Application & Background Packet

INSTRUCTION TO APPLICANT:

Please complete all sections of this packet. This will be part of your background investigation. Any falsification or omissions of information in this packet could result in a denial for hiring with our agency or denial for enrollment to the NLETC academy. Any future discovery of falsification or omissions of information in this packet could results in termination if you are hired.

If a section does not apply to you, market "N/A" for not applicable.

Please include any document files requested or referenced within this packet.

If you have any questions, please feel free to ask: Sgt. Brock Juracek at bjuracek@gagecountyne.gov or Chief Deputy Klaus

Personal Identification

Legal Name

Current Address

Other Names Used:

Social Media

Please list the types of social media you currently use:

Employment History

Please list your last 10 years of employment. List all full time and part time employment.

Past Employer

Past Employer

Past Employer

Past Employer

Past Employer

Past Employer

Education & Training History

List all schools attended starting with high school:

Military Service Information

Have you served in the military? *
Were you ever court-martialed?
Were you allowed to resign in lieu of court-martial?
Did you ever receive non-judicial punishment?

Were you ever administratively:

Discharged from service?
Flagged for any action?
Barred from reenlistment?
Did you ever receive an annual evaluation report?
Can you provide the last 3 evaluations for review?

Driving History

Current Driver's License

All Licenses

Please list all driver's licenses held from any state:

Have you ever had your vehicle operator's license suspended or revoked? *
If suspended/revoked, was your license reinstated/restored? *
Have you ever been involved in a motor vehicle accident? (as driver) *

Criminal History

Please ensure you list all the required information requested to include citations, arrests, charges, or convictions which occurred as a juvenile and as an adult.

Please explain any "yes" answers:

(1) Have you ever used marijuana or THC concentrate for any purpose in the last five (5) years? *
(2) Have you used any illegal drug/narcotic for any purpose in the last ten (10) years? (non-prescription) *
(3) Have you ever used prescription medication in a manner it wasn't subscribed (abused) or someone else's prescription? *
(4) Have you ever been detained by police for any investigative purpose? (apart from traffic infractions) *
(5) Have you ever been investigated by a law enforcement agency, or been a person of interest, for a criminal offense? *
(6) Have you ever stolen anything since you were 16 years old whether or not you were caught, cited, charged, or arrested? *
(7) Have you ever been involved in a physical fight since you were 16 years old whether or not you were caught, cited, charged, or arrested? *
(8) Have you ever vandalized anything since you were 16 years old whether or not you were caught, cited, charged, or arrested? *
(9) Have you ever committed any criminal sex act since you were 16 years old whether or not you were caught, cited, charged, or arrested? (This includes sexual assault, sexual abuse, etc.) *
(10) Have you ever been involved in any domestic abuse/assault incident whether or not you were caught, cited, charged, or arrested? *
(11) Have you ever been arrested for driving under the influence of drugs or alcohol at any time? *
(12) Have you ever driven while under the influence of alcohol or drugs whether or not you were caught, cited, charged, or arrested? *
(13) Have you ever been involved in any child abuse/neglect incident whether or not you were caught, cited, charged, or arrested? *
(14) Were you ever subject to a protection order, no contact order, or harassment order? *

Criminal Violations

Have you ever been cited, arrested, charged, or convicted for any violation of any law (except traffic and parking violations) since the age of 16 years old? *

If yes, complete the information below for each incident. List all information requested.

Booked into jail?
Booked into jail?
Booked into jail?

Traffic Violations

Have you ever been cited, arrested, charged, or convicted for any moving traffic violation since the age of 16 years old? (except minor parking violations) *

If yes, complete the information below for each incident.

Booked into jail?
Booked into jail?
Booked into jail?
Booked into jail?

