PUBLIC SAFETY EMPLOYMENT PACKAGE - _ 9-1-1 _FIRE/EMS - Pickens County Georgia
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PUBLIC SAFETY
EMPLOYMENT
PACKAGE
APPLYING FOR
_____ 9-1-1 _____FIRE/EMS
Revised 05/27/2014
EMPLOYMENT REQUIREMENTS Must be at least 18 years of age Must have a high school diploma from an accredited high school or an equivalency from an accredited program. FIRE/EMS applicants must have a current Georgia Firefighter Certification, and EMT I, or EMT A, (Emergency Medical Technician Intermediate or Advanced). Must possess or obtain a valid Georgia Driver’s License; Class E or F is required for FIRE/EMS. Pass a background check to include Criminal and Driving History. Pass a drug screening Pass a physical agility test.
PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
APPLICATION #: ________________________
____________________________________________________________________________
LAST NAME FIRST NAME MIDDLE NAME
_____________________________________________________________________________
MAILING ADDRESS
______________________________________________________________________________
CITY STATE ZIP CODE
__________________________________________________________________________________
_____________________________ ____________________________
RESIDENCE TELEPHONE CELLULAR TELEPHONE
_____________________________ ____________________________
BUSINESS TELEPHONE PAGER NUMBER
_____________________________ ____________________________
OTHER CONTACT NUMBER EMAIL ADDRESS
AN EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION EMPLOYER DRUG FREE WORKPLACE
Signature: ___________________________________ Page 1 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
ITEM # ITEM DESCRIPTION RECEIVED
Required. Must be notarized.
1. Applicant Questionnaire
Do not include a photo or thumb print.
2. Birth Certificate Required. Must submit a copy of Birth Certificate.
3. Verification of Naturalization If applicable
Photocopy applicable Georgia
4. Required
Certifications
Consent to Release
5. Required. Must be notarized.
Confidential Records
High School Diploma or
6. Required.
Equivalent
If applicable, must submit copies of any documentation that
Legal Name Change
7. shows change of name. (i.e. marriage and/or divorce certificate,
Documentation
etc)
Military Honorable Discharge
8. If applicable
DD214-long form
Photocopy of Social Security
9. Required.
Card
Required. Must be valid. Must be class B or higher for fire
10. Photocopy of Driver’s License
applications.
11. Previous Addresses Required.
Required. Must be current and an original letter.
Three (3) Letters of Photocopies are not accepted. Must be persons other than
12.
Recommendations current or prior supervisor/employer. Include address and
contact number.
__________________________________________ _____________________________________
Date and Time of Return Applicant Signature
_________________________________________ _____________________________________
Date and Time of Receiving Human Resources Signature
Signature: ___________________________________ Page 2 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
POSITION APPLYING FOR: DATE:
GENERAL INSTRUCTIONS: Answer each question. If questions do not apply to you, state N/A. You must sign each page.
If space is insufficient, use a separate sheet and precede each answer with the number of the
referenced block. DO NOT MISSTATE OR OMIT facts since the statements made herein
are subject to verification to determine your qualifications for employment. It is your
responsibility to have ALL three (3) forms at the end of this application notarized prior to its
return.
1. LAST NAME: FIRST NAME: MIDDLE NAME: 2. MALE FEMALE
( ) ( )
3. ALIAS (ES), NICKNAME(S), 4. SOCIAL SECURITY #
MAIDEN NAME, OTHER CHANGES IN NAME:
5. RACE:
6. PRESENT RESIDENCE
ADDRESS STREET CITY/POST OFFICE STATE/ZIP CODE
______________________________________________________________________________________________________
HOW LONG AT PRESENT RESIDENCE? _________ YEARS __________ MONTHS
7. HOW DID YOU LEARN OF OUR POSITION?
8. DATE OF BIRTH (MONTH/DAY/YEAR) PLACE OF BIRTH (CITY/COUNTY/STATE/COUNTY)
9. U.S. CITIZEN NATURALIZED CERT IF DERIVED, PARENT DATE, PLACE, & COURT
YES ( ) NUMBER CERT. NUMBER
NO ( )
10. MARITAL STATUS: ( ) SINGLE ( ) MARRIED ( ) SEPARATED ( ) DIVORCED ( ) WIDOWED
11. RESIDENCE:
LIST ALL RESIDENCES DURING THE LAST 10 YEARS. PLEASE INCLUDE ALL RESIDENCES OUTSIDE THE
UNITED STATES, BEGINNING WITH YOUR PRESENT ADDRESS:
FROM TO STREET & NUMBER CITY COUNTY STATE COUNTRY
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
( ) PLEASE CHECK BOX IF YOU HAVE ATTACHED A SHEET WITH ADDITIONAL INFORMATION.
