APPLICATION FOR EMPLOYMENT - Newton County Sheriff's Office › PDF › Employment_Application_interactiv… · the Newton County Sheriff’s Office at (678) 625-1212. The Newton

N E W TO N C O U N T Y

SHERIFF’S OFFICEA P P L I C A T I O N F O R E M P L O Y M E N T

15151 Alcovy Rd., NE • Covington, Georgia 30014 • Ph: (678) 625-1212www.newtonsheriffga.org • An Equal Opportunity Employer.

COMMITTED TO EXCELLENCE

GA.

NEW

TON COUNTYGEORGIA

SH

ER

IFF ’S A S S O CIATI

ON

GA.

NEW

TON COUNTY

GEORGIA

SH

ER


ON

Ezell Brown, Sheriff

To be considered for employment, applicants must meet the following minimum qualifications: Applicants must be at least 21 years of age for Deputy Sheriff positions, 18 years of age for Detention Officer and civilian positions, possess a high school diploma or equivalent, possess a valid driver’s license, honorable discharge (if prior military), be a US citizen, have no adverse driving record nor felony or family violence convictions, and be of good moral character.

The applicant must complete ALL FORMS ACCURATELY, LEGIBLY, and COMPLETELY. DO NOT LEAVE ANY BLANK SPACES. If a question does not apply to you write “N/A” in the space. PRINT ANSWERS to questions with a BLACK INK PEN ONLY. Be absolutely truthful, a false statement or the omission of requested information is grounds for automatic rejection before appointment or termination after employment. If you answer “yes” to a question, you need to be complete in explaining the circumstances. Do not omit an explanation because you think the incident was minor and of no importance. If the space is insufficient to complete your answers, please attach supplementary pages.

The following documents are required to begin the application process and must be mailed in with the application:• A copy of your high school diploma or equivalent• A copy of your birth certificate• A photo copy of your current driver’s license• A full MVR from Department of driver’s services• A copy of your COMPASS or ASSET scores

The following documents are required if they are applicable to you and must be mailed in with the application:• Long DD214 Form, showing Honorable Discharge (if former military)• Certified College Transcripts (sealed)• Any name change documents• Citizenship Papers• Copy of Bankruptcy discharge papers

The completed application and required documents must be returned to Newton County Human Resources at thefollowing address:

Newton County Human Resources1113 Usher Street Ste. 203Covington, GA 30014

**NOTE: Some pages require Notary.Upon submission, your application and supporting documents will be reviewed for completeness. If your application is incomplete, it will be returned to you. Applications that are complete and meet the minimum requirements will be forwarded to the Newton County Sheriff’s Office, Office of Professional Standards for processing. The hiring process includes but is not limited to the following: an oral board interview, an intensive background investigation, voice stress analysis, and, following a conditional job offer, medical examination, drug screen and psychological examination.

If you have any questions concerning this process please contact the Newton County Sheriff’s Office at (678) 625-1212.

The Newton County Sheriff’s Office is an Equal Opportunity Employer and does not discriminate on the basis of race, color, National origin, sex, religion, or disability in employment or provision of services.


SHERIFF’S OFFICEEZELL BROWN, SHERIFF

GA.

NEW

TON COUNTY

GEORGIA

SH

ER


ON

GA.

NEW

TON COUNTY

GEORGIA

SH

ER


ON

15151 A lcovy Rd. , NE • Cov ington, Georg ia 30014 • Ph: (678) 625-1212 • www.newtonsher i f fga .org

COMMITTED TO EXCELLENCE

INSTRUCTION SHEET

APPLICATIONFOR EMPLOYMENT


SHERIFF’S OFFICE15151 Alcovy Rd., NE • Covington, Georgia 30014Ph: (678) 625-1212

Position Applied For: Deputy Sheriff Detention Officer Civilian Reserve Deputy

Page 1 of 28

Name (Last, First, Middle) Social Security #

Home Address (Street Number/Name, City, State, Zip Code)

How long have you lived at your current address?