Personal Declarations

Have you ever been a party in civil litigation? *
Can you provide documentation of the civil litigation? *
Have you ever declared bankruptcy? *
Can you provide documentation of the bankruptcy? *
Have you ever had a professional license investigated/suspended? *
Can you provide documentation of the suspension? *
Are you subject to any court order? (child support, judgement, etc) *
Can you provide documentation? *
Have you ever been subject to a protection order at any time? *
Can you provide documentation? *
Have you ever been terminated, suspended, disciplined, or permitted to resign in lieu of termination from any job? *
Can you provide documentation? *
Have you ever had a complaint filed against you in any civil, criminal, or administrative forum alleging fraud, misrepresentation, forgery? *
Have you ever had a civil case dismissed because of a finding of criminal, or administrative forum alleging fraud, misrepresentation, forgery? *
Have you ever had a professional license that you hold be under investigation for any purpose? *
Have you had a law enforcement certification or any other professional license/certificate revoked or suspended? *
Is a professional license you hold currently under investigation? *
Have you had a law enforcement certification or any other professional license/certificate revoked or suspended? *
Are you currently in violation of a court order to include an order for child support? *
Have you ever been terminated, suspended, disciplined, or permitted to resign in lieu of termination from any job? *

Statement of Health and Physical Abilities

Do you currently have any condition or impairment (including but not limited to substance abuse, alcohol abuse, or a mental emotional, or nervous disorder or condition) which in any way currently affects or if left untreated could affect your ability to perform the duties of a law enforcement officer in a competent professional manner? *

Drug & Alcohol Information

Describe your use of alcohol.

Describe your use (present and/or past) of marijuana.

Describe your use (present and/or past) of drugs/narcotics.

References

Personal References

Please list a minimum of 3 personal references who are not family members:

Professional/Educational References

Please list a minimum of 3 professional or educational references:

Places Lived in the Last 10 Years

Fingerprinting

Have you ever been fingerprinted? *

If yes, complete the information below for each incident.

Authorization to Release Information

Reference:

To Whom It May Concern:

As an applicant for a position with the Gage County Sheriff's Office, I am required to furnish information for use in determining my moral, physical, and mental qualifications.

I respectfully request and authorize you to permit the background investigator(s) to review my personnel, credit, and medical records and to copy materials contained therein.

I hereby release you, you organization, or others from any liability or damage which may result from furnishing the requested information.

This authorization shall expire at the conclusion of this pre-employment background investigation.

Applicant Attestation Verification

I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the forgoing statements and answers to questions and that all statement and answers are true and correct to the best of my knowledge and belief.

I understand this information will be used in my background investigation. I understand that any misrepresentations, omissions, or falsifications could disqualify me from consideration for employment, or if hired, could be grounds for termination.

Training Agreement

In order to assure that the Gage County Sheriff's Office does not invest time and money training persons for the position of Deputy Sheriff without receiving the service of a fully trained officer, the following agreement is made by and between, applicant name below (herein after referred to as "Deputy Candidate" and the Gage County Sheriff's Office (herein after referred to as the "Agency")

