HCSO Application

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Qualified applicants are considered for all positions without regard to race, color, religious creed, national origin, sex, genetic information, sexual orientation, ancestry, marital status or handicap, which does not preclude the applicant from performing the essential functions of the job with or without reasonable accommodation.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subjected to criminal penalties and civil liability.

Instructions: Please read the application for employment carefully and answer every question in full. You may exclude all information indicative of any status in the protected categories mentioned in the first paragraph.

The minimum age requirement for full-time employment consideration is 19 years of age. Are you at least 19 years old?(Required)

Yes

Date of Application(Required)

MM slash DD slash YYYY

Email(Required)

Do you belong to any social network(s)? If so, please check applicable boxes:

Facebook

Twitter

Instagram

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone Number(Required)

Home Phone Number

Position(s) Applied for:(Required)

Referred By:

Date you are available to start work?(Required)

MM slash DD slash YYYY

Are you applying for the Law Enforcement Division?

Yes

The following additional documents must be attached to this application if you are applying for Deputy Sheriff for the Law Enforcement Division.
1. A certified copy of birth certificate
2. A certified copy of high school diploma
3. A copy of military discharge(s) (DD214)
4. A copy of Driver’s License
5. A copy of your current LTC Permit
6. A copy of police academy certifications held (Basic Recruit, Reserve Academy, etc͘ )
7. A copy of CPR card and First Responder Certification
The above documents can either be attached to the application or delivered in person to the main HR office at 627 Randall Road in Ludlow

Indicate any law enforcement education/training that you have received and the year:

Have you ever applied to the Hampden County Sheriff’s Office or the Law Enforcement Division (L.E.D.)?

Yes

If so what year?

Indicate and attach any type of special license or certifications such as pilot, radio operator, Breathalyzer operator, speed detection equipment operator which might be relevant to the L.E.D.

Indicate any other special skills you possess and equipment you can use which may be relevant to the L.E.D.

Have you used any narcotic or controlled substance within the last year except as prescribed by your doctor?

Yes

If yes, please list.

Have you ever been a plaintiff or defendant in a civil court action?

Yes

If yes, provide details and attach a copy of any judgment that was issued.

Birth certificate

Max. file size: 8 MB.

High school diploma

Max. file size: 8 MB.

Military discharge(s) (DD214)

Max. file size: 8 MB.

Driver’s License

Max. file size: 8 MB.

Current LTC Permit

Max. file size: 8 MB.

Academy certifications held (Basic Recruit, Reserve Academy, etc )

Max. file size: 8 MB.

CPR card and First Responder Certification

Max. file size: 8 MB.

Family Disclosure Form

Max. file size: 8 MB.

Education

List(Required)

High School Name/Address

Course of Study

Year Completed

Diploma Degree

List

Undergraduate School Name/Address

Course of Study

Year Completed

Diploma Degree

List

Graduate School Name/Address

Course of Study

Year Completed

Diploma Degree

List

Other (Specify) School Name/Address

Course of Study

Year Completed

Diploma Degree

Indicate any languages other than English you can speak, read and/or write

Fluent

Good

Fair

Describe any specialized training, apprenticeship, skills, employment, or academic awards or honors and any extra-curricular activities that may relate to the position applied for

If you have ever served in the Armed Forces, Including the Reserves, complete the following: (Upon hire a copy of your DD214 is required)

Branch:

Type, Place and date of discharge:

Any special training or skills:

Duties performed:

Reserve Obligations (list branch and unit):

Employment Experience

Please detail employment and positions held for the past ten years.

Start with your present or last job. Include any job-related military service assignments and volunteer activities. List all full-time and part-time employment held in the past ten years.

1.(Required)

Employer

Town/City

Job Title

Supervisor Name(Required)

First & Last Name

Supervisor/Business Phone Number(Required)

Work Performed(Required)

Reason for Leaving(Required)

Dates Employed(Required)

1.(Required)

Avg.hrs. worked per week

May we contact this employer?(Required)

Yes

If no, please give reason

2.(Required)

Employer

Town/City

Job Title

Supervisor Name(Required)

First & Last Name

Supervisor/Business Phone Number(Required)

Work Performed(Required)

Reason for Leaving(Required)

Dates Employed(Required)

Avg.hrs. worked per week

May we contact this employer?(Required)

Yes

If no, please give reason

3.(Required)

Employer

Town/City

Job Title

Supervisor Name(Required)

First & Last Name

Supervisor/Business Phone Number(Required)

Work Performed(Required)

Reason for Leaving(Required)

Dates Employed(Required)

Avg.hrs. worked per week

May we contact this employer?