Home Telephone: Business Telephone:

Cellular Telephone: Email Address:

Are you a citizen of the United States? Yes No

If no, are you a permanent resident? Yes No

Place of Birth (City, County, State/Country)

Have you ever used another name or had your name changed? Yes No

Have you ever applied with the Newton County Sheriff’s Office before? Yes No

Position last applied for and date:

Are you currently employed with Newton County? Yes No

Were you previously employed with Newton County? Yes No

If yes: Date started/ Date left/ Position(s) held:

I. PERSONAL INFORMATION

Previous Name Date of Change Location of Change Reason for Change

(This includes Maiden Names, Former Married Names, Adopted Names, Nicknames, etc.) If you answered yes, please provide the following information:

Page 2 of 28

Do you have any relatives employed with Newton County? Yes No

How did you learn of this position?

Relative’s Name Relationship Department Employed

Please list any technical skills that you possess that may relate to the position applied for:

Skill How Long Related Training

Please list any foreign language that you have learned and the extent of your proficiency:

Language Proficiency (some, moderate, fluent)




Name of Organization Date Began Date Ended Position Held

If yes, indicate each:

Please list all organizations, Clubs and Associations which you are now, or have ever been a member of:

Page 3 of 28




What is your highest grade completed?

Are you a high school graduate? Yes No

Name of High School: Dates Attended:

Address (Street Number/Name, City, State, Zip Code)

How long have you lived at your current address?

Telephone Number: Date Graduated:

Did you receive a GED certificate? Yes No

Name of School or Local Board of Education:


II. EDUCATION

III. LAW ENFORCEMENT EXPERIENCE

Name of school Address Start Date End Date Major/Minor Degree Earned

List all colleges, universities, business/technical schools or graduate schools that you have attended:

List all law enforcement or corrections agencies that you have applied with. List the agency name, date of application, and status of your application (how far are you or did you get in the process).

Agency Name Date of Application Application Status Contact name (if known)

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Are you currently a Georgia P.O.S.T. Certified Peace Officer Yes No

Georgia P.O.S.T. PBLE number:

Have you been awarded any Georgia P.O.S.T. certification or certification from another state? Yes No

How many years and months experience do you have as a certified law enforcement officer?

Is your Law Enforcement, Correction, Jailer, Probation, or Parole Officer Certification under investigationby any state or federal Law Enforcement Training Council? Yes No

If yes, please attach a narrative on a separate sheet of paper explaining in detail the cause for theinvestigation.

Has your Law Enforcement, Correction, Jailer, Probation, or Parole Officer certification ever been revokedor placed on probation by any state or federal Law Enforcement Training Council? Yes No

If yes, please attach a narrative on a separate sheet of paper explaining in detail the cause for the revocationor probation.

If yes, please provide:

State of Issuance Type of Certification Certification Number


Page 5 of 28




Have you ever resigned from employment while under active internal investigation? Yes No

If yes, explain:

Have you ever served in any branch of the United States Armed Forces? This also includes Reserves, National Guard, and Coast Guard. Yes No

If yes, what branch?

What type of military discharge did you receive? (Honorable, Dishonorable, General, Under Honorable Conditions,Entry Level Separation, Medical, etc.) Be specific:

Have you ever been involved in, or been accused of being involved in, a subversive act against the United StatesGovernment, or any other government, such as mutiny, treason, sabotage, espionage, etc.? Yes No

If yes, fully explain on a separate attached narrative.

List ALL disciplinary action received while working in a law enforcement position. Include any oral or written reprimands, suspensions, demotions or termination, the date of the action, reason for the action, and indicate whether you are currently involved in an internal investigation.

Agency Name Disciplinary Action

Date of Action

Internal AffairsInvestigation (open or closed)

Reason fordisciplinary action

IV. MILITARY SERVICE


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Have you ever been court-martialed, tried on charges, or subject of an Article 15, company punishment, or any otherdisciplinary action while a member of any branch of the Armed Forces? Yes No

*If yes, please explain in detail on a separate attached narrative. Include type of disciplinary action taken, branch ofservice, date of action, disposition of action and explanation of offense.

Applicants that served in the military must complete the following:

Please list five (5) personal references. These must be people who are responsible adults of reputable standing in their community and who have known you for at least 4 years. They may not be relatives, anyone living within your household or current/former employers. Confirm that all the addresses and telephone numbers are current before submitting your application.

