Application for Employment  Please Print  Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation tot the  application and/ori interview process should notify a representative of the Human Resources Department.  Position(s) applied for Name Address Telephone # (  Date ofa application, Applicant ID#  Last  First  Middle City E-mail Address  Street  State  ZIPC Code Yes ONo OYes No Yes ONo OYes ONo Educational Co-Op  Cellular/Other: #  Referral Source (How didy you hear about us?).  Ify you are under 18 and iti is required, can you furnish a work permit? Have you ever been employed herel before? Ify yes, give dates and positions: Ify yes, additionali information may be requested. Arey you legally eligible for employment in this country?. Date available for work. Type of employment desired: Full-Time  If no, please explain:  Ist this application a request for reemployment: following an extended military leave ofa absence from this company?  What is your desired salary rangel.  Part-Time  Temporary  OSeasonal  Arey you able toj perform the "essential functions" of thej job for which you are applying (with or without reasonable accommodation) This question is not designed to elicit information about an applicant's disability. Please dor not provide information about the existence ofac disability, particulara accommodation, or whether accommodation is necessary. Thesei issues may be addressed atal later stage tot the extent permitted by law. Answering "yes" to either part of the following question does not constitute an automatic bar to employment. Factors such as date oft the offense,  Yes No Need more: information about thej jobs "essential functions" to respond Driver's license number required if driving may be required in thej jobf for which you are applying: seriousness and nature of the violation, rehabilitation and position applied for will bet takeni into account. Have you ever pleaded "guilty" or "no contest" to, or been convicted of, a crime?..  State_ Yes ONo  Ifyes, please provide date(s) and details: Employment History Employer Street address, Starting jobt title/final jobt title Immediates supervisora andt titie (forn most recent position held) Why.d didy youl leave? Summarize the type of work performed and jobr responsibilities. Employer. Street address Starting job! tite/final job title Immediates supervisora andt title (forn mostr recent position held) Why didy youl leave? Summarize thet type ofworkp performed andj jobr responsibilities. Employer Streeta address Startingj jobt title/final jobt title Immediate supervisor andt title (forn mostr recent position held) Why didy youl leave? Summarize thet type of work performed andj job responsibilities.  Starting with your most recent employer, provide the following information.  Telephone# City  Dates employed: Month Compensation (Starting) Hourtly Osalay Commision/omuyptier Compensation $ Compensition.(finay Salay Commisien/Pomusypihert Compensation Dates employed: Month Hourly Commision/Bonu/Dther Compensation $ Commisian/Bonus/Other Compensation $ Dates employed: Month Hourly Salary Commision/Ponuypther Compensation $ Commision/Bomusyptier Compensation $  Month  State Mayw wecontact forr reference? Yes: No Later Hourly E-mail: Telephone# Gity  to Month  State Mayy we contactf forre reference? Dyes LNo Later Hourly Salary E-mail: Telephone# # City  Compensation (Starting) Salary Compensation (Final)  per per Year per  Year Compensation (Starting) sation(Final)  State Maywe contactf forn referenice? Yes LNo Later Hourly Salary E-mail:  ANE EQUAL OPPORTUNITY EMPLOYER    Skills and Qualifications  Summarize any special training, skills, licenses and/or certificates that may assist youi inj performing the position for which you are: applying:  Computer Skills (Check appropriate boxes. Include software titles and years of experience.)  Word Processing OSpreadsheet Presentation, Educational Background  Years: Years: Years:  E-mail Internet DOther  Years: Years: Years:  Starting with your most recent school attended, provide the following information.  School (include City & State)  Completed Years  Completed Diploma OGED Degree Certification Other Diploma OGED Degree Certification Other Diploma OGED Degree Certification_ Other  Class GPA Rank Major/Minor  References  List names and telephone numbers of three business/work references who are not related to) you and are not previous supervisors.  If not applicable, list three school or personal references who are not related to) you.  Name  Title  Relationship toYou  Telephone  E-mail  #of Known Years  Social Security Number Applicant Statement  SS#  We will uset chis information only for employment purposes and make reasonable efforts tos safeguard your privacy.  Icertify that alli information. Ihave provided inc order to apply fora ands secure work with this employer is true, complete and correct.  Iexpressly authorize, without reservation, the employer, its representatives, employees or agentst to contact and obtaini information: from all references (personal and professional), employers, public agencies, licensing authorities and educational. institutions. andt to otherwise verify thea accuracy ofa alli information provided by mei in this application, resumé orj jobi interview. Ihereby waive: any and: all rights and claimsl I may! have regarding the employer, its agents, employees or representatives, fors seeking, gatheringa and usingt truthful: and non-defamatory. information, ina al lawful manner, int the employment process and all other persons, corporations or organizations for lunderstand that this employer does not unlawfully discriminate! inc employment and no question ont chis application ist used fort the purpose ofl limiting ore eliminating any Iunderstand that this application remains current for only 30 days. Att the conclusion oft that time, ifI have not heard from the employer and stilly wish tob bec