IMPORTANT
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.
MGL Ch.149, Section 19B
FALSE OR INACCURATE INFORMATION OR THE OMISSION OF INFORMATION ON THIS APPLICATION WILL BE CAUSE FOR DISQUALIFICATION FOR EMPLOYMENT OR DISMISSAL AT ANY TIME AFTER EMPLOYMENT HAS COMMENCED.
This application will be kept on file for at least one year.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
It is the policy of the Berkshire County Sheriff’s Office to afford equal employment opportunity to all qualified persons regardless of race, color, religion, national origin, age, military status, sex, sexual orientation, disability, gender, genetic information, or veteran’s status except where age or sex is a bonafide occupational qualification as allowed by the Civil Rights Act of 1964.
Instructions for completing the application form
1. Type or print clearly in black or blue ink.
2. Answer every question fully and accurately even if you have submitted a résumé. If you cannot answer or do not understand any part of this application notify the Sheriff’s Office representative immediately. In addition to the information required below, please provide any other information you think would be helpful to us in considering you for employment. You may exclude all information indicative of any status in a protected category (age, race, religion, national origin, race, color, religious creed, national origin, sex, sexual orientation, genetic information, ancestry, marital status, veteran status or handicap).
3. The Commonwealth will review, if applicable:
◦ Criminal Offender Record Information (C.O.R.I) and;
◦ The Central Registry of Child Abuse/Neglect reports maintained in accordance with M.G.L. Chapter 119, Section 51 B.
4. If an offer of employment is made to you, the Commonwealth may identify that it is contingent upon the results of a medical exam and/or a tax and background check.
5. FALSE OR INACCURATE INFORMATION OR THE OMISSION OF INFORMATION ON THIS APPLICATION WILL BE CAUSE FOR DISQUALIFICATION FOR EMPLOYMENT OR DISMISSAL AT ANY TIME AFTER EMPLOYMENT HAS COMMENCED.
6. Read certification and releases carefully before signing.
7. Return completed and Signed application. ****(Must be a wet signature)****
8. Incomplete applications will not be considered.
This application will be kept on file for at least one year.
PERSONAL INFORMATION Prefix Name(Required)
First
Last
Mailing Address(Required)
Street Address (If different than mailing)
Are you authorized to work in the U.S. on an unrestricted basis?(Required) Are you over age 19?(Required)
EMPLOYMENT DESIRED Berkshire County Sheriffs Office, 467 Cheshire Road, Pittsfield, MA 01201
Have you worked for the Commonwealth before?(Required) Are you available for full time work?(Required) Are you available for part time work?(Required) Are you available to work nights and weekends?(Required) In addition to your work history, what other experiences, skills or qualifications would qualify you for work with our agency?
Who referred you to us?(Required)
EDUCATION
First School Did you graduate from School 1?
Second School Did you graduate from School 2?
Third School Did you graduate from School 3?
Fourth School Did you graduate from School 4? List any additional education or training:
PROFESSIONAL REFERENCES (not personal): List 3 people not related to you who can comment on your work
First Professional Reference
Second Professional Reference
Third Professional Reference
PERSONAL REFERENCES (not professional): List 3 people not related to you who can comment on your work
performance.
First Personal Reference
Second Personal Reference
Third Personal Reference Check all that apply to you: Dates of Service:
If Vietnam Era Veteran, have you been certified by the State Office of Affirmative Action? (Please attach Form DD214 or a copy of SOAA certification.)
IMMEDIATE FAMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT
Per Executive Order 444, please disclose any immediate family members, including those related to your immediate family by marriage, who are employed by the Commonwealth of Massachusetts. You are required to complete the information below. “Immediate family” is defined as a spouse, child, parent, and sibling; and the spouse’s child, parent and sibling. Include those employed in all branches of state government: judicial, legislative, executive, higher education and state authorities; and those employed as regular or contract employees, or elected officials. This "sunshine disclosure" is intended to ensure that the citizens of our Commonwealth have full confidence in their government and its hiring process. The disclosure will not be used to exclude any qualified applicant seeking a position within the Executive
Branch from receiving full consideration based on the merits of his/her credentials and the requirements of the job. Attach additional pages if needed.