Branch of Service Enlistment Period Highest Rank Held Service Number

V. PERSONAL REFERENCES

Name: Relationship: Contact Phone Number:


Occupation: Years Known: E-mail Address:

Reference 1:

IV. MILITARY SERVICE

Page 7 of 28




Name: Relationship:


Occupation: Years Known:

Reference 2:

Name: Relationship:



Reference 3:

Name: Relationship:



Reference 4:

Name: Relationship:



Reference 5:

Contact Phone Number:

E-mail Address:


E-mail Address:


E-mail Address:


E-mail Address:

Page 8 of 28




Please provide three (3) current neighbor references. The neighbor reference may live next door to you or within three (3) houses or apartment units in any direction of your residence. Please confirm that all addresses and telephone numbers are current before submitting your application.

VI. NEIGHBOR REFERENCES

Name: Relationship:



Reference 1:

Name: Relationship:



Reference 2:

Name: Relationship:



Reference 3:


E-mail Address:


E-mail Address:


E-mail Address:

Page 9 of 28




Please list all of your addresses for the last ten years. Start with your present address. You must include all permanent, temporary, part-time, military, and school addresses in which you have resided.

VII. RESIDENCE HISTORY

FROMMO/YR

TOMO/YR

STREET ADDRESS CITY COUNTY STATE ZIP

Page 10 of 28




List all jobs worked in the last 15 years. Include military, volunteer experience, self-employment, internships, and periods of unemployment, ALL part-time work and ALL full-time work. For any gap of unemployment, write UNEMPLOYED under “Employer” section and explain your means of support (i.e. parents, spouse income, unemployment benefits, etc.). All periods of time should be accounted for during the last fifteen years. A resume may be attached ONLY as additional information and WILL NOT be accepted in lieu of completing this section. If more space is needed, attach additional pages including all information that is asked. Begin with your most recent or current employment. Please provide current telephone numbers (including area code) for all employers.

VIII. EMPLOYMENT HISTORY

Employer: Telephone Number: Dates Employed (from/to)

Address (Street Number/Name, City, State, Zip Code) Total time employed:

Job Title: Supervisor’s Name: Out of business?

Brief description of duties:

Reason for leaving:

Employer 1:





Reason for leaving:

Employer 2:

Page 11 of 28










Reason for leaving:

Employer 3:





Reason for leaving:

Employer 4:

Page 12 of 28










Reason for leaving:

Employer 5:





Reason for leaving:

Employer 6:

Page 13 of 28










Reason for leaving:

Employer 7:





Reason for leaving:

Employer 8:

Page 14 of 28










Reason for leaving:

Employer 9:





Reason for leaving:

Employer 10:

Page 15 of 28




If you answer YES to questions 4-29, you must explain in full detail on the explanation sheet provided with this questionnaire. Be sure to indicate the question number that you are addressing.

IX. APPLICANT QUESTIONNAIRE

1. Are you available to work any hour of the day, day of the week, including holidays and be available during unusual occurrences for call-outs? Yes No

2. Will you consent to a thorough background investigation of your character? Yes No

3. Will you consent to a medical examination by a physician and a psychological evaluation upon a conditional offer of employment? Yes No

4. Have you ever been rejected for employment, for any reason, by any law enforcement agency? If yes, what agency and why? Yes No

5. Have you ever been terminated by any law enforcement agency? If yes, give the agency, date of termination, and reason. Yes No

6. Have you ever been terminated or asked to resign from any job? If yes, list the name of the employer(s), dates of employment, and reason for termination or resignation under pressure. Yes No

7. Have you ever been physically arrested or given a copy of charges for violation of any city, municipal, state, or federal law? Yes No

8. Have you ever appeared in any court (including juvenile) as a defendant to answer any city, municipal, state, or federal criminal charge? If so, give the court in which you appeared and the disposition of the case (i.e. conviction, First Offenders, charges dismissed, etc). Yes No

9. Have you ever been detained by any law enforcement representative, been the subject of any criminal investigation, or been named as the accused on a warrant? If yes, explain in detail. Yes No

10. Have you ever received any tickets for traffic violations (excluding parking tickets) on any license that you have held since you began driving? If yes, list type of violation, date received, jurisdiction, and disposition (i.e. fine, suspension, charges dismissed).

Yes No

11. Have you ever used, tried, ingested, or experimented with marijuana (including as a juvenile or even one experimental use)? If yes, write the number of times used, the first date used, and the date of last use. Yes No

12. Have you ever used, tried, ingested, or experimented with any other type of illegal narcotics or dangerous drugs (i.e. heroin, cocaine, hashish, speed, LSD, anabolic steroids, etc.)? If yes, indicate what type of drug and when you used it? Yes No

13. Have you ever sold any type of illegal drug, delivered illegal drugs, shared drugs with another person, or directed another person where to buy drugs? If yes, indicate what type of drug and when. Yes No

Page 16 of 28




If you answer YES to questions 4-29, you must explain in full detail on the explanation sheet provided with this questionnaire. Be sure to indicate the question number that you are addressing.