Signature: ___________________________________ Page 3 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
12. MILITARY STATUS: HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES: YES ( ) NO ( )
IF YES, PLEASE ATTACH A PHOTOCOPY OF DISCHARGE AND SEPERATION PAPERS.
A. PLEASE PROVIDE THE FOLLOWING INFORMATION:
BRANCH DATES OF SERVICE RANK RESPONSIBILITIES
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
B. WHILE IN THE MILITARY SERVICE, WERE YOU EVER GIVEN ANY DISCIPLINARY ACTION OR WERE
YOU EVER A DEFENDANT IN ANY LEGAL PROCEEDING? YES ( ) NO ( )
IF YES, GIVE DATE, PLACE, LAW ENFORCING AUTHORITY OR TYPE OF COURT OR COURT-MARTIAL,
CHARGE, AND ACTION TAKEN FOR EACH INCIDENT, USING A SEPARATE SHEET TO RECORD THIS
INFORMATION.
C. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE U.S. RESERVE OR NATIONAL OR
STATE GUARD? YES ( ) NO ( )
IF YES, PLEASE PROVIDE THE:
BRANCH DATES OF SERVICE RANK RESPONSIBILITIES
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
D. ARE YOU REQUIRED TO ATTEND MILITARY TRAINING MEETINGS? YES ( ) NO ( )
IF YES, EXPLAIN IN DETAIL, INCLUDING DATE OBLIGATION IS COMPLETED:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
E. LIST ANY SPECIALIZED SCHOOLS YOU ATTENDED WHILE IN THE ARMED FORCES.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
F. LIST ALL COMMENDATIONS AND CITATIONS AWARDED TO YOU AS A MEMBER OF THE ARMED
FORCES.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Signature: ___________________________________ Page 4 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
13. SELECTIVE SERVICE:
ARE YOU REGISTERED WITH SELECTIVE SERVICE? YES ( ) NO ( )
SELECTIVE SERVICE NO. : ________________________________________________________________________
DATE REGISTERED: ______________________________________________________________________________
BOARD LOCATION: ______________________________________________________________________________
14. EDUCATION:
A. LIST ALL ELEMENTARY, MIDDLE AND HIGH SCHOOLS (K-12) ATTENDED (INCLUDE EDUCATION OUTSIDE THE
U.S.)
NAME LOCATION DATES ATTENDED YEARS GRADUATED
COMPLETED (YES/NO)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
B. HIGHER EDUCATION. LIST BELOW ALL COLLEGES OR UNIVERSITIES ATTENDED. FORWARD
CERTIFIED TRANSCRIPTS FROM EACH INSTITUTION OF HIGHER EDUCATION ATTENDED.
NAME AND LOCATION OF DATES ATTENDED CREDIT HOURS DEGREE YEAR
COLLEGE OR UNIVERSITY FROM TO SEMESTER/QUARTER REC’D REC’D
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAJOR AND MINOR COURSES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
C. OTHER SCHOOLS OR TRAINING (TRADE, BUSINESS, OR MILITARY). PROVIDE FOR EACH THE NAME
AND LOCATION OF SCHOOL, DATES ATTENDED, SUBJECTS STUDIED, CERTIFICATES, AND ANY OTHER
PERTINENT DATA.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
15. ARE YOU PROFICIENT IN ANY OTHER WORLD LANGUAGE BESIDES ENGLISH?
LANGUAGE:_____________________________ LANGUAGE:_____________________________
( ) READ ( ) WRITE ( ) SPEAK ( ) READ ( ) WRITE ( ) SPEAK
LANGUAGE:_____________________________ LANGUAGE:_____________________________
( ) READ ( ) WRITE ( ) SPEAK ( ) READ ( ) WRITE ( ) SPEAK
Signature: ___________________________________ Page 5 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
16. VEHICLE OPERATOR’S LICENSE(S):
PROVIDE THE FOLLOWING INFORMATION CONCERNING ANY OTHER OPERATOR’S LICENSE(S) YOU
HAVE HELD OR NOW HOLD, IN GEORGIA AND IN OTHER STATES.
