NEWTON COUNTY
SHERIFF’S OFFICE
A P P L I C AT I O N F O R E M P L OY M E N T
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15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014 • Ph: (678) 625-1210 • Fax: (678) 625-1222
www.newtonsheriffga.org • An Equal Opportunity Employer.
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COMMITTED TO EXCELLENCE
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Ezell Brown, Sheriff
NEWTON COUNTY
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SHERIFF’S OFFICE
EZELL BROWN, SHERIFF
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INSTRUCTION SHEET
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 completed application and required documents must be
returned to Newton County Human Resources at the
following address:
Newton County Human Resources
1124 Clark Street
Covington, 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) 625-1210.
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.
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
COMMITTED TO EXCELLENCE
15151 Alcovy- Jersey Rd., NE • Covington, Georgia 30014 • Ph: (678) 625-1210 • Fax: (678) 625-1222 • www.newtonsheriffga.org
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
Position Applied For:
Deputy Sheriff
Detention Officer
Civilian
I. PERSONAL INFORMATION
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
If no, are you a permanent resident?
No
Yes
No
Place of Birth (City, County, State/Country)
Have you ever used another name or had your name changed?
Yes
No
(This includes Maiden Names, Former Married Names, Adopted Names, Nicknames, etc.) If you answered yes, please provide the
following information:
Previous Name
Date of Change
Location of Change
Have you ever applied with the Newton County Sheriff’s Office before?
Yes
Position last applied for and date:
Are you currently employed with Newton County?
Were you previously employed with Newton County?
Yes
Yes
If yes: Date started/ Date left/ Position(s) held:
Page 1 of 28
No
No
Reason for Change
No
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
Do you have any relatives employed with Newton County?
Yes
No
If yes, indicate each:
Relative’s Name
Relationship
Department Employed
How did you learn of this position?
Please list all organizations, Clubs and Associations which you are now, or have ever been a member of:
Name of Organization
Date Began
Date Ended
Position Held
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)
Page 2 of 28
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
II. EDUCATION
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:
Address (Street Number/Name, City, State, Zip Code)
List all colleges, universities, business/technical schools or graduate schools that you have attended:
Name of school
Address
Start Date
End Date
Major/Minor
Degree Earned
III. LAW ENFORCEMENT EXPERIENCE
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
Page 3 of 28
Contact name (if known)
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
III. LAW ENFORCEMENT EXPERIENCE
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
If yes, please provide:
State of Issuance
Type of Certification
Certification Number
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 investigation
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
investigation.
Has your Law Enforcement, Correction, Jailer, Probation, or Parole Officer certification ever been revoked
or 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 revocation
or probation.
Page 4 of 28
No
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
III. LAW ENFORCEMENT EXPERIENCE
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 Affairs
Investigation (open or closed)
Have you ever resigned from employment while under active internal investigation?
Yes
Reason for
disciplinary action
No
If yes, explain:
IV. MILITARY SERVICE
Have you ever served in any branch of the United States Armed Forces?
This also includes Reserves, National Guard, and Coast Guard.
Yes
If yes, what branch?
No
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 States
Government, or any other government, such as mutiny, treason, sabotage, espionage, etc.?
Yes
If yes, fully explain on a separate attached narrative.
Page 5 of 28
No
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
IV. MILITARY SERVICE
Applicants that served in the military must complete the following:
Branch of Service
Enlistment Period
Highest Rank Held
Service Number
Have you ever been court-martialed, tried on charges, or subject of an Article 15, company punishment, or any other
disciplinary 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 of
service, date of action, disposition of action and explanation of offense.
V. PERSONAL REFERENCES
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.
Reference 1:
Name:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Page 6 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
APPLICATION
FOR EMPLOYMENT
Reference 2:
Name:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Reference 3:
Name:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Reference 4:
Name:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Reference 5:
Name:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Page 7 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
APPLICATION
FOR EMPLOYMENT
VI. NEIGHBOR REFERENCES
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.
Reference 1:
Name:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Relationship:
Home Phone Number:
Years Known:
Cellular Telephone Number:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Reference 2:
Name:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Reference 3:
Name:
Address (Street Number/Name, City, State, Zip Code)
Occupation:
Page 8 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
VII. RESIDENCE HISTORY
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.
FROM
MO/YR
TO
MO/YR
STREET ADDRESS
CITY
Page 9 of 28
COUNTY
STATE
ZIP
NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
VIII. EMPLOYMENT HISTORY
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.
Employer 1:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Employer 2:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Page 10 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
VIII. EMPLOYMENT HISTORY
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.
Employer 3:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Employer 4:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Page 11 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
VIII. EMPLOYMENT HISTORY
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.
Employer 5:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Employer 6:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Page 12 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
VIII. EMPLOYMENT HISTORY
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.
Employer 7:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Employer 8:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Page 13 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
VIII. EMPLOYMENT HISTORY
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.
Employer 9:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Employer 10:
Employer:
Telephone Number:
Dates Employed (from/to)
Address (Street Number/Name, City, State, Zip Code)
Total time employed:
Job Title:
Out of business?