IX. APPLICANT QUESTIONNAIRE

14. Have you ever used, tried, ingested, or experimented with any drug legally prescribed to another person? If yes, indicate what type of drug and when. Yes No

15. Have you ever filed or declared bankruptcy, had any judgments, repossessions, foreclosures, or collections? Yes No

16. Do you know of anything that might prevent you from obtaining this position? Yes No

17. Have you ever been sued? Yes No

18. Have you ever had your wages garnished? Yes No

19. Are there any unpaid judgments against you? Yes No

20. Are you delinquent in property taxes or other taxes? Yes No

21. Have you ever had a charge, complaint, or lawsuit filed against you alleging the use of excessive force? Yes No

22. Have you ever had a charge, complaint, or lawsuit filed against you alleging false arrest? Yes No

23. Have you ever been a complainant, victim, or been involved in a complaint of domestic violence? Yes No

24. Do you have any visible tattoos and/or brands? Visible is defined as the area that is exposed to public view in short sleeves or the areas that are exposed in shorts. If yes, provide location and meaning of each one on the explanation sheet. Yes No

25. Are you now or have you ever been, engaged in any business as an owner, partner, or corporate member? Yes No

26. Have you received written reprimands from supervisors or employers for not doing your job correctly or conduct violations? Yes No

27. Have you been counseled or received warning for being late or absent from work? Yes No

28. Have you ever been suspended from a job for a period of time with or without pay? Yes No

29. Have you purposely omitted any information from your employment application? Yes No

Page 17 of 28




Please make sure that all explanations are detailed, accurate, and true. Be sure to list the number to the question that you are explaining. Attach additional sheets if necessary.

X. EXPLANATION TO APPLICANT QUESTIONNAIRE

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Page 20 of 28




I certify that I have read and understand all questions and instructions in this application, and that my answers are true and complete. I understand that this application is not an offer of or a contract for employment.

I understand that any untrue statement in this application may result in my dismissal at any time during my employment with the Newton County Sheriff’s Office. I understand that any intentional false statement will result in my disqualification from the hiring process and may result in criminal prosecution under O.C.G.A. 16-10-20 and 16-10-71.

XI. APPLICANT SWORN STATEMENT

THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT.ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED.

Name (First, Middle, Last)

Signature: Date:

Notary Public: Date:

Page 21 of 28




The Official Code of Georgia Annotated Title 35 Chapter 8 Section 22 (O.C.G.A. 35-8-22) states the following:

35-8-22.(GCA § 92A-2122.1) Reimbursement for Peace Officer’s Mandated or Formalized Training

(a) Unless otherwise provided by an employment contract to the contrary, if the State of Georgia or any county or municipality thereof employs a peace officer and said peace officer is hired by another agency within 15 months after completing mandated or formalized training requirements, then the total expense of training, including salary paid during training, shall be reimbursed by the hiring agency to the State of Georgia or any county or municipality thereof which initially paid for such training. If said officer is hired by another agency during a period of 15 to 24 months after mandated or formalized training requirements are completed, then one-half of the total expense of training, including salary paid during training, shall be reimbursed by the hiring agency to the State of Georgia or any county or municipality thereof which initially paid for such training. The council shall set standards for reimbursement by hiring agencies based upon actual expenses incurred in mandated or formalized training by individual departments.

(b) The State of Georgia or any county or municipality thereof which initially paid for the training of a peace officer shall submit an itemized, sworn statement to the new employer of the peace officer and shall demand payment thereof and may enforce collection of such obligation through civil remedies and procedures.

(c) Effective July1, 2003, in order for the State of Georgia or any county or municipality thereof to demand reimbursement, the demanding governmental unit must be able to document that the peace officer in question signed an acknowledgment of the terms of this Code section or an employment contract specifying the provisions of this Code section prior to such peace officers employment with the demanding governmental unit. Otherwise, this Code section shall not apply to such demand for reimbursement.

I, _______________________________ (Applicant), have read in full and do agree to abide by the provisions of O.C.G.A 35-8-22 Reimbursement for Peace Officer’s Mandated or Formalized Training.