Yes

If no, please give reason

Employer

Town/City

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

Avg.hrs. worked per week

Work Performed

May we contact this employer?

Yes

If no, please give reason

Employer

Town/City

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

Avg.hrs. worked per week

Work Performed

May we contact this employer?

Yes

If no, please give reason

Employer

Town/City

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

Avg.hrs. worked per week

Work Performed

May we contact this employer?

Yes

If no, please give reason

Employer

Town/City

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

Avg.hrs. worked per week

Work Performed

May we contact this employer?

Yes

If no, please give reason

Additional Information

Have any of the following happened to you in the last 10 years: 1. Fired from a job? 2. Quit a job after being told you may be fired? 3. Left a job by mutual agreement following allegations of misconduct? 4. Left a job by mutual agreement following allegations of unsatisfactory performance or attendance? 5. Left a job for other reasons under unfavorable circumstances?

Click YES if any of these 5 events has occurred in the last 10 years:

YES

If YES

If you answered YES to this question describe in detail when this occurred, what happened, the employer's identity and a detailed explanation for each instance.

List

Please list any additional paid or volunteer work experience relevant to the position you are applying for.

Should you be offered employment, would you consent to a medical examination and a drug test as a condition of employment?(Required)

YES

General Information (Please click yes or no)

Are you a United States citizen or authorized to work in the United States?(Required)

You will be required to produce documentation to establish your identity and your authorization to work in the United States according with the Immigration Reform and Control Act of 1986.

YES

Are you presently on lay-off status subject to recall?(Required)

YES

Have you ever applied here before? If yes, when?

Untitled(Required)

YES

Have you ever volunteered, interned or worked here before? If yes, when and why did you leave?

Untitled(Required)

YES

Person To Notify In Case Of Emergency:(Required)

Name:

Telephone:(Required)

Address

Personal References(Required)

(list three references not related to you that you have known for more than one (1) year)

Name

Address

Phone(Required)

Personal Reference 2(Required)

Name

Address

Phone(Required)

Personal Reference 3(Required)

Name

Address

Phone(Required)

Applicant's Agreement To Release Records and Information

Please read the following statements carefully: I hereby affirm that I have read and understand this application and that the information that I have provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I agree that any omission or falsified information shall subject me to disqualification from further consideration for employment and shall be considered justification for my immediate dismissal if discovered at a later date. I hereby authorize all persons, schools, current employer(s) and other organizations named in this application (and accompanying resume, if any) to provide the Hampden County Sheriff's Office with any relevant information that may be helpful in arriving at an employment decision. I hereby release, indemnify and hold harmless said persons and entities and the Hampden County Sheriff's Office from any and all liability for providing and/or using this information. This release shall be considered active for a period of one (1) year.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

DISCLOSURE OF NAMES OF FAMILY MEMBERS WHO ARE STATE EMPLOYEES Disclosure Required by G.L. c. 268A, Sec. 6B

Is your spouse, parent, brother, sister or child, or the spouse of your parent, brother, sister or child, a state employee?(Required)

YES

If you answered Yes, please list below the name(s) of any state employee who is your spouse, parent, brother, sister or child, or who is the spouse of your parent, brother, sister or child, and indicate their relationship to you. Please also list the name of the state agency that employs those relatives. NOTE: For purposes of this disclosure, a "state employee" is a person holding a paid or unpaid office, position, employment or membership in a Massachusetts state agency. For purposes of this disclosure, a "state agency" is any department of Massachusetts state government, including any department or agency within the executive, legislative or judicial branch, and all councils thereof and thereunder, and any division, board, bureau, commission, institution, tribunal or other instrumentality within such department or agency, and any independent state authority, commission, instrumentality or agency, but NOT INCLUDING an agency of a county, city or town.

List

Name of Relative

Relationship to Applicant

Name of State Agency

Resume and/or cover letter

Max. file size: 20 MB.