2. Position applying for:*

   1. Merit Deputy
   2. Jail Deputy
   3. Administration
   4. Control
   5. Dispatch
4. Last Name*
5. First Name*
6. Middle Name
8. Maiden Name (if applicable)
10. Street Address*
12. City*
13. County*
14. State*
15. Zip Code*
17. Home Phone
18. Cell Phone
20. Email
22. Are you a US Citizen? *

    1. Yes
    2. No
23. If no, please explain.
25. Date of Birth*
27. High School Diploma?*

    1. Yes
    2. No
28. GED?

    1. Yes
    2. No
30. Have you ever been employed by a police department? If so where?*
32. Are you ILEA Certified? If so when?*
36. Have you ever served in the military on active duty?*

    1. Yes
    2. No
38. Military Branch
39. From
40. To
42. Highest Rank Attained and Rank at Separation
43. Type of Discharge and Reenlistment Code
45. Military Branch
46. From
47. To
49. Highest Rank Attained and Rank at Separation
50. Type of Discharge and Reenlistment Code
54. Have you ever been arrested for a criminal offense?*

    1. Yes
    2. No
56. Date
57. Location
59. Charge
60. Fine or Sentence
62. Date
63. Location
65. Charge
66. Fine or Sentence
68. Date
69. Location
71. Charge
72. Fine or Sentence
76. I swear or affirm under the penalty of perjury that all information contained in this application is true and accurate to the best of my knowledge.
78. Signature (Type Name)*
79. Date*
81. I consent to sign and submit this document electronically.*

    1. Yes
85. Further information may be required in the future including, but not limited to, high school or college transcripts, resumes, and DD 214s.
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field