Supervisor’s Name:
Brief description of duties:
Reason for leaving:
Page 14 of 28
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
IX. APPLICANT QUESTIONNAIRE
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.
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 15 of 28
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
IX. APPLICANT QUESTIONNAIRE
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.
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?
16. Do you know of anything that might prevent you from obtaining this position?
17. Have you ever been sued?
Yes
18. Have you ever had your wages garnished?
19. Are there any unpaid judgments against you?
20. Are you delinquent in property taxes or other taxes?
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
No
21. Have you ever had a charge, complaint, or lawsuit filed against you alleging the use of excessive force?
22. Have you ever had a charge, complaint, or lawsuit filed against you alleging false arrest?
Yes
Yes
23. Have you ever been a complainant, victim, or been involved in a complaint of domestic violence?
No
No
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
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?
Page 16 of 28
Yes
No
No
NEWTON COUNTY
SHERIFF’S OFFICE
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
APPLICATION
FOR EMPLOYMENT
X. EXPLANATION TO APPLICANT QUESTIONNAIRE
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.
Page 17 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
APPLICATION
FOR EMPLOYMENT
X. EXPLANATION TO APPLICANT QUESTIONNAIRE
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.
Page 18 of 28
NEWTON COUNTY
SHERIFF’S OFFICE
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
APPLICATION
FOR EMPLOYMENT
X. EXPLANATION TO APPLICANT QUESTIONNAIRE
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.
Page 19 of 28
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
XI. APPLICANT SWORN STATEMENT
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.
Name (First, Middle, Last)
Signature:
Date:
Notary Public:
Date:
THIS FORM MUST BE SIGNED AND MAILED TO:
NEWTON COUNTY HUMAN RESOURCES DEPARTMENT.
ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED.
Page 20 of 28
NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
XII. EMPLOYEE REIMBURSEMENT AGREEMENT
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.
Applicant Signature:
Date:
Notary:
Date:
THIS FORM MUST BE SIGNED AND MAILED TO:
NEWTON COUNTY HUMAN RESOURCES DEPARTMENT.
ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED.
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NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
XIII. NEWTON COUNTY SHERIFF’S OFFICE CONSENT WAIVER
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.
Applicant Signature:
Date:
Date of Birth:
Social Security #
Notary:
Date:
THIS FORM MUST BE SIGNED AND MAILED TO:
NEWTON COUNTY HUMAN RESOURCES DEPARTMENT.
ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED.
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NEWTON COUNTY
SHERIFF’S OFFICE
APPLICATION
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
FOR EMPLOYMENT
XIV. APPLICANT RELEASE AND HOLDHARMLESS AGREEMENT
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.
Applicant Signature:
Print Name:
Date:
Notary:
Notary Signature:
My commission expires:
THIS FORM MUST BE SIGNED AND MAILED TO:
NEWTON COUNTY HUMAN RESOURCES DEPARTMENT.
ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED.
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NEWTON COUNTY
APPLICATION
SHERIFF’S OFFICE
FOR EMPLOYMENT
15151 Alcovy-Jersey Rd., NE • Covington, Georgia 30014
Ph: (678) 625-1400 • Fax: (678) 625-1473
XV. CRIMINAL HISTORY CONSENT FORM
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:
Name (Last, First, Middle)
Maiden Name:
Social Security #
Date of Birth (Month, Day, Year)
Race:
Sex:
State:
Zip Code:
Street Address:
City:
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**********************************************
Signature of operator completing history request:
Date:
****************************This authorization is valid for 30 DAYS from date requestor signs*************************
*********************************Release will not be processed if submitted incomplete*****************************
THIS FORM MUST BE SIGNED AND MAILED TO: NEWTON COUNTY HUMAN RESOURCES DEPARTMENT.
ELECTRONIC SUBMISSIONS WILL NOT BE ACCEPTED.
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XVI. ACKNOWLEDGEMENT OF AT WILL EMPLOYMENT
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.
Employee/Applicant signature:
Date:
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NEWTON COUNTY HUMAN RESOURCES
1124 Clark Street
Covington, Georgia 30014
Tel: (678) 625-1212 • (678) 625-1210
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.
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:
Page 26 of 28
Purpose Code:
NEWTON COUNTY HUMAN RESOURCES
1124 Clark Street
Covington, Georgia 30014
Tel: (678) 625-1212 • (678) 625-1210
NOTICE TO JOB APPLICANTS
NEWTON 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.
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Employment Data Record
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.
VOLUNTARY SURVEY
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.
Name:
Date:
Address:
City:
State:
Zip:
Social Security No.
Complete Only The Sections Below That Apply
Gender:
Male
Age:
Female
Check One of the Following: (Ethnic Origin): NOTE: Any choice other than Hispancic/Latino means Not Hispanic/Latino
White
Black/African American
Asian
Native Hawaiian/Pacific Islander
Check If Any of the Following are Applicable:
Hispanic/Latino
American Indian/Alaskan Native
Two or more races
Vietnam Era Veteran
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Disabled Veteran
Person with Disability