  1. The Deputy Candidate agrees to undertake the Basic Law Enforcement Training Center, along with all other specialized training necessary to obtain the status of sworn Deputy Sheriff offered at the Nebraska Law Enforcement Training Center, Grand Island, Nebraska, for a period of sixteen (16) weeks commencing on _______________, and to successfully complete such training. He/she then agrees to serve as a Deputy Sheriff within Gage County Sheriff's Office, Beatrice, Nebraska in any duty assignment or location assigned by supervisory personnel of the Gage County Sheriff's Office.
  2. The Deputy Candidate agrees to the requirement of successful completion of the Nebraska Las Enforcement Training Center's Basic training curriculum without remediation or rescheduling due to academic performance. The Deputy Candidate also agrees to the requirement of successful completion of the Gage County Sheriff's Office Field Training Program. The Deputy Candidate further agrees to devote full time to the above mentioned training and subsequent service and to perform all assignments in a satisfactory manner. All cases of such doubtful performance will be resolved in favor of the County. Failure to complete either the NLETC training or the FTO training will result in termination from the Gage County Sheriff's Office.
  3. The agency agrees to provide the law enforcement training specified above, to furnish food and lodging on premises for the Deputy Candidate while in training and to pay the Deputy Candidate his or her regular wage during said training.
  4. Deputy Candidate agrees to pay his/her certification fee of $75.00 upon successful completion of the Nebraska Law Enforcement Training Center's Basic training curriculum.
  5. Because many of the costs in training are difficult to allocate with exactitude and damages for breach of this agreement are, likewise, difficult to assess, the Deputy Candidate agrees to pay the Gage County Sheriff's Office the sum of $10,492.00, not as a penalty but as agreed upon liquidated damages, in the event that he/she terminates his or her employment with the agency during training or within the first forty-eight (48) months subsequent to the completion of said training.
  6. No liquidated damages will be payable in the event that the Deputy Candidate fails to satisfactorily complete or is dismissed during the basic training session or in the event that he or she is required to terminate his or her employment due to a disabling illness or injury.
  7. The exception in paragraph six, above, shall not apply in the event that there is substantial evidence that the Deputy Candidate has been dismissed as a result of misrepresenting his or her basic qualifications for employment, or has caused her or her dismissal, failure, illness or injury in an attempt to avoid paying liquidated damages under the terms of this agreement.
  8. Damages will be prorated according to the amount of training completed, in the event liquidated damages become payable before the Deputy Candidate has completed said training.
  9. In the event the Deputy Candidate is called to active military duty, has his or her introductory period extended, or is granted leave of absence during the period covered by this agreement, the period of this agreement shall be extended accordingly.
  10. The Deputy Candidate state that he or she meets the basic qualifications for employment as outlined below:
    1. 21 years of age on or before the date that the oath of office is taken;
    2. Good moral character;
    3. Good physical condition;
    4. GED or High School Diploma;
    5. United States Citizen; and
    6. No felony or disqualifying misdemeanor convictions.
  11. This agreement shall become effective at 5:00 P.M. on the second day of the basic training session and remains in full force and effect for forty-eight (48) months following the completion of said training, unless extended as provided in paragraph (6) above.
  12. Should this be my second (2nd) attempt attending the Nebraska Law Enforcement Training Center, I understand that the grant funds that pay for Basic Training will not be made available again to me.
    1. I understand that if I am still afforded the opportunity of employment with Gage County as a Deputy Sheriff, I agree to the following repayment plan.
      1. As of January 1, 2024, the estimated total cost for attending the Basic Training is $10,492.00. (NOTE: Should you need to make payment arrangements to pay for the training, you will need to contact the Training Academy and they will work with you on payment arrangements.)
      2. I agree to pay for any and all expenses associated with Basic Training while attending.
      3. In exchange for my attendance, becoming certified and remaining employed by Gage County, I will be reimbursed at the following rate: Three (3) annual payments of $2,623.00. NOTE: The $75.00 certification fee will be deducted from my fourth (4th) payment, as this is a professional license that goes with me. My final payment will be $2,548.00. I will be reimbursed on or about my anniversary date following my certification for the next four (4) years.
      4. While attending training, Gage County will pay my wage and provide me with a vehicle and fuel.
    2. I understand that employment with the County as a law enforcement officer is contingent on my successful completion of Certification and FTP.
    3. I acknowledge that this Agreement contains the entire understanding between the County and myself.
  13. This document embodies the whole agreement between the parties hereto and there are to inducements, promises, terms, conditions or obligations made or entered into by the agency or other than contained herein. The foregoing provisions are understood and agreed to by the undersigned. In witness whereof the parties have executed this agreement at the Gage County Sheriff's Office, Beatrice, Nebraska this _______________.

Patrol Unit Agreement

I, _______________, do hereby voluntarily agree to share a patrol unit as necessary and with whomever is deemed necessary and/or appropriate by the Sheriff or his designee.