Employment Application

Employment History

(begin with last or most recent employer)
Employer
Position Title
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Start Date

MonthDayYear
End Date

MonthDayYear
Still Employed?

YesNo
Reason for Leaving
Starting Salary
Ending Salary
Immediate Supervisor
Number of Employees you Supervised
Your name when emplyed if different from present

First NameLast Name
May we contact this employer for references and/or verification?

YesNo
Major Duties
Do you have additional employers to enter?

YesNo

Employment History

(continued)
Employer
Position Title
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Start Date

MonthDayYear
End Date

MonthDayYear
Still Employed?

YesNo
Reason for Leaving
Starting Salary
Ending Salary
Immediate Supervisor
Number of Employees you Supervised
Your name when emplyed if different from present

First NameLast Name
May we contact this employer for references and/or verification?

YesNo
Major Duties
Do you have additional employers to enter?

YesNo

Employment History

(continued)
Employer
Position Title
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Start Date

MonthDayYear
End Date

MonthDayYear
Still Employed?

YesNo
Reason for Leaving
Starting Salary
Ending Salary
Immediate Supervisor
Number of Employees you Supervised
Your name when emplyed if different from present

First NameLast Name
May we contact this employer for references and/or verification?

YesNo
Major Duties
Do you have additional employers to enter?

YesNo

Employment History

(continued)
Employer
Position Title
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Start Date

MonthDayYear
End Date

MonthDayYear
Still Employed?

YesNo
Reason for Leaving
Starting Salary
Ending Salary
Immediate Supervisor
Number of Employees you Supervised
Your name when emplyed if different from present

First NameLast Name
May we contact this employer for references and/or verification?

YesNo
Major Duties
If you have additional employment history to add, please include as an attachement on the next page.

Education
Do you have a High School Diploma*

YesNo
Date Received

MonthDayYear
Name and location of high school attended
Do you have a GED?

YesNo
Date Received

MonthDayYear
Highest Grade Completed*
College Coursework
Name and Location of Institution
Degree Received
Major Area of Concentration
Start Date

MonthDayYear
End Date

MonthDayYear
Name and Location of Institution
Degree Received
Major Area of Concentration
Start Date

MonthDayYear
End Date

MonthDayYear
If you have additional educational history to add, please include as an attachement on the next page.
Applicable certifications and/or licenses
Applicable skills (equipment, software, languages, etc.)
References
List names, addresses, phone numbers, and relationships of three individuals who have not supervised you and are not related to you
Reference Info 1
Reference Info 2
Reference Info 3
Where you referred by a current RRJ empoyee?*

YesNo
If referred by a current RRJ employee, please identify
If referred by a current RRJ employee, please identify
File Attachment
If you have a resume or other additional documentation you would like to include, please submit here.
*pdf/doc/docx files only (Resume)

Upload a File

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Certification
I hereby certify that all entries on this application including any attachments are true and complete, and I agree and fully understand that any falsification of information herein, regardless of time and discovery, may cause forfeiture on my part to any employment with the Riverside Regional Jail. I understand that information on this application is subject to verification and I consent to references, former employers, and educational institutions listed being contacted, and criminal history, credit, and DMV check being conducted regarding this application.
Application Information Certification Statement*

I acknowledge and agree with the above certification statement.
Signature*

Pre-Background Form
In order to efficiently process applications, the following information is required. Be honest and as accurate as possible.
Personal History
Position Title*
Date of Birth*

MonthDayYear
SSN*
E-mail*
Name*

First NameMiddle NameLast Name
Other names used, to include nicknames, maiden names, etc.
Home Phone*
Alternate Phone
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Country of Citizenship*
Racial or Ethnic Group*
Hospital of Birth
City or County of Birth*
State or Country of Birth*
Height*
Weight*
Eye Color*
Hair Color*
Family History
Please list the names, ages, phone numbers, occupations, places of employment and residences of your parents or legal guardians, any siblings, spouse, children and parents or legal guardians of your spouse. Please identify the relationship of each person listed.
Family Info 1
Family Info 2
Family Info 3
Family Info 4
Family Info 5
Has any member of your family ever been arrested for or convicted of a felony?*

YesNo
(If yes, please explain in detail)
Are you or any members of your family currently or formerly a member of any subversive organizations?*

YesNo
(If yes, please explain in detail)
Are you currently serving or have you previously served in the military?*

YesNo

Military Status
Branch of Service
Date of Entry

MonthDayYear
Place of Entry
Service Number
Date of Basic Training

MonthDayYear
Location of Basic Training
Please list the length and locations of Permanent Duty stations
Primary Duties and/or Rank
Highest rank or rate
Date of Promotion

MonthDayYear
Service schools attended
Medals or awards received
Have you had any disciplinary actions (in-house or formal)

YesNo
(if yes please explain in detail)
Date of discharge or release

MonthDayYear
Type
DD-214 Upload - Please upload a copy of your Certificate of Release or Discharge from Active Duty
*pdf/doc/dox files only (DD 214)

Upload a File

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Are you currently a member of any military reserve organization?*

YesNo
(if yes, what is the termination date of your reserve obligation)

MonthDayYear
(if yes, what is the name of your reserve organization and your current status to include obligated time, drill status and compulsory active duty status)
Did you serve your complete term of service?

YesNo
(if no, please explain in detail)
Were you ever rejected for military service?*

YesNo
(if yes, please explain in detail)

Additional Background Information
Have you ever applied for employment with any other law enforcement agency?*

YesNo
(if yes, please explain in detail to include date, agency, and outcome of your application(s))
Have you ever applied for employment with the Riverside Regional Jail in the past?*

YesNo
(if yes, when?)

MonthDayYear
Do you know anyone that works for the Riverside Regional Jail now or has worked for the jail in the past?*

YesNo
(if yes, who?)
List all internet domains, e-mail addresses, and social networking accounts that you are associated with.

Affidavit

I hereby certify that all statements contained in this questionnaire are true and complete to the best of my knowledge. I have neither withheld nor misrepresented any facts contained herein. I authorize the Riverside Regional Jail and its agents to conduct a complete and comprehensive investigation into my background for the purposes of determining my fitness and qualifications for the position I am seeking. I also understand that my omission or misstatement of material facts may be grounds for rejection of my application or dismissal from employment. All information may require the applicant to submit to a polygraph examination.
Affidavit Agreement*

I have read and agree to the affidavit statement
Affidavit Date*

MonthDayYear
Signature*

Authority for Release of Information

To whom it may concern:

I hereby authorize any duly accredited representative of the Riverside Regional Jail bearing this release or a copy thereof, to obtain any information from schools, residential management agents, employers, criminal justice agencies, credit references, or individuals relating to my activities. The information may include, but is not limited to, academic, disciplinary, and conviction records. I hereby direct you to release such information upon request of the bearer. I understand that the information released is for official use of the Riverside Regional Jail and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities.

I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind of nature which; may at any time result to me on account of compliance, or any attempts to comply with this authorization.
Authority for Release of Information Agreement*

I have read and agree with the release of information authorization
Authority for Release of Information Signature*
Authority for Release of Information Date*

MonthDayYear

Credit Authorization

I hereby authorize the Riverside Regional Jail to obtain a copy of my credit report as part of the background investigation.
Credit Authorization Agreement*

I have read and agree with the credit report authorization statement
Credit AuthorizationSignature*
Credit Authorization Date*

MonthDayYear
Should be Empty:

Employment Application

Employment History

Employment History

Employment History

Employment History

Education

References

Pre-Background Form

Personal History

Family History

Military Status

Financial Status

Motor Vehicle Operation

Police Record

Additional Background Information