Other names (including nicknames) you have been known by
Please list address at which you can be contacted
Please list the local telephone number(s) at which you can be contacted.
You must be a citizen of the United States and a resident of the United States for one year prior
For the purpose of identification, please provide the following:


During the course of the background investigation, persons who know you will be asked to comment on your suitability for the position
Please supply the appropriate information in the spaces provided below. If a category is not applicable, write in “N.A.”, If living please list below.
Please list 2 personal references and 2 professional references


The Stephenson County Sheriff’s Office Merit Commission requires a peace officer to possess a high school diploma or its equivalent. Please indicate your current situation with regard to this requirement by checking one of the appropriate boxes.
Please indicate below all the schools you have attended, beginning with high school. During the background investigation, persons who have known you in a learning environment will be contacted. A review of your school records may be made, in conjunction with these contacts.
Have you ever been suspended or expelled from any high school or post-secondary school? (Post-secondary schools include colleges and universities, graduate schools, business and vocational schools—any formal education beyond high school level.)


Individuals who have become acquainted with you by reason of your residing in different locations are often helpful in providing useful information for the background investigation.
Please list all of your residences during the past 10 years (list no information prior to your 15th birthday). Begin with your current residence

Experience and Employment

Beginning with your most current employment, please list all jobs (including part-time, temporary and voluntary positions) you have held in the past 10 years. (For the purpose of this personal history statement, voluntary work should be included as employment.) For identification and verification, please indicate the nature of the activity, i.e., full-time, part-time or voluntary. If you have had intervening periods of military service or unemployment, please list those periods in sequence in the spaces provided.

Employer #1

Not Employed #1 Reason

Employer #2

Not Employed #2 Reason

Employer #3

Not Employed #3 Reason

Employer #4

Not Employed #4 Reason

Employer #5

Not Employed #5 Reason

Employer #6

Not Employed #6 Reason

Employer #7

Not Employed #7 Reason

Would any problem result if your present employer was contacted during the course of the background investigation?
If you have had no prior employment, please explain
Have you had any extended work absences for reasons other than earned vacations?
Have you ever been fired or asked to resign from any place of employment?
Have you ever been a successful or unsuccessful candidate for another position requiring peace officer powers?


Have you ever been arrested or convicted for any crime (excluding traffic citations)?


I have read the description of the position that I'm applying

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