KIND OF LICENSE STATE AND NUMBER PLACE ISSUED DATE ISSUED
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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A. DO YOU POSSESS A GEORGIA COMMERCIAL DRIVER’S LICENSE? YES ( ) NO ( )
CLASS: __________ ENDORSEMENTS: ______________ RESTRICTIONS: _______________
LICENSE NUMBER: ______________________________________ EXPIRATION DATE: ___________
B. HAVE YOU EVER BEEN DENIED ISSUANCE OF A LICENSE, HAD A LICENSE SUSPENDED OR HAD A LICENSE
REVOKED FOR ANY REASON? YES ( ) NO ( )
IF YES, EXPLAIN FULLY:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
C. HAVE YOU EVER HAD AUTOMOBILE INSURANCE WITHDRAWN OR REVOKED, OR HAVE YOU EVER
BEEN DENIED AUTOMOBILE INSURANCE? YES ( ) NO ( )
IF YES, GIVE DETAILS, INCLUDING REASONS, NAMES OF COMPANIES, DATES, ETC:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
GIVE NAME AND ADDRESS OF THE INSURANCE COMPANY WITH WHOM YOU NOW HAVE AUTOMOBILE
INSURANCE, INCLUDE AGENT NAME AND NUMBER.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
POLICY NUMBER AND COVERAGE:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: ___________________________________ Page 6 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
17. EMPLOYMENT:
BEGIN WITH YOUR MOST RECENT POSITION AND LIST YOUR WORK HISTORY FOR THE LAST TEN (10)
YEARS, INCLUDING PART-TIME, TEMPORARY OR SEASONAL EMPLOYMENT AND ALL PERIODS OF
UNEMPLOYMENT.
FROM: ____________ TO: ____________ POSITION TITLE: ______________________________________________
(MM/DD/YR) (MM/DD/YR)
EMPLOYER: ______________________________________________ STARTING SALARY: $ ____________per ______
STREET ADDRESS: ________________________________________ FINAL SALARY: $ ________________per_______
CITY & STATE: ___________________________________ NAME OF SUPERVISOR: ____________________________
TELEPHONE NUMBER: ___________________________ NAME OF CO-WORKER: ____________________________
DESCRIPTION OF DUTIES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REASON FOR LEAVING:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAY WE CONTACT THIS EMPLOYER REGARDING YOUR DUTIES AND EMPLOYMENT RECORDS?
YES ( ) NO ( )
_________________________________________________________________________________________
FROM: ____________ TO: ____________ POSITION TITLE: ______________________________________________
(MM/DD/YR) (MM/DD/YR)
EMPLOYER: ______________________________________________ STARTING SALARY: $ ____________per ______
STREET ADDRESS: ________________________________________ FINAL SALARY: $ ________________per_______
CITY & STATE: ___________________________________ NAME OF SUPERVISOR: ____________________________
TELEPHONE NUMBER: ___________________________ NAME OF CO-WORKER: ____________________________
DESCRIPTION OF DUTIES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REASON FOR LEAVING:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAY WE CONTACT THIS EMPLOYER REGARDING YOUR DUTIES AND EMPLOYMENT RECORDS?
YES ( ) NO ( )
Signature: ___________________________________ Page 7 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
FROM: ____________ TO: ____________ POSITION TITLE: ______________________________________________
(MM/DD/YR) (MM/DD/YR)
EMPLOYER: ______________________________________________ STARTING SALARY: $ ____________per ______
STREET ADDRESS: ________________________________________ FINAL SALARY: $ ________________per_______
CITY & STATE: ___________________________________ NAME OF SUPERVISOR: ____________________________
TELEPHONE NUMBER: ___________________________ NAME OF CO-WORKER: ____________________________
DESCRIPTION OF DUTIES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REASON FOR LEAVING:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAY WE CONTACT THIS EMPLOYER REGARDING YOUR DUTIES AND EMPLOYMENT RECORDS?