considered for Iflam! hired, understand thatI Iam free tor resign at any time, with orv without cause andy with or without prior notice, and the employer reserves thes same. rightt tot terminate. my employment ata anyt time, with or without cause and with or without prior notice, excepta as may be required! byl law. This application does noto constitute an: agreement or contract fore employment fora any specified period or definite duration. I understand that nos supervisor or representative oft the employer isa authorized to make any assurances to the contrary and thati noi implied oral orv written agreements contraryt tot thef foregoinge express language are valid unlesst theya arei in writing and signed by the employer's president. Ialso understand thati ifI am! hired, Iwill ber required top provide proof ofi identity andl legal authorization to work int the United States andt that federali immigration laws This Company does not tolerate unlawful discrimination, ini its employment practices. No question ont this application. is used fort the purpose oflimiting ore excluding ana applicant from consideration: fore employment ont thel basis ofhis orl her sex, race, color, religion, national origin, citizenship, age, disability, ora any other protected status under applicable federal, state, orl local law.' This Company) likewise does not tolerate! harassment based ons sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints ofh harassment seriously and all complaints will bei investigated promptly and thoroughly. Iunderstand that any information provided byr me thati is found to bef false, incomplete orr misrepresented in any respect, will bes sufficient cause to (i) eliminate me from further consideration for employment, or (i) may result inr myi immediate discharge from the employer's service, whenever itis discovered. DOI NOT SIGN UNTILYOU HAVE READTHE, ABOVE. APPLICANT STATEMENT. Icertify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.  furnishing suchi information about me.  applicant from consideration: fore employment on: any basis prohibited by applicable local, state or federall law.  employment, itv willb ber necessary for met tor reapply and fill out a new application.  require me to complete anl I-91 Form int this regard.  Signature of Applicant Neil 800-999-9111 vgpalcomoroader.  Date  02008G.Neil 7201 InternationalP Parkway, Sunrise, FL3 33325 Apliationf for Emplayment (ShorF Form)a ARB-A1064  G.Neila assumes non responsibility! fort thee employerisu useofthis formo oranyd decisiond cheemplayern makes thatm mayv violarelocal,s sateorfederallaw. Bysellingthis form, GNeilisnorg givinglegala advice Thepurchasero ofthis formis lisglanteda alimitedli licenseo top photocopy checompletedf formf foritsinternalu useonly. Anye otherp photocopyingorre reproducingina any form, whetheri wholeori rimpart, isstrictly prohibited.    Crowley County Sheriff Office 110 East 6th Ordway, Co 81063 phone: 719-267-5555 Fax: 719-267-3089 AUTHORITY FOR RELEASE OF INFORMATION  Last Name Place of Birth  First Name  Middle Name  Sex Race State  Date of Birth SSN:  City  Country  do hereby authorize a review of and full disclosure of all records, or any part  thereof concerning myself, by and to ANY duly authorized agent of the Crowley County Sheriff Office, whether the said The intent oft this authorization is to give.my consent for full and complete disclosure of the records of educational institutions: financial or credit institutions, including records of deposits, withdrawals and balances of checking and savings accounts, and loans, and also the records of.commercial or retail creditagencies (including credit reports and lor ratings); public utility companies; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me, and salary reçords; real and personal property tax statements and records, and other financial statements and reçords wherever filed; records of complaint, arrest, trial and/or çonvictions for alleged or actual violations of law, including criminal, civil and/or traffic records; the results of any polygraph examinations; records of complaint of a civil nature made by or against me, wheresoever located, and toi include the records and pecollections of attorneys at law, or of other counsel, whether, representing me or another person in any case in whichl reiterate, and emphasize that the intent of this authorization is to provide full and free access to the background. and history of my personal life, for the specific purpose of pursuing a background investigation which may provide pertinent data fort the Crowley County Sheriff Office to consider in determining my suitabilityfor employment by that department. It Is my specific intent to provide access to personal information, however personal or confidential itr may appear to be, and lunderstand 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 omployment by the Crowley County Sheriff Office. lunderstand that all materials pertaining to this background nvestigation becomes the property of the Crowley County Sheriff Office and will not be returned to me.  records are of public, private or confidential nature.  presently have, or have had a interest.  the sources ofi information specifically identified herein.  agree to indemnify, and hold harmless the person to, whom this request is presented and his agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out oforby reason of zomplying with this request. Tfurther understand that in the event my application is disapproved, the sources of photocopy of this release form will be valid. as an original hereof, even though the sald photocopy does not contain an  zonfidential information cannot be revealed to me.  priginal writing of my signature.  MUST BE SIGNED IN THE PRESENCE OF A NOTARY: Subscribed and sworn before me this  Signature: Street Address: City:  day of.  20_  My commission expires  20_  Notary:  State:  Zip Code: