any crime involving the threat of or the actual use of physical violence that would constitute a Class I Misdemeanor in this state. 9. I have NOT been convicted of any crime involving the threat of or the actual sexual assault or abuse. 10.I have NOT been convicted of any crime of physical violence or sexual abuse against a child or children. 11.I have NOT been adjudicated or convicted or a crime of domestic violence as defined in the United States Code, 18 U.S.C. 922(g)(9), that would disqualify me from possessing a firearm. 12.I am NOT subject to an order of protection that would disqualify me from possessing a firearm under the provisions of United States Code, U.S.C. 922(g)(8). Details Have you EVER, either as an adult or juvenile, been cited, arrested, charged, or convicted for a violation of ANY law (except moving traffic violations to be reported under the next question, and except for minor parking violations)? * Yes No If YES, provide complete information regarding the offense and a narrative description of the circumstances on the following form. Law Violations Original Charge/citation Arresting Agency, city and state Date of Incident Booked into jail Dispostion If guilty, what was the final charge(s)? Narrative Yes No Add Row Have your EVER been cited, arrested or convicted of any moving traffic violation with the exception of minor parking violations? * Yes No If YES, provide complete information regarding the offense and a narrative description of the circumstances on the following form. Traffic Violations Traffic Violation Citing/arresting agency, city and state Date of offense Disposition of case Narrative Add Row Have you ever been party in civil litigation? * Yes No Civil litigation details * Character Declarations Any "Yes" answers will require explanation in the box below. 1. Have you ever had a complaint filed against you in any civil, criminal, or administrative forum, alleging fraud, deceit, misrepresentation, or forgery? * Yes No 1. Details * 2. Have you ever had a civil case dismissed because of a finding of abuse of legal process including the filing of a frivolous lawsuit? * Yes No 2. Details * 3. Have you ever had a professional license that you hold be under investigation? * Yes No 3. Details * 4. Is a professional license that you hold currently under investigation? * Yes No 4. Details * 5. Have you ever filed a petition for bankruptcy or had a credit or charge account turned over to a collection agency, or a credit card or charge account debt charged off or revoked? * Yes No 5. Details * 6. Are you currently in violation of a court order to include an order for child support? * Yes No 6. Details * 7. Have you had a law enforcement certification or any other professional license/certificate revoked or suspended in this state or any other state? * Yes No 7. Details * 8. Have you ever been terminated, suspended, disciplined, or permitted to resign in lieu of termination from any job? * Yes No 8. Details * Statement of Health Do you currently have any condition or impairment (including but not limited to substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) which in any way currently affects or if untreated could affect your ability to perform the duties of an employee of the Sheriff’s Department in a competent and professional manner? * Yes No If YES, explain below. Explain I have answered all the questions on this affidavit true and correct to the best of my knowledge. I understand fully that any false and misleading statements may be cause for rejection of my application and/or if employed may be just cause for subsequent dismissal. * Type your full name indicating understanding and agreement with this statement. Date * > Pre-Employment Information WE ARE AN EQUAL OPPORTUNITY EMPLOYER In compliance with Federal and State Equal Employment Opportunity laws, qualified applicants are considered for employment without regard to race, color, religion, sex, national origin, military status, age, marital status, or the presence of a non-job-related medical condition or handicap. So that we can comply with Federal/State Equal Opportunity Employment record keeping requirements and other legal requirements, please complete this form. This Pre-Employment Information will be detached and kept in a confidential file separate from the Employment Application, and shall not be used in making any hiring decision or any selection procedure. Position applied for Name * First MIddle Middle Last * Last Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Date of Birth Nearest age Are you a U.S. Citizen? * Yes No If not, do you possess an Alien (Work) Registration Card? * Yes No Race/Ethnic Group Caucasian Black Hispanic Asian/Pacific Islander American Indian/Alaskan Native Sex Male Female Marital Status * Single Married Divorced Widowed Separated Other Explain Are you a veteran? * Yes No Service Dates * Are you a disabled veteran? * Yes No V.A. Disability Rate (%) How were you referred to us? * Self Friends Employee School Ad Nebraska Job Service Employment Agency Internet Other Other (Explain) * Signature * Please type full name in the box Date * > Physical Fitness Six foot wall Pass Fail Did not test Information about the physical fitness testing can be found here Submit Review and submit. You will not be able to submit the application until all required fields are completed.