YES ( ) NO ( )
_________________________________________________________________________________________
FROM: ____________ TO: ____________ POSITION TITLE: ______________________________________________
(MM/DD/YR) (MM/DD/YR)
EMPLOYER: ______________________________________________ STARTING SALARY: $ ____________per ______
STREET ADDRESS: ________________________________________ FINAL SALARY: $ ________________per_______
CITY & STATE: ___________________________________ NAME OF SUPERVISOR: ____________________________
TELEPHONE NUMBER: ___________________________ NAME OF CO-WORKER: ____________________________
DESCRIPTION OF DUTIES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REASON FOR LEAVING:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAY WE CONTACT THIS EMPLOYER REGARDING YOUR DUTIES AND EMPLOYMENT RECORDS?
YES ( ) NO ( )
Signature: ___________________________________ Page 8 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
FROM: ____________ TO: ____________ POSITION TITLE: ______________________________________________
(MM/DD/YR) (MM/DD/YR)
EMPLOYER: ______________________________________________ STARTING SALARY: $ ____________per ______
STREET ADDRESS: ________________________________________ FINAL SALARY: $ ________________per_______
CITY & STATE: ___________________________________ NAME OF SUPERVISOR: ____________________________
TELEPHONE NUMBER: ___________________________ NAME OF CO-WORKER: ____________________________
DESCRIPTION OF DUTIES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REASON FOR LEAVING:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAY WE CONTACT THIS EMPLOYER REGARDING YOUR DUTIES AND EMPLOYMENT RECORDS?
YES ( ) NO ( )
_________________________________________________________________________________________
FROM: ____________ TO: ____________ POSITION TITLE: ______________________________________________
(MM/DD/YR) (MM/DD/YR)
EMPLOYER: ______________________________________________ STARTING SALARY: $ ____________per ______
STREET ADDRESS: ________________________________________ FINAL SALARY: $ ________________per_______
CITY & STATE: ___________________________________ NAME OF SUPERVISOR: ____________________________
TELEPHONE NUMBER: ___________________________ NAME OF CO-WORKER: ____________________________
DESCRIPTION OF DUTIES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REASON FOR LEAVING:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MAY WE CONTACT THIS EMPLOYER REGARDING YOUR DUTIES AND EMPLOYMENT RECORDS?
YES ( ) NO ( )
( ) PLEASE CHECK BOX IF YOU HAVE ATTACHED A SHEET WITH ADDITIONAL EMPLOYMENT
INFORMATION
Signature: ___________________________________ Page 9 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
18. HAVE YOU EVER BEEN FIRED, ASK TO RESIGN, QUIT, RESIGNED IN LIEU OF DISCHARGE, LAID OFF, OR
SUBJECTED TO DISCIPLINARY ACTION WHILE IN ANY POSITION, EXCEPT THE MILITARY?
YES ( ) NO ( )
IF YES, STATE CIRCUMSTANCES:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
19. LITIGATION RECORD: CRIMINAL RECORDS WILL BE CHECKED. INFORMATION CONCERNING
CONVICTIONS WILL NOT NECESSARILY DISQUALIFY AN APPLICANT UNLESS THE CONVICTION RECORD
INDICATES THAT THE APPLICANT WOULD NOT BE SUITABLE OR DESIRABLE FOR EMPLOYMENT IN A
PARTICULAR POSITION OR PER STATE STATUES FOR FIREFIGHTERS, PARAMEDICS, EMT’S AND DISPATCHERS.
