Full Text
PUBLIC SAFETY EMPLOYMENT PACKAGE APPLYING FOR 9-1-1 _____FIRE/EMS Revised February 16, 2023 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE LAST NAME FIRST NAME MIDDLE NAME MAILING ADDRESS CITY STATE ZIP CODE PRIMARY PHONE NUMBER ALTERNATE PHONE NUMBER EMAIL ADDRESS INITIALS: 1 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE ITEM # RECEIVED 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Date and Time of Return Applicant Signature Date and Time of Receiving Human Resources Signature Birth Certificate Applicant Questionnaire ITEM Military Discharge DD-214 High School Diploma or Equilivent Consent to Release Confidential Records Certifications Verification of Naturalization DESCRIPTION 3 REQUIRED - Must be current and an original letter. Photocopies are not accepted. Must be persons other than current or prior supervisor/employer. Include address and contact number. REQUIRED - Photocopies are acceptable. Must be valid REQUIRED - Photocopies are acceptable LONG FORM REQUIRED - If applicable REQUIRED - Photocopies are acceptable REQUIRED - MUST BE NOTARIZED REQUIRED - Photocopies are acceptable If Applicable REQUIRED - Must submit a copy of birth certificate REQUIRED - MUST BE NOTARIZED Letters of Recommendations Drivers License Social Security Card INITIALS: 2 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE GENERAL INSTRUCTIONS: 1. LAST NAME: FIRST NAME: MIDDLE NAME: 2. SEX: 3. ALIAS(ES), NICKNAME(S) MAIDEN NAMES, OTHER CHANGES IN NAME: 4. SOCIAL SECURITY NUMBER: 5. RACE: 6. CURRENT ADDRESS: ADDRESS STREET CITY STATE ZIP CODE HOW LONG AT PRESENT RESIDENCE? 7. CAN YOU, IF HIRED, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES: NO 8. RESIDENCE: List all residences during the past 10 years, beginning with the most current. FROM: TO: ADDRESS CITY STATE COUNTRY NOTICE TO APPLICANTS AND EMPLOYEES Pickens County is a Drug-Free Workplace. Screening tests for alcohol and illegal drug use may be required before and during your employment here. Answer each question. If questions do not apply to you, state N/A. You must initial 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 statements made herein are subject to verification to determine your qualifications for employment. It is your responsibility to have this application notarized in the required places. AN EQUAL OPPORTUNITY EMPLOYER It is our policy to comply fully with all federal, state and local equal employment opportunity laws. This organization provides equal employment and advancement opportunities for all persons regardless of race, creed, gender, national origin, age, religion, disability or any other classification protected by law. DATE: POSITION APPLYING FOR: INITIALS: 3 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE 9. 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. INITIALS: 4 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE 10. EDUCATION: A. HIGH SCHOOL DIPLOMA OR EQUILIVANT? YES ( ) NO ( ) B. HIGHER EDUCATION. LIST BELOW DEGREES OBTAINED. 11. CERTIFICATIONS: List all certifications (i.e. FF1, Haz-Mat, EMT-A, EMT-P and numbers for each) pertinent to the job applying for: 12. MISCELLANEOUS A. ARE YOU WILLING TO WORK: ROTATING SHIFT SCHEDULES YES ( ) NO ( ) 12 HOUR SHIFTS? (911 APPLICANTS) 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: INITIALS: 5 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE 13. REFERENCES 14. EMPLOYMENT HISTORY TO: POSITION TITLE: EMPLOYER: SALARY: ADDRESS: SUPERVISOR: PHONE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: 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. NAME: NAME: HOME ADDRESS: YEARS KNOWN: ALTERNATE PHONE: NAME: HOME ADDRESS: EMAIL ADDRESS: CITY STATE ZIP: OCCUPATION: PHONE NUMBER: LIST THREE 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 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. ALTERNATE PHONE: PHONE NUMBER: CITY STATE ZIP: HOME ADDRESS: YEARS KNOWN: EMAIL ADDRESS: CITY STATE ZIP: OCCUPATION: PHONE NUMBER: YEARS KNOWN: ALTERNATE PHONE: OCCUPATION: EMAIL ADDRESS: INITIALS: 6 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE TO: POSITION TITLE: EMPLOYER: SALARY: ADDRESS: SUPERVISOR: PHONE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: TO: POSITION TITLE: EMPLOYER: SALARY: ADDRESS: SUPERVISOR: PHONE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: TO: POSITION TITLE: EMPLOYER: SALARY: ADDRESS: SUPERVISOR: PHONE: DESCRIPTION OF DUTIES: REASON FOR LEAVING: INITIALS: 7 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE 15. SIGNATURE: PRINT NAME: DATE SIGNED: SOCIAL SECURITY DRIVERS LICENSE DATE OF BIRTH: STATE OF (COUNTY OF THE FOREGOING INSTRUMENT WAS EXECUTED BEFORE ME THIS DAY OF BY WHO IS PERSONALLY KNOWN BY ME (OR WHO HAS PRODUCED IDENTIFICATION) AND WHO TOOK AN OATH. NOTARY PUBLIC NAME OF NOTARY STATE OF NOTARY SEAL: 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. INITIALS: 8 ---PAGE BREAK--- PICKENS COUNTY, GEORGIA PUBLIC SAFETY EMPLOYMENT QUESTIONAIRE 16. REMARKS - ANY PERTINANT INFORMATION FOR US TO KNOW. 17. APPLICANT CERTIFICATION - READ CAREFULLY SIGNATURE OF APPLICANT: DATE: I understand all offers of employment are conditional upon satisfactory reference checks, successful completion of all pre-employment tests, including alcohol and illegal drug testing and production of all documents necessary for the employer to verify my identity and work authorization in accordance with the requirements of the Immigration and Naturalization Services. As an employer, this organization is subject to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Applicants who believe they are covered by these Acts are invited to identify their disabilities and special accommodations they feel are necessary to adequately perform their jobs. Submission of this information is strictly voluntary and may be made to the Human Resources Director. I certify the information provided in this application is true and complete to the best of my knowledge. I understand withholding pertinent information or submitting false or misleading information on this application, my resume, during interviews or at any other time during the hiring process constitutes valid grounds for disqualification from further consideration for hire or immediate dismissal from employment and loss of all