Madison County Sheriff’s Office
317 Denmark Jackson Rd.
Denmark, Tennessee 38391
731-423-6000
www.mcso-tn.org
Sheriff Julian Wiser
Application for Employment
The Madison County Sheriff’s Office is an equal opportunity employer, dedicated to a
place of nondiscrimination in employment on any basis including age, sex, color, race,
creed, national origin, religious persuasion, marital status, political belief, military service,
or disability that does not prohibit performance of essential job functions.
Employment Application
JOIN THE TEAM!
“The Madison County Sheriff’s Office Is An Equal Opportunity Employer
Dedicated To A Workplace Of Nondiscrimination Regarding Employment
On Any Basis, Including Age, Sex, Color, Race, Creed, National Origin,
Religion, Marital Status, Politics, Military Service, Or Disability That Does
Not Prohibit The Performance Of Essential Job Functions.”
Madison County Sheriff- Julian Wiser
Applicants may obtain an Employment application at the Sheriff’s Office or download a copy online at
www.mcso-tn.org Complete the application fully, attach required documents, sign and obtain a notary
stamp and signature to certify your application prior to submitting it by mail or in person.
All information provided will remain confidential
INSTRUCTIONS
 Type or print using black ink only, if a question does not apply, mark N/A.
 Do not submit a double sided copy of any document.
 Do not omit information; provide complete, accurate, and truthful information.
 Review application, sign all signature lines, and attach all requested documents.
 Notarize application and submit in person or by mail.
FOR USE BY ADMININSTRATIVE STAFF ONLY
09/10/2022 APPLICANT__________________________________________
Michael T Trimm
DATE_____________
Sheriff Deputy
POSITION_____________________________________________________________
NOTES:_______________________________________________________________
DISPOSITION_______________________ RETENTION DATE_____________________
Page 1 of 18
INDEX
SECTION
INFORMATION
PAGE
One
Personal Information
3
Two
Personal Inquiry
4
Three
Application Information
5-6
Four
Work History
7-8
Five
Character References
9
Six
Education
10
Seven
Skills
11
Eight
Military Service
12
Nine
Financial History
13
Ten
Driving History
14
Eleven
Alcohol-Drug Use
15
Twelve
Criminal History
16
Thirteen
NOTARIZED STATEMENTS
17
Fourteen
Documents
18
Page 2 of 18
SECTION ONE- PERSONAL INFORMATION
1. Last Name
2. First Name
3. Middle Name
4. Other names
5. Date Of Birth
6. Social Security #
7. Street Address
8. City
TRIMM
MICHAEL
TANNER
N/A
09/27/1998
426-85-9273
125016677
98-1328990-8
372 Kitchen Dr.
Henderson
9. State
TN
10. Cell Phone
662-760-6771
11. Email Address
Drivers License #
State of issue
Selective
Service #
Zip
Home Phone
38340
N/A
Ttrimm123@gmail.com
Page 3 of 18
SECTION TWO- PERSONAL INQUIRY
QUESTIONS
1. Do you affirm or swear to support
the Constitution of the United
States and the State of
Tennessee?
2. Have you ever belonged to any
group or organization that
advocates the overthrow of the
United States by force, violence, or
any other means?
3. Do you discriminate or have any
bias based on age, sex, race,
creed, national origin, religion,
marital status, politics, military
service, or disability?
4. Have you ever associated with or
been a member of a Gang of two
or more members involved in a
pattern of criminal activities?
5. Are you related to or associated in
any way to someone currently who
is incarcerated in jail or prison?
6. The Prison Rape Elimination Act:
Have you ever engaged, convicted of
engaging, adjudicated to have engaged,
in sex abuse, by force, coercion, or non
consent, in prison, jail, community
confinement, juvenile facility, detention
facility, or any other institution.
YES
NO
PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
✔
✔
✔
✔
✔
✔
Page 4 of 18
SECTION THREE- APPLICATION INFORMATION
DATE OF APPLICATION
09/10/2022
POSITION?
PLACE AN X IN BOX
WORK HOURS?
PLACE AN X IN BOX
QUESTIONS
PATROL DEPUTY ✔
CORRECTIONS
ADMIN./ CLERK
FULL TIME
YES
1. Can you describe the duties and
responsibilities of the position?
✔
2. Can you explain why you want to work
at the MCSO?
✔
3. Can you advise why we should hire
you?
✔
4. Are you over 18 years of age?
5. Are you a U.S. Citizen?
6. Have you ever applied or worked at
Madison County Sheriff’s Office?
7. Have you ever been fired, ask to resign,
laid off, or failed to complete probation
on the job?
8. Are you currently employed?
NO
✔
RESERVE DEPUTY
DISPATCHER
OTHER
PART TIME
PLACE AN X IN YES OR NO BOX.
TYPE OR PRINT YOUR EXPLANATIONS BELOW
✔
✔
✔
✔
✔
I am not currently employed due to relocating back to TN.
Page 5 of 18
SECTION THREE- APPLICATION INFORMATION
QUESTIONS
YES
9. Are you related to any Madison County
Sheriff’s Office employee?
10. Are any Madison County Sheriff’s
Office employees, listed as character
references?
James Hensley
✔
✔
12. Are you currently a certified corrections
officer or jailer?
✔
✔
14. May we contact your current employer
regarding your work history?
15. Would you be able to report to work
two weeks after being offered a job?
PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
✔
11. Are you currently a certified police
officer or deputy sheriff?
13. May we contact you by phone
sometime between Mon-Friday
8am-4pm?
NO
I'm not currently employed.
✔
✔
I can start immediately.
Page 6 of 18
SECTION FOUR- WORK HISTORY
INSTRUCTIONS- LIST YOU’RE LAST SIX JOBS, START WITH MOST CURRENT.
Organization
Street Address
City
State
Dates of Employment
Position/ Title
Duties/ Tasks
Reason For Leaving
Organization
Street Address
City
State
Dates of Employment
Position/ Title
Duties/ Tasks
Reason For Leaving
Organization
Street Address
City
State
Dates of Employment
Position/ Title
Duties/ Tasks
Reason For Leaving
U.S. Army National Guard
2254 Westover Rd.
Jackson
TN
Zip
38301
Phone #
731-425-5652
Pay Rate
E5
01/2018-Current
Blackhawk Mechanic
Performed various maintenance tasks to ensure proper flight of the UH-60 Blackhawk.
N/A
Will's Metal Buildings
5226 Hwy 341
Pontotoc
MS
Zip
38863
Phone #
N/A
Pay Rate
$15/hr
01/2022-09/2022
Construction Worker
Worked with a crew to construct metal buildings. Did things such as welding and driving powered equipment.
Relocated
Autozone
345 West Main St.
Henderson
TN
Zip
38340
Phone #
731-989-3443
Pay Rate
17.56/hr
07/2019-01/2022
Parts Sales Manager
Supervised a team of associates to provide customer satisfaction. Created schedules for associates and maintained paperwork.
Relocated to MS.
Page 7 of 18
SECTION FOUR- WORK HISTORY
INSTRUCTIONS- LIST YOUR LAST SIX JOBS, START WITH MOST CURRENT.
Organization
Street Address
City
State
Dates of Employment
Position/ Title
Duties/ Tasks
Reason For Leaving
Organization
Street Address
City
State
Dates of Employment
Position/ Title
Duties/ Tasks
Reason For Leaving
Organization
Street Address
City
State
Dates of Employment
Position/ Title
Duties/ Tasks
Reason For Leaving
Lowe's Home Improvement
2071 S Highland Ave.
Jackson
TN
Zip
38301
Phone #
731-265-5399
Pay Rate
$14
02/2017-07/2019
Lead Receiver
Received stock from incoming trucks while taking inventory. Stocked shelves with freight.
Job opportunity with Autozone
N/A
Zip
Phone #
Pay Rate
N/A
Zip
Phone #
Pay Rate
Page 8 of 18
SECTION FIVE- CHARACTER REFERENCES
INSTRUCTIONS- LIST 2- FRIENDS, 2- NEIGHBORS, AND 2 –COWORKERS, YOU HAVE KNOWN AT LEAST ONE YEAR. (NO RELATIVES)
Name-Friend
Street Address
City
State
Name-Friend
Street Address
City
State
Name-Neighbor
Street Address
City
State
Name-Neighbor
Street Address
City
State
Name-Coworker
Street Address
City
State
Name-Coworker
Street Address
City
State
Years Known
Justin Vales
15
N/A
Selmer
TN
Zip
38375
Phone #
731-439-2424
Years Known
Joey Alexander
4
N/A
Jackson
TN
Zip
38301
Phone #
731-267-6158
Years Known
Dustin Mathis
8
N/A
Pontotoc
MS
Zip
38863
Phone #
662-419-3260
Years Known
Rocky Smith
12
290 Jacks Creek ST
Henderson
TN
Zip
38340
Phone #
731-803-4612
Years Known
James Hensley
3
4880 Glendale Rd
Henderson
TN
Zip
38340
Phone #
731-602-0953
Years Known
Nick Newman
8
N/A
Henderson
TN
Zip
38340
Phone #
731-608-6903
Page 9 of 18
SECTION SIX- EDUCATION
High School
Dates attended
Location-City/State
GED Education
Dates attended
Location-City/State
Technical- Vocational
Dates attended
Location-City/State
College/ University
Dates attended
Location-City/State
Dates attended
Location-City/State
Dates attended
Location-City/State
Dates attended
Location-City/State
Dates attended
Location-City/State
Chester County High School
08/2013-05/2017
Henderson,TN
N/A
N/A
N/A
Year Graduated
Diploma/ Certificate
Subject
Year Graduated
Diploma/ Certificate
Subject
Year Graduated
Diploma/ Certificate
Subject
Year Graduated
Degree
Subject
Year Graduated
Degree
Subject
Year Graduated
Degree
Subject
Year Graduated
Degree
Subject
Year Graduated
Degree
Subject
2017
Diploma
General
* IF YOU NEED TO DOCUMENT MORE EDUCATION ATTACH AN ADDITIONAL SHEET.
Page 10 of 18
SECTION SEVEN- SKILLS
QUESTIONS
1. Are you familiar with the use of
semiautomatic pistols, rifles, and
shotguns?
2. Do you have a TN state issued
handgun permit?
YES
NO
PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
✔
✔
3. Do you know how to operate, speak,
and hear over a police radio?
✔
4. Can you type and use a personal
computer?
✔
5. Can you operate office equipment such
as: Fax, Scanner, Copier, etc.
✔
6. Are you familiar with using Excel
spreadsheets and Word documents?
✔
7. Have you ever spoken to a group or
conducted a presentation?
✔
8. Do you speak any foreign languages
and how fluent are you?
✔
9. Are you able to read and write complex
reports?
✔
10. Do you have any special skills and
qualifications related to the position
you are applying that we need to know
about?
✔
Page 11 of 18
SECTION EIGHT- MILITARY SERVICE
QUESTIONS
YES
1. Are you registered with the
Selective Service?
✔
2. Have you ever been a member of
the US Military?
✔
3. Can you provide your military dates
of service?
✔
4. Can you describe your Jobs,
Duties, and Assignments?
✔
5. Have you ever been a member of
the Reserves, National, or State
Guard?
6. Do you currently have any military
service obligations?
7. Can you provide your current
Military Unit and duty station?
NO PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
NOTE- All males 18-25 years of age are required to be
registered for the military draft.
✔
✔
✔
8. Can you provide a DD 214 or NBG
22 regarding your military service?
9. Have you ever been convicted of a
criminal offense by a military court?
✔
10. Did you receive an Honorable
Discharge upon your release from
service?
✔
Page 12 of 18
SECTION NINE- FINANCIAL HISTORY
QUESTIONS
YES
NO
1. Do you know your current credit
score?
✔
2. Have you ever filed/ declared
bankruptcy?
✔
3. Do you have any wage
garnishments on your income?
✔
4. Do you have any civil law suit
judgments against you?
✔
5. Do you have any tax liens against
you?
✔
6. Have you ever owned a business?
✔
7. Do you pay child support –alimony
payments?
✔
8. Are you behind on any payments,
loans, or arrears in child support?
✔
9. Do you owe any student loans?
10. Do you owe any court fees, traffic
violation -parking fines?
PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
✔
✔
Page 13 of 18
SECTION TEN- DRIVING HISTORY
QUESTIONS
YES
1. Do you have a valid TN Driver’s
License?
✔
NO
(Provide the number and state of issue)
2. Have you ever had your Driver’s
license suspended?
✔
3. Have you ever had your Driver’s
License revoked?
✔
4. Have you ever been cited for a
speeding violation?
✔
5. Have you ever been cited for a nonmoving violation?
✔
6. Have you ever been cited for a
reckless driving violation?
✔
7. Have you ever been cited or
assessed points for a traffic crash?
✔
8. Have you ever been arrested for
Driving under the influence of
alcohol or drugs?
9. Have you ever been cited for a
traffic violation in another state?
10. Have you ever been court ordered
to attend a traffic safety/ driving
course?
PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
✔
✔
✔
Page 14 of 18
SECTION ELEVEN- ALCOHOL AND DRUG USE
QUESTIONS
1. Do you consume alcoholic beverages
and how often?
2. Have you ever been treated for
abuse of alcohol or drugs?
3. Have you ever sold any illegal drugs?
YES
NO
✔
✔
✔
4. Have you used any illegal drugs
within the past 7 years?
✔
5. Have you used any illegal drugs more
than five times?
✔
6. Have you ever used prescription
drugs not prescribed to you?
✔
7. Have you used Marijuana within 2
years?
✔
8. Have you ever used Heroin, LSD,
PCP, Meth, or Crack Cocaine?
✔
9. Have you ever used stimulants,
sedatives, hallucinogens, or opoid
pain drugs for recreation?
10. Have you ever inhaled glue,
refrigerant, paint thinner, aerosols, or
gases, for recreation?
PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
✔
✔
Page 15 of 18
SECTION TWELVE- CRIMINAL HISTORY
QUESTIONS
YES NO PLACE AN X IN YES OR NO BOX .
TYPE OR PRINT YOUR EXPLANATIONS BELOW.
1. Have you ever been indicted by a
grand jury or convicted of a crime?
✔
2. Have you ever pled guilty to a
crime?
✔
3. Have you ever pled “No Contest” or
“Nolo Contendere” to a crime?
✔
4. Have you ever had an order of
protection or restraint order placed
against you?
5. Have you ever been arrested for a
felony crime?
6. Have you ever been arrested
for using force or violence?
7. Have you ever been arrested for
theft, dishonesty, gambling, bribery,
or abuse of authority?
8. Have you ever been arrested for a
crime re: liquor, alcohol, or drugs?
✔
✔
✔
✔
✔
9. Have you ever been arrested for a
sex crime?
✔
10. Have you ever been arrested for
criminal impersonation, tamper/
destroy govt. records, or misuse of
official information?
✔
Page 16 of 18
Authorization to Release Information
To whom it concerns, I authorize the complete release of records or data pertaining to me
which an individual, company, firm, corporation or public agency may have. I hereby
authorize and request any present or former employer, school, police department,
financial institution or other persons having knowledge of my reputation and character,
my marriage status, family members, employment records, school records, financial
records, credit report, medical records, psychiatric records, driving records, criminal
history records, and any other information needed to furnish the Madison County
Sheriff’s Office or its designated agents with any and all information in their possession
to determine my qualifications and fitness in considering my application of employment.
Authorization of Employment Background Check
I authorize the Madison County Sheriff’s Office to conduct a thorough investigation of my
background for employment purposes. I also release Madison County Sheriff’s Office and
its agents, officials, including officers, employees or related personnel, both individually
and collectively, from any and all liability for damages of whatever kind, which may at
anytime result to me, my heirs, family or associates as a result of this investigation. I
understand that all information, reports, and other materials obtained are the property
of the Madison County Sheriff’s Office and make no claims of ownership. I also
understand that all information and sources of information will remain confidential.
Affirmation of Truth
I affirm that all information provided by me in this employment application is
complete, accurate, and truthful to the best of my knowledge. I also understand
and consent to immediate disqualification or discharge from employment if any
omissions, misrepresentations, or false statements are found.
Michael Trimm
09/10/2022
Applicant printed name__________________________________
Date___________________
*notary public must witness signature
Applicant signature_______________________________________ Date___________________
State of Tennessee
County of Madison
On this ________ day of ______________20__________
Before me personally appeared ______________________
To me known to be the person described herein and
who executed the foregoing instrument and
acknowledged that such person (s) executed the same
as such person (s) free act and deed.
Notary Public print________________________________
Notary Public signature__________________________
My Commission Expires____________________________
Page 17 of 18
DOCUMENTS
LIST OF DOCUMENTS
YES
NO
PLACE AN X IN YES OR NO BOX IF YOU
PROVIDED COPIES OF THE DOCUMENT.
1. Photograph
(Current-6 Months)
2. Drivers license(Legible Photocopy)
3. Birth Certificate(Certified Copy)
4. Social Security Card
(Legible Photocopy)
5. Documentation of name change.
(Marriage, Divorce, etc.)
6. Military discharge papers
(DD214 or NGB-22)
7. High School Diploma, Certificate,
or Transcripts
8. College/ University Diploma,
Certificate, or Transcripts
9. P.O.S.T. Certification
Documentation.
(Out of State Officers need LE
Curriculum from their State)
Academy
10. Credit Report
(Current- 6 Months And Show Score)
*ATTACH DOCUMENTS TO BACK OF THIS SHEET.
Page 18 of 18
Voluntary Self-Identification of Disability
Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 05/31/2023
Name:
Employee ID:
Date:
09/10/2022
(if applicable)
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people
with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals
with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability.
Because a person may become disabled at any time, we ask all of our employees to update their information at least
every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer
will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel
decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in
the past. For more information about this form or the equal employment obligations of federal contractors under Section
503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs
(OFCCP) website at www.dol.gov/ofccp.
How do you know if you have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially
limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities
include, but are not limited to:
•
•
Autism
Autoimmune disorder, for example,
lupus, fibromyalgia, rheumatoid
arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
•
•
•
•
•
•
•
•
•
•
•
Deaf or hard of hearing
Depression or anxiety
Diabetes
Epilepsy
Gastrointestinal disorders, for
example, Crohn's Disease, or
irritable bowel syndrome
Intellectual disability
•
•
•
Missing limbs or partially missing
limbs
Nervous system condition for
example, migraine headaches,
Parkinson’s disease, or Multiple
sclerosis (MS)
Psychiatric condition, for example,
bipolar disorder, schizophrenia,
PTSD, or major depression
Please check one of the boxes below:
☐
☐
☐
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
I Don’t Wish To Answer
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond
to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5
minutes to complete.
For Employer Use Only
Employers may modify this section of the form as needed for recordkeeping purposes.
For example:
Job Title: _______________
Date of Hire: _______________
EEO Candidate Voluntary Self-Identification
Madison County Sheriff's Office
The Madison County Sheriff's Office believes that all persons are entitled to equal employment opportunities and we do
not discriminate against our employees, applicants, or job seekers because of race, color, gender, religion, national origin,
disability, veteran status, age, marital status, or any other protected group status as defined by the laws. In order to comply
with the laws, we invite you to voluntarily self-identify your race/ethnicity and gender. Please complete the information
below, which includes the option to choose not to self-identify, and return with your application.
This information will be kept confidential and separate from the application for employment. Your submission of this
information is entirely voluntary and refusal to provide it will not influence our screening or hiring decisions.
Name:_________________________________________________________
Date:_________________________
Position Applied For:____________________________________________________________________________
Referral Source:
□ Internal (Current Employee)
□ Employment Agency
mcso-tn.org
□ Chemonics.com
□ Friend
□ Relative
□ Other: _______________________________________
(please specify)
□ I do not wish to complete the information requested below.
Sex:
Race/Ethnicity:
□ Female
□ Male
□ Hispanic/Latino
□ Black/African American
□ White
□ American Indian/Alaskan Native
□ Asian
□ Native Hawaiian or Other Pacific Islander □ Two or More Races (Not Hispanic or Latino)
Race/Ethnic Definitions:
• Hispanic/Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race.
• Black/African American (not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.
• White (not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
• American Indian/Alaskan Native (not Hispanic or Latino): A person having origins in any of the original peoples of
North and South America (including Central America) and who maintain tribal affiliation or community attachment.
• Asian (not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
• Native Hawaiian or Other Pacific Islander (not Hispanic or Latino): A person having origins in any of the peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
• Two or More Races (not Hispanic or Latino): A person who identifies with two or more race categories named above.