A. HAVE YOU EVER BEEN ARRESTED? YES ( ) NO ( )
IF YES, PLEASE LIST BELOW THE DATE, PLACE AND FULL DETAILS OF EACH INCIDENT.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
B. HAVE YOU EVER BEEN CONVICTED, PLED NOLO CONTENDERE (NO CONTEST), PLED GUILTY OR BEEN
FOUND GUILTY OF A FELONY OR A MISDEMEANOR, INCLUDING ANY INSTANCES WHERE THE
CONVICTION, PLEA OF NOLO CONTENDERE, GUILTY PLEA, OR ADJUDICATION OF GUILT HAS BEEN
EXPUNGED FROM YOUR RECORD? YES ( ) NO ( )
IF YES, PLEASE LIST BELOW THE DATE, PLACE AND FULL DETAILS OF EACH INCIDENT.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
ACIRCUMSTANCES:
: ___________________________________________________________________________________________
C. HAVE YOU EVER BEEN PLACED ON PROBATION FOR A CRIMINAL MATTER BY A FEDERAL, STATE, OR
___________________________________________________________________________________________
LOCAL COURT IN THE UNITED STATES OR ANY OTHER COUNTRY? YES ( ) NO ( )
___________________________________________________________________________________________
IF YES, PLEASE LIST BELOW THE DATE, PLACE AND FULL DETAILS OF EACH INCIDENT.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
D. HAVE YOU EVER BEEN INVOLVED IN ANY COURT ACTION, CIVIL OR CRIMINAL, EXLUDING EMPLOYMENT
DISCRIMINATION CLAIMS AND CLAIMS OF A SIMILAR NATURE? INCLUDE ALL TRAFFIC VIOLATIONS,
PARKING, ETC., IN THIS STATE OR ELSEWHERE? YES ( ) NO ( )
IF YES, PLEASE LIST BELOW THE DATE, PLACE AND FULL DETAILS OF EACH INCIDENT.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
20. DO YOU CURRENTLY USE OR HAVE YOU EVER USED ANY ILLEGAL DRUGS OR ANY PRESCRIPTION
MEDICATION WITHOUT A DOCTOR’S PRESCRIPTION? YES ( ) NO ( )
IF YES, PLEASE LIST BELOW.
___________________________________________________________________________________________
Signature: ___________________________________ Page 10 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
21. CHARACTER REFERENCE:
LIST FIVE (5) CHARACTER REFERENCES. LIST ONLY CHARACTER REFERENCES WHO HAVE DEFINITE
KNOWLEDGE OF YOUR QUALIFICATIONS AND FITNESS FOR THE POSITION FOR WHICH YOU ARE
APPLYING, AND HAVE KNOWN YOU FOR THE PAST FIVE (5) YEARS. (DO NOT INCLUDE RELATIVES,
FORMER OR CURRENT EMPLOYERS OR SUPERVISORS, SIGNIFICANT OTHERS OR PERSONS LIVING OUTSIDE
THE UNITED STATES OR IT’S TERRITORIES). NOTE: REFERENCES WILL BE CONTACTED.
COMPLETE NAME: HOME ADDRESS:
EMAIL ADDRESS: CITY, STATE & ZIP CODE
OCCUPATION: HOME PHONE:
YEARS KNOWN: ALTERNATE PHONE:
COMPLETE NAME: HOME ADDRESS:
EMAIL ADDRESS: CITY, STATE & ZIP CODE
OCCUPATION: HOME PHONE:
YEARS KNOWN: ALTERNATE PHONE:
COMPLETE NAME: HOME ADDRESS:
EMAIL ADDRESS: CITY, STATE & ZIP CODE
OCCUPATION: HOME PHONE:
YEARS KNOWN: ALTERNATE PHONE:
COMPLETE NAME: HOME ADDRESS:
EMAIL ADDRESS: CITY, STATE & ZIP CODE
OCCUPATION: HOME PHONE:
YEARS KNOWN: ALTERNATE PHONE:
COMPLETE NAME: HOME ADDRESS:
EMAIL ADDRESS: CITY, STATE & ZIP CODE
OCCUPATION: HOME PHONE:
YEARS KNOWN: ALTERNATE PHONE:
22. PAST AND/OR PRESENT MEMBERSHIP IN ORGANIZATIONS:
NAME AND ADDRESS TYPE (SOCIAL, OFFICE HELD MEMBERSHIP HELD
FRATERNAL, PROF, ETC.) (FROM-TO)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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Signature: ___________________________________ Page 11 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
23. IS THERE ANY OTHER INFORMATION ABOUT YOU WHICH, IF BE KNOWN, WOULD CAUSE EMBARRASSMENT
TO PICKENS COUNTY? YES ( ) NO ( )
IF YES, GIVE DETAILS:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
24. HAVE YOU EVER APPLIED FOR ANY POSITION WITH ANY OTHER FIRE DEPARTMENT? YES ( ) NO ( )
IF YES, LIST BELOW:
AGENCY DATE APPLIED STATUS OF APPLICATION
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
25. CERTIFICATIONS:
A. WHERE DID YOU OBTAIN YOUR FIREFIGHTER CERTIFICATION?
FIRE ACADEMY NAME: ______________________________________________________
LOCATION OF ACADEMY: ____________________________________________________
SPONSORING DEPARTMENT: __________________________________________________
DATES OF ATTENDANCE: ____________________________________________________
CLASS NUMBER: _____________________________________________________________
GRADUATION DATE: _________________________________________________________
B. WHERE DID YOU OBTAIN YOUR EMT/PARAMEDIC CERTIFICATION?
SCHOOL NAME: ______________________________________________________________
DATES OF ATTENDANCE: _____________________________________________________
TYPE OF CERTIFICATION: _____________________________________________________
GRADUATION DATE: __________________________________________________________
Signature: ___________________________________ Page 12 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
26. HAVE YOU EVER BEEN THE SUBJECT OF ANY INTERNAL AFFAIRS INVESTIGATIONS? YES ( ) NO ( )
IF YES, GIVE DETAILS
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
27. HAVE YOU EVER BEEN COUNSELED, REPREMANDED, OR RECEIVED DISCIPLINE OF ANY KIND?
YES ( ) NO ( )
IF YES, GIVE DETAILS
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
28. MISCELLANEOUS
A. ARE YOU WILLING TO WORK:
ROTATING SHIFT SCHEDULES? YES ( ) NO ( )
EIGHT HOUR DAYS? YES ( ) NO ( )
TWELVE HOUR SHIFTS (9-1-1) YES ( ) NO ( )
WEEKENDS? YES ( ) NO ( )
NIGHTS? YES ( ) NO ( )
HOLIDAYS? YES ( ) NO ( )
B. ARE YOU WILLING TO WEAR UNIFORMS? YES ( ) NO ( )
C. ARE YOU RELATED TO ANYONE CURRENTLY EMPLOYED BY PICKENS COUNTY GOVERNMENT IN
ANY CAPACITY? YES ( ) NO ( )
IF YES, PLEASE PROVIDE THE FOLLOWING INFORMATION:
EMPLOYEE’S NAME: _________________________________________________________________________
RELATIONSHIP: ____________________________ POSITION HELD: _____________________________
EMPLOYEE’S NAME: _________________________________________________________________________
RELATIONSHIP: ____________________________ POSITION HELD: _____________________________
29. REMARKS (ANY COMMENTS YOU THINK ARE IMPORTANT)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: ___________________________________ Page 13 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
30. IN YOUR OWN WORDS, (NO LESS THAN 200 WORDS AND NO MORE THAN 500 WORDS), PLEASE TELL US WHY
YOU CHOSE TO APPLY WITH PICKENS COUNTY FOR THE POSITION OF FIREFIGHTER, EMT/PARAMEDIC OR
COMMUNICATIONS OFFICER?
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Signature: ___________________________________ Page 14 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
31. THIS PAGE HAS BEEN LEFT BLANK FOR YOUR USE TO PROVIDE ADDITIONAL INFORMATION. INDICATE PAGE
NUMBER AND QUESTION NUMBER. IF NO INFORMATION IS PROVIDED IN THIS SPACE, INDICATE BY “N/A”
AND SIGN BELOW
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Signature: ___________________________________ Page 15 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
32. AFFIDAVIT
I, ______________________________________________, AM BEING CONSIDERED FOR EMPLOYMENT FOR THE
POSITION OF _______________________________________________. I UNDERSTAND THAT THE ATTACHED
QUESTIONNAIRE IS CONSIDERED AS PART OF MY OFFICIAL APPLICATION FOR THE ABOVE POSITION.
BY SIGNING THIS DOCUMENT, I HEREBY VERIFY THAT ALL INFORMATION CONTAINED IN THE ATTACHED
QUESTIONNAIRE AND ALL ACCOMPANYING DOCUMENTS SUBMITTED ARE TRUE, ACCURATE AND
COMPLETE TO THE BEST OF MY KNOWLEDGE AND THAT THERE IS NO MATERIAL FALSIFICATION,
MISREPRESENTATION OR OMISSION. I ALSO UNDERSTAND THAT ALL STATEMENTS AND ACCOMPANYING
DOCUMENTS ARE SUBJECT TO INVESTIGATION AND THAT ANY MATERIAL FALSIFICATION,
MISREPRESENTATION, OMISSION OR OTHER UNFAVORABLE INFORMATION DEVELOPED DURING ANY PHASE
OF THE BACKGROUND INVESTIGATION PROCESS OR ANYTIME THEREAFTER, IS SUBJECT CAUSE FOR
IMMEDIATE DISQUALIFICATION, IMMEDIATE DISMISSAL FROM COUNTY SERVICE AND/OR SUBJECT TO
PROSECUTION FOR THE CRIMINAL VIOLATION OF PERJURY AND SPECIFIED IN O.C.G.A. § 16-10-20.
I CONSENT TO SUBMITTING TO THE FOLLOWING BACKGROUND INVESTIGATIVE PROCEDURES WHICH MAY
INCLUDE, BUT NOT LIMITED TO, FINGERPRINT PROCESSING, JOB INTERVIEW, AND OTHER MEANS AS
DEEMED NECESSARY AND PROPER BY PICKENS COUNTY GOVERNMENT TO COMPLETE ITS INVESTIGATION
AS TO MY FITNESS AND SUITABILITY FOR THE POSITION WHICH I HAVE APPLIED. I THOROUGHLY
UNDERSTAND THAT I MUST SUCCESSFULLY COMPLETE THE ABOVE-MENTIONED PROCESS, PER
O.C.G.A. § 20-4-8.
IN THE EVENT THAT I AM OFFERED A POSITION, I UNDERSTAND THAT SUCH OFFER IS CONDITIONED UPON A
MEDICAL, DRUG TEST, EXTENSIVE BACKGROUND CHECK AND ORAL INTERVIEW. I HEREBY CONSENT TO
THE RELEASE OF ALL EVALUATIONS AND TESTING RESULTS, PER O.C.G.A. § 20-4-8.
I UNDERSTAND THAT THE PICKENS COUNTY GOVERNMENT WILL NOT REIMBURSE ANY EXPENSE I MIGHT
INCUR IN SEEKING THIS POSITION OTHER THAN THE REQUIREMENTS UNDER THE CONDITIONAL PHASE. I
RECOGNIZE THAT THE TIME REQUIRED TO PROCESS AND SELECT EMPLOYEES FOR THIS POSITION IS
LENGTHY AND TIME CONSUMING. NO PROMISES OR COMMITMENTS ARE EXPECTED BY ME AS TO A TIME
WHEN A HIRING DECISION AND/OR ACTUAL HIRING MIGHT TAKE PLACE.
I UNDERSTAND AND CONSENT TO ALL OF THE ABOVE STATEMENTS AND CONDITIONS.
_______________________ _____________________________________
DATE APPLICANT SIGNATURE
STATE OF ___________________ (COUNTY OF _______________________)
THE FOREGOING INSTRUMENT WAS EXECUTED BEFORE ME THIS _____ DAY OF ________________________,
20____, BY __________________________________________________, WHO IS PERSONALLY KNOWN BY ME
(OR WHO HAS PRODUCED ____________________________AS IDENTIFICATION) AND WHO TOOK AN OATH.
____________________________ _______________________________________________
NOTARY PUBLIC NAME OF NOTARY
STATE OF ____________________ NOTARY SEAL:
AN EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION EMPLOYER
DRUG FREE WORKPLACE
Signature: ___________________________________ Page 16 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
33. MILITARY RECORDS RELEASE WAIVER
I AUTHORIZE THE NATIONAL PERSONNEL RECORDS CENTER, ST. LOUIS, MO., OR OTHER CUSTODIAN(S) OF
MY MILITARY RECORDS TO RELEASE TO PICKENS COUNTY GOVERNMENT, 1266 EAST CHURCH ST, JASPER,
GA 30143, INFORMATION PERTAINING TO ARTICLE 15 AND COURT MARTIAL HEARINGS. THIS SHALL INCLUDE
A PHOTOCOPY OF MY DD FORMS 214 REPORT OF SEPARATION.
THIS INFORMATION IS TO BE USED TO ASSIST THE DEPARTMENT IN DETERMINING MY QUALIFICATIONS AND
FITNESS FOR THE POSITION THAT I AM SEEKING.