XII. EMPLOYEE REIMBURSEMENT AGREEMENT


Applicant Signature: Date:

Notary: Date:

Page 22 of 28




I, _______________________________________, do hereby authorize a review of and full disclosure of all records concerning myself to any duly authorized agent of the Newton County Sheriff’s Office, or to any authorized agent of a criminal justice agency or any private agency upon request of the Newton 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 military service records, “authority to release law enforcement or criminal records or information from a law enforcement agency;” educational institutions; financial or credit institutions, including records of loans, the records of commercial or retail credit agencies (including credit reports and/or rating) and financial statements and records wherever filed; medical and psychiatric treatment and/or consultation including hospitals, clinics, private practitioners, and the U.S. Veterans Administration; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me and the records and recollections of attorneys at law, or of the other counsel whether representing me or another person in any case, either criminal or civil, in which I presently have or have had an interest.

I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly in whole or in part, upon this release authorization, will be considered in determining my suitability for employment by the Newton County Sheriff’s Office. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I hereby release said person(s) from any and all liability, which may be incurred as a result of furnishing such information.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature.

XIII. NEWTON COUNTY SHERIFF’S OFFICE CONSENT WAIVER


Applicant Signature: Date:

Date of Birth: Social Security #

Notary: Date:

Page 23 of 28




I, __________________________, hereby acknowledge that I am a Peace Officer applicant, or a candidate for appointment or certification to a position as a Peace Officer in the State of Georgia, or for attendance at a basic training course required for such appointment and certification.

1. I hereby request that my former employers release to any law enforcement agency requesting employment related information as defined in O.C.G.A. § 35-8-8(c)(1) the following:

All written information contained in a prior employer’s records or personnel files that relates to an applicant’s, candidate’s, or peace officer’s performance or behavior while employed by such prior employer, including performance evaluations, records of disciplinary actions, and eligibility for rehire. Such term shall not include information prohibited from disclosure by federal law or any document not in the possession of the employer at the time a request for such information is received.

2. In consideration of your providing such information to my prospective Law Enforcement employer, I hereby forever release and agree to hold harmless and to defend from all liability for any claims, causes of action or suits or charges by every former employer who provides such complete and accurate information about my employment to the requesting law enforcement agency in accord with O.C.G.A. § 35-8-8(c)(2).

3. I understand that O.C.G.A. § 35-8-8(c)(5) provides as follows:

Before taking final action on an application for employment based, in whole or in part, on any unfavorable employment related information received from a previous employer, a law enforcement agency shall inform the applicant, candidate, or peace officer that it has received such employment related information, and that the applicant, candidate, or peace officer may inspect and respond in writing to such information. Upon the applicant’s, candidate’s, or peace officer’s request, the law enforcement agency shall allow him or her to inspect the employment related information and to submit a written response to such information. The request for inspection shall be made within five business days from the date that the applicant, candidate, or peace officer is notified of the law enforcement agency’s receipt of such employment related information. The inspection shall occur not later than ten business days after said notification. Any response to the employment related information shall be made by the applicant, candidate, or peace officer not later than three business days after his or her inspection.

XIV. APPLICANT RELEASE AND HOLDHARMLESS AGREEMENT


Applicant Signature: Print Name:

Date:

Notary: Notary Signature:

My commission expires:

Page 24 of 28




I hereby authorize, Newton County Law Enforcement Center to receive any and all criminal history record information pertaining to me which may be in the files of any local or national criminal justice agency. This name based criminal history will be completed using the Georgia Criminal Information Center (GCIC) system and the NCIC System.

Please print the following:

XV. CRIMINAL HISTORY CONSENT FORM


Name (Last, First, Middle) Maiden Name:

Social Security #

Date of Birth (Month, Day, Year) Race: Sex:

Street Address:

City: State: Zip Code:

Phone Number:

Criminal History for mandated position (PC “Z”) Criminal History for civilian position (PC “J)

*Signature (required) *Date of request (required)

*****************************************Sheriff ’s Office Use Only**********************************************

****************************This authorization is valid for 90 DAYS from date requestor signs**********************************************************Release will not be processed if submitted incomplete*****************************

Signature of operator completing history request: Date:

Page 25 of 28

I hereby acknowledge that my employment relationship with Newton County is strictly one of AT WILL

employment. I understand that I may end the employment relationship at any time and for any reason not

prohibited by law, and my employer may do the same. I understand that my AT WILL employment status

may not be changed except by express written contract approved by the Board of Commissioners.

