CCSONE Test Form

[{"type":"checkbox-group","required":true,"label":"Department(s) and Position(s) Applying For (check all that apply)","inline":true,"name":"positions-applying-for","className":"d-block","values":[{"label":"Cass County Sheriff Sworn Deputy","value":"sworn-deputy"},{"label":"Plattsmouth Police Officer","value":"police-officer"},{"label":"Both Agencies","value":"both-agencies"}]},{"type":"text","required":true,"label":"Applicant's Name (Last, First, Middle Initial)","name":"applicants-name-last-first-mi","className":"d-block","subtype":"text"},{"type":"text","label":"Street Address","name":"street-address","className":"col-md-6","subtype":"text"},{"type":"text","label":"City, State, Zip Code","name":"city-state-zip","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number","placeholder":"xxx-xxx-xxxx","name":"phone-number","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h2","label":"Applicant Statement","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I certify that all information I have provided in order to apply for and secure work at the Cass County Law Enforcement Center & jail is true, complete, and correct. I understand that any information provided by me is found to be false, incomplete, or misrepresented in any respect will be sufficient cause to (I) cancel further consideration of this application or (II) immediately discharge me from the employer’s service whenever it is discovered. I expressly authorize, without reservation, the Cass County Sheriff’s Office and/or the Plattsmouth Police Department, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the Cass County Sheriff’s Office or the Plattsmouth Police Department, its agents, employees, or representatives for seeking, gathering, and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the Cass County Sheriff’s Office and the Plattsmouth Police Department do not unlawfully discriminate in employment, and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer(s) and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with proper notice, and the employer reserves the same right to terminate my employment at any time, with or without cause, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the Sheriff’s Office or Police Department is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Cass County Sheriff or the Plattsmouth Police Chief. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard. I also understand that a complete background check will be conducted on me and that some positions require a polygraph and psychological and medical testing. As per Nebraska Law, a complete background check must be completed prior to offering employment in the Law Enforcement field. In order to complete this requirement, your date of birth and driver’s license number are required.","className":"d-block"},{"type":"date","required":true,"label":"Date of Birth","name":"applicant-date-of-birth","className":"col-lg-4"},{"type":"text","required":true,"label":"Social Security Number","name":"ssn-applicant","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"applicant-email","className":"col-lg-4"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"applicant-email-confirmed","className":"col-lg-4"},{"type":"paragraph","subtype":"p","label":"DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.I certify that I have read, fully understand and accept all terms of the foregoing Application Statement. ","className":"d-block"},{"type":"text","required":true,"label":"Signature of Applicant","name":"applicant-signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Applicant Statement Signature","name":"date-of-applicant-signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h2","label":"AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT","className":"d-block"},{"type":"paragraph","subtype":"p","label":"TO WHOM IT MAY CONCERN: I am an applicant for a position with the Cass County Sheriff’s Office and/or the Plattsmouth Police Department, Plattsmouth, Nebraska.  The agency or agencies needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied.  It is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the above agency or agencies.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I hereby authorize any representative of the Cass County Sheriff’s Office, and the Plattsmouth Police Department, Plattsmouth, Nebraska bearing this release, to obtain any information in your files pertaining to my employment records, and I hereby direct to release such information upon request by, and to any duly authorized agent of the Cass County Sheriff’s Office and Plattsmouth Police Department, Plattsmouth, Nebraska, whether said records are public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the Cass County Sheriff’s Office and the Plattsmouth Police Department, Plattsmouth, Nebraska to consider in determining my suitability for employment in that agency or agencies.  It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I consent to your release of any and all public and private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my investigatory files, efficiency ratings, complaints or grievances filed by or against me, records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential, and /or sealed.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div>I hereby release you, your organization, and all others from liability or damages that may result from furnishing the information requested, including any liability or damages pursuant to any state or federal offices, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it.</div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I direct you to release such information upon the request of the duly accredited representative of the Cass County Sheriff’s Office and Plattsmouth Police Department, Plattsmouth, Nebraska regardless of any agreement I may have made with you previously of the contrary.  