I HEREBY RELEASE YOU, YOUR ORGANIZATION, OR OTHERS FROM ANY LIABILITY OR DAMAGES WHICH
MAY RESULT FROM FURNISHING THE REQUESTED INFORMATION.
_______________________ _____________________________________
DATE APPLICANT SIGNATURE
STATE OF ___________________ (COUNTY OF _______________________)
THE FOREGOING INSTRUMENT WAS EXECUTED BEFORE ME THIS _____ DAY OF ________________________,
20____, BY __________________________________________________, WHO IS PERSONALLY KNOWN BY ME
(OR WHO HAS PRODUCED ____________________________AS IDENTIFICATION) AND WHO TOOK AN OATH.
____________________________ _______________________________________________
NOTARY PUBLIC NAME OF NOTARY
STATE OF ____________________ NOTARY SEAL:
NOTE: IF YOU HAVE NEVER SERVED IN THE MILITARY, THIS FORM DOES NOT NEED TO BE NOTARIZED.
WRITE “N/A” ON APPLICANT’S SIGNATURE LINE AND SIGN BOTTOM OF PAGE.
AN EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION EMPLOYER
DRUG FREE WORKPLACE
Signature: ___________________________________ Page 17 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
ATTESTMENT OF MILITARY SERVICE
1.) I, _________________________________, do attest that I have never served in
the Armed Forces of the United States.
______________________________________ ________________________
Applicant’s Signature Date
2.) I, _________________________________, do attest that I have served in the
Armed Forces of the United States.
______________________________________ ________________________
Applicant’s Signature Date
STATE OF ___________________ (COUNTY OF _______________________)
THE FOREGOING INSTRUMENT WAS EXECUTED BEFORE ME THIS _____ DAY OF ________________________,
20____, BY __________________________________________________, WHO IS PERSONALLY KNOWN BY ME
(OR WHO HAS PRODUCED ____________________________AS IDENTIFICATION) AND WHO TOOK AN OATH.
____________________________ _______________________________________________
NOTARY PUBLIC NAME OF NOTARY
STATE OF ____________________ NOTARY SEAL:
Signature: ___________________________________ Page 18 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
34. APPLICANT CERTIFICATION – READ CAREFULLY BEFORE SIGNING:
I hereby certify that I have sincere interest in obtaining this position and that each answer to questions herein and all other
information otherwise furnished is true and correct. I understand that any incorrect, incomplete, or false statements of information
furnished may subject me to disqualification or discharge at any time.
Signature of applicant: _________________________________________________ Date: _______________________
Signature: ___________________________________ Page 19 of 20PICKENS COUNTY, GEORGIA
PUBLIC SAFETY EMPLOYMENT QUESTIONNAIRE
CONSENT TO RELEASE CONFIDENTIAL RECORDS AND INFORMATION
As a person applying for a position with Pickens County Government in the Public Safety Department, I
hereby consent to a routine background investigation conducted by the department. In connection with
this investigation, I consent to the release of any and all records and information concerning me, to the
department upon the department’s request.
This consent includes release of all records and information concerning me to the full extent permitted by
law, including the release of all confidential records and information that may not be released without my
prior written consent.
I understand that such records and information may include, but is not necessarily limited to: reasons for
termination of employment, including military service, criminal history, on the job performance,
educational records, and/or any other personal information which may not be otherwise obtained without
my prior written consent.
____________________________________________________________________________________
SIGNATURE: _________________________________________________
PRINT NAME: _________________________________________________
DATE SIGNED: _________________________________________________
SOCIAL SECURITY #: _________________________________________________
DRIVERS LICENSE #: _________________________________________________
STATE OF ___________________ (COUNTY OF _______________________)
THE FOREGOING INSTRUMENT WAS EXECUTED BEFORE ME THIS _____ DAY OF ________________________,
20____, BY __________________________________________________, WHO IS PERSONALLY KNOWN BY ME
(OR WHO HAS PRODUCED ____________________________AS IDENTIFICATION) AND WHO TOOK AN OATH.
____________________________ _______________________________________________
NOTARY PUBLIC NAME OF NOTARY
STATE OF ____________________ NOTARY SEAL:
Signature: ___________________________________ Page 20 of 20You can also read