XVI. ACKNOWLEDGEMENT OF AT WILL EMPLOYMENT

Employee/Applicant signature: Date:

Page 26 of 28

AUTHORIZATION TO RELEASE INFORMATION

I have applied to Newton County, Georgia, for employment. Part of the employment process is an investigation and verification of information I provide or will provide on my application for employment and in occasional reports during my employment with Newton County, Georgia.

I do hereby authorize a review of and full disclosure of all records concerning me to Newton County. The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; employment records; financial statements and records wherever files; medical and psychiatric treatment and/or consultation including hospitals, clinics and private practitioners, and employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me whether representing me or another person in any case either criminal or civil, in which I presently have or have not had an interest; criminal history record information which may be in the files of the State of Georgia or local criminal justice agency and/or any other information contained in your files relevant to my employment with Newton County, Georgia.

I hereby fully and finally release and discharge newton County, Georgia, and its officials, employees and agents from any and all liability for acts and ommissions taken pursuant to this authorization. I similarly release all persons, corporations, and other entities who release any information or documents pursuant to this authorization. I represent and warrant that I will not, directly or indirectly, seek disclosure of information obtained pursuant to this authorization either to me or to anyone else. I also understand that this executed document may be used in any process of promotion, transfer or demotion to a position for which I have applied.

I have carefully read and fully understand the contents of this authorization and I execute it voluntarily as my own free act and deed.

NEWTON COUNTY HUMAN RESOURCES 1124 Clark StreetCovington, Georgia 30014Tel: (678) 625-1212 • (678) 625-1210

Full Name (printed or typed) Date:

Street Address (City, State, Zip)

Social Security Number: Signature:

Notary Public (must be notarized)

• This authorization is valid for 60 days or until application is invalidated. To be completed by Human Resources:

Date of Birth: Race: Sex: Purpose Code:

Page 27 of 28

NOTICE TO JOB APPLICANTSNEWTON COUNTY’S DRUG SCREENING POLICY

Newton County has a strong commitment to its employees to provide a safe work environment and to promote high standards of employee health. The County also has a strong commitment to provide high quality public service. Consistent with the spirit and intent of these commitments, the Board of County Commissioners has determined that there is a compelling need for a county policy on drug use, which includes chemical testing for recent use of controlled substances.

Upon an offer of employment by the County and prior to final appointment, job applicants will be asked to consent to a controlled substance screening test. If the initial screening test indicates that the applicant has recently used controlled substances, the applicant will be notified of the test results.

Before a test is administered, applicants will be asked to sign a consent form authorizing the test and permitting release of test results to those county officials with a need to know.

If an applicant refuses to consent to a test, or if testing indicates use of controlled substances, the offer of employment will be retracted, and the applicant will be denied employment with the County. Applicants will be informed if they are rejected on the basis of test results.

All information from an applicant’s drug evaluation is confidential and only those with a need to know are to be informed of test results. Disclosure of such information to any other person, agency, or organization is prohibited unless written authorization is obtained from the applicant.

NEWTON COUNTY HUMAN RESOURCES 1124 Clark StreetCovington, Georgia 30014Tel: (678) 625-1212 • (678) 625-1210

Page 28 of 28

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status.

The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a confidential file and are not part of your employment application or personnel file.

Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

Employment Data Record

VOLUNTARY SURVEY

Name: Date:

Address:

City: State: Zip:

Social Security No.

Government agencies at times require periodic reports on the sex, ethnicity, disabled veteran and other protected status of employees. This data is for statistical analysis.

Complete Only The Sections Below That Apply

Gender: Male Female Age:

Check One of the Following: (Ethnic Origin): NOTE: Any choice other than Hispancic/Latino means Not Hispanic/Latino

White Black/African American Hispanic/Latino American Indian/Alaskan Native

Asian Native Hawaiian/Pacific Islander Two or more races

Check If Any of the Following are Applicable: Vietnam Era Veteran Disabled Veteran Person with Disability

Documents

APPLICATION FOR EMPLOYMENT - Newton County Sheriff's Office › PDF › Employment_Application_interactiv… · the Newton County Sheriff’s Office at (678) 625-1212. The Newton