The law enforcement organization requesting the information pursuant to this release will discontinue processing my application if you refuse to disclose the information requested.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"For and in consideration of the Cass County Sheriff’s Office and the Plattsmouth Police Department, Plattsmouth, Nebraska’s acceptance and processing of my application for employment, I agree to hold you and the company’s/organization’s agents and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the Cass County Sheriff'’ Office or the Plattsmouth Police Department, Plattsmouth, Nebraska.  I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I understand my rights under Title 5, United States Code, Section 552a, Privacy Act of 1974, with regard to access and to the disclosure of records, and I wave those rights with the understanding that the information furnished will be used by the Cass County Sheriff’s Office or the Plattsmouth Police Department, Plattsmouth, Nebraska in conjunction with employment procedures.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"A photocopy or FAX copy of this release form will be valid as an original thereof, even though the said photocopy or FAX does not contain an original writing of my signature.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"This waiver is valid for a period of one year from the date of my signature. ","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I agree to identify and hold harmless the person to whom this request is presented and his/her agents and employees, from and again stall claims, damages, losses, and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request.","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<br>","name":"Authorization-for-Release-of-Information-Agreement","className":"d-block","values":[{"label":"I agree to the Authorization for Release of Information Agreement","value":"Authorization for Release of Information Agreement - TO WHOM IT MAY CONCERN: I am an applicant for a position with the Cass County Sheriff’s Office, Plattsmouth, Nebraska.  The agency needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied.  It is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the above agency.I hereby authorize any representative of the Cass CountySheriff’s Office, Plattsmouth, Nebraska bearing this release to obtain any information in your files pertaining to my employment records, and I hereby direct to release such information upon request by, and to any duly authorized agent of the Cass County Sheriff’s Office, Plattsmouth, Nebraska, whether said records are public, private, or confidential nature.  The intent of this authorization is to give my consent for full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the Cass County Sheriff’s Office, Plattsmouth, Nebraska to consider in determining my suitability for employment in that agency.  It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.I consent to your release of any and all public and private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my investigatory files, efficiency ratings, complaints or grievances filed by or against me, records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential, and /or sealed. I hereby release you, your organization, and all others from liability or damages that may result from furnishing the information requested, including any liability or damages pursuant to any state or federal offices, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct you to release such information upon the request of the duly accredited representative of the Cass County Sheriff’s Office, Plattsmouth, Nebraska regardless of any agreement I may have made with you previously of the contrary.  The law enforcement organization requesting the information pursuant to this release will discontinue processing my application if you refuse to disclose the information requested.For and in consideration of the Cass County Sheriff’sOffice, Plattsmouth, Nebraska’s acceptance and processing of my application for employment, I agree to hold you and the company’s/organization’s agents and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the Cass County Sheriff'’ Office, Plattsmouth, Nebraska.  I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.I understand my rights under Title 5, United States Code, Section 552a, Privacy Act of 1974, with regard to access and to the disclosure of records, and I wave those rights with the understanding that the information furnished will be used by the Cass County Sheriff’s Office, Plattsmouth, Nebraska in conjunction with employment procedures.A photocopy or FAX copy of this release form will be valid as an original thereof, even though the said photocopy or FAX does not contain an original writing of my signature.This waiver is valid for a period of one year from the date of my signature. I agree to identify and hold harmless the person to whom this request is presented and his/her agents and employees, from and again stall claims, damages, losses, and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request."}]},{"type":"text","required":true,"label":"Applicant's Signature","name":"Applicants-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Authorization for Release of Information Agreement","name":"Date-of-Authorization-for-Release-of-Information-Agreement","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"**Complete your profile with GUARDIAN ALLIANCE TECHNOLOGIES. You will receive an email within 48 hours of this submission. <div><br></div><div>Email Dr. Amber Mahan at amahan@casscountyne.gov with questions. </div>","className":"d-block"}]