employee benefits and privileges. I further understand and agree that the employer shall not be liable in any respect if my employment is so denied or terminated. I understand the acceptance of this application by the employer neither expresses nor implies I will be offered employment. I understand my employment is at will and I may resign at any time for any reason; similarly, my employment may be terminated by the county at any time without cause. Any changes to this at-will employment agreement will not be valid unless in writing signed by me and a duly authorized representative of this employing organization. INITIALS: 9 FIRE APPLICANTS STOP HERE ---PAGE BREAK--- PICKENS COUNTY 9-1-1 STANDARD OPERATING PROCEDURES POLICY: 23.7 TITLE: GCIC/NCIC Created: September 01, 2021 SUB-TITLE: Applicant Privacy Rights PURPOSE: Applicant Notification Policy for Information derived from the Georgia Crime Information Center (GCIC) Criminal Justice Information System (CJIS) network. POLICY: The Pickens County 9-1-1 Center conducts or requests fingerprint-based background checks for criminal justice or governmental non-criminal justice employment through GCIC. Prior to fingerprinting, individuals must complete an application and receive a copy of the Applicant Privacy Rights and the Privacy Act Statement. The Applicant Privacy Rights and Privacy Act Statement are provided to the applicant by: A copy is provided as part of the application packet. Once the applicant had read the Applicant Privacy Rights and the Privacy Act Statement, the applicant will sign the Applicant Privacy Rights Notification Signature form stating the notification was received. The agency will maintain the signed document for the duration of the audit cycle, no less than three years. RECORD/CHALLENGE CORRECTION: If an applicant chooses to challenge the accuracy of the criminal history record or needs to correct or update a record, they will be given 30 days to do so. The applicant is notified that the procedures for challenging an FBI record are set forth in 28 CFR 16.30 through 16.34 and the procedures for challenging a Georgia record can be found on the GBI website. The applicants will not be given a copy of the fingerprint-based criminal history record. The agency is not authorized to release the name-based criminal history record. APPEAL PROCESS: The applicant is provided an opportunity to appeal an adverse decision based on the criminal history record information provided from the fingerprint-based background check. The procedures for the appeal process are as follows: If the applicant wishes to appeal this adverse decision, he/she shall submit a written request to the 9-1-1 Director with the agency within 10 days of notification of the adverse decision. The 9-1-1 Director will review the results of the fingerprint-based background check and make a decision within 10 days. If the appeal results in adverse decision, the applicant may appeal that decision in writing to the Public Safety Director within 10 days. The Public Safety Director shall make a final decision within 10 days. ---PAGE BREAK--- Applicant Privacy Rights As an applicant who is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/biometric-based criminal history check for a non-criminal justice purpose (such as an application for criminal justice or non-criminal justice employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code Section 552a, and Title 28 Code of Federal Regulation (CFR), 50.12, among other authorities. • You must be provided written notification that your fingerprints/biometrics will be used to check the criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a federal record check is so authorized. • You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later) when you submit your fingerprints and associated personal information. This Privacy Act Statement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searched, shared, or explained. • You must be advised in writing of the procedures for obtaining a change, correction, or update of your criminal history record as set forth at 28 CFR 16.34. • You must be provided the opportunity to complete or challenge the accuracy of the information in your criminal history record (if you have such a record). • If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on the information in the criminal history record. • If agency policy permits, the officials may provide you with a copy of your criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may find information regarding how to obtain a copy of your Georgia criminal history record at the GBI website: information-frequently-asked-questions Information regarding how to obtain a copy of your FBI criminal history record is located at the FBI website: • If you decide to challenge the accuracy or completeness of your criminal history record, you should contact and send your challenge to the agency that contributed the questioned information. If the disputed arrest occurred in the State of Georgia, you may send your challenge directly to the GCIC. Contact information for the GCIC can be found at criminal-history-record-information-frequently-asked-questions Alternatively, you may send your challenge directly to the FBI by submitting a request via The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenge entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) • You have the right to expect that officials receiving the results of the criminal history record check will use it only for the authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. ---PAGE BREAK--- Privacy Act Statement This privacy act statement is located on the back of the (blue) FD-258 fingerprint card. Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principle Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. As of 02/04/2021 ---PAGE BREAK--- Applicant Privacy Rights Notification Signature Form Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure of obtaining a change, correction or updating an FBI identification record is set forth in Title 28, Code of Federal Regulations (CFR), 16.34. Procedures for obtaining a copy of the FBI criminal history record are set forth in 28 CFR 16.30 through 16.33 or review the FBI website. Signature Print Name Date ---PAGE BREAK---