RELATIVE 1
RELATIVE 2
RELATIVE 3
RELATIVE 4
RELATIVE 5
Are you employed right now?(Required) Most Recent:
Address (Most Recent Employer)
Specific Duties (Most Recent Employer)
Second Most Recent:
Address (2nd Most Recent Employer)
Specific Duties (2nd Most Recent Employer)
Third Most Recent:
Address (3rd Most Recent Employer)
Specific Duties (3rd Most Recent Employer)
Fourth Most Recent:
Address (4th Most Recent Employer)
Specific Duties (4th Most Recent Employer)
Leaving 1
Leaving 2
Leaving 3
Leaving 4
Leaving 5
Leaving 6
RELEASE AND CERTIFICATION
PLEASE READ BEFORE SIGNING
I understand that the foregoing will be verified in order to expedite my application for employment with the Berkshire County Sheriff’s Office.
I hereby authorize the Berkshire County Sheriff’s Office to conduct a full investigation into my background.
I authorize the Berkshire County Sheriff’s Office to obtain my previous work records, employment records, character references and any other information concerning character, ability and habits and all other necessary information. Further I grant authority to the keeper of these records to release said records to the Berkshire County Sheriff’s Office for the purpose of making its hiring decision.
I agree that the Berkshire County Sheriff’s Office shall not be liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statement, omissions or answers made by me on this application.
I agree that my previous employers shall not be liable with regard to any information provided by them in connection with this release.
I certify under the pains and penalty of perjury that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably.
I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.
In compliance with the Immigration and Reform and Control Act of 1986, I understand that I will be required to provide approved documentation that verifies my right to work in the United States on my first day of employment. I have received the list of approved documents with this application.
I understand that unless I am subject to the terms of a collective bargaining agreement providing otherwise, my employment will be at-will, which means that both the Berkshire County Sheriff’s Office and I are free to terminate the employment relationship at any time for any non-statutorily prohibited reason or for no reason at all, with or without notice.
I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.
___+++
Release and Certification Consent(Required) I agree to the below
I understand that the foregoing will be verified in order to expedite my application for employment with the Berkshire County Sheriff’s Office.
I hereby authorize the Berkshire County Sheriff’s Office to conduct a full investigation into my background.
I authorize the Berkshire County Sheriff’s Office to obtain my previous work records, employment records, character references and any other information concerning character, ability and habits and all other necessary information. Further I grant authority to the keeper of these records to release said records to the Berkshire County Sheriff’s Office for the purpose of making its hiring decision.
I agree that the Berkshire County Sheriff’s Office shall not be liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statement, omissions or answers made by me on this application.
I agree that my previous employers shall not be liable with regard to any information provided by them in connection with this release.
I certify under the pains and penalty of perjury that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably.
I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.
In compliance with the Immigration and Reform and Control Act of 1986, I understand that I will be required to provide approved documentation that verifies my right to work in the United States on my first day of employment. I have received the list of approved documents with this application.
I understand that unless I am subject to the terms of a collective bargaining agreement providing otherwise, my employment will be at-will, which means that both the Berkshire County Sheriff’s Office and I are free to terminate the employment relationship at any time for any non-statutorily prohibited reason or for no reason at all, with or without notice.
I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.
Name(Required)
First
Last
MISCELLANEOUS JOB-RELATED INFORMATION Job Interest
Shift Preferred(Required) Are you available to work EVERY Saturday and Sunday?(Required) License 1:
License 2:
License 3:
(English Language) Simple Conversation:(Required) (English Language)Simple Reading:(Required) (English Language) Read and Speak Fluently:(Required) (Lang. A) Conversational (Lang. A) Reading (Lang. A) Writing (Lang. B) Conversational (Lang. B) Reading (Lang. B) Writing (Lang. C) Conversational (Lang. C) Reading (Lang. C) Writing (Lang. D) Conversational (Lang. D) Reading (Lang. D) Writing * If language proficiency is required, the Commonwealth may administer a Bilingual Certification Examination.
IN CASE OF EMERGENCY, PLEASE NOTIFY Address(Required)
Criminal Offender Record Information (C.O.R.I)
PLEASE READ BEFORE SIGNING Criminal Offender Record Information (C.O.R.I) Consent(Required) I hereby acknowledge that I have read in full and understand the below statement.
If employed, I agree to abide by all rules and regulations of the Berkshire County Sheriff’s Office. I understand if convicted of a felony, I will notify my supervisor immediately. I agree to furnish such additional information and complete such examination as may be required to complete an employment process and understand that this application for employment in no way obligates the Berkshire County Sheriff’s Office to employ me. I acknowledge that the Berkshire County Sheriff’s Office will, if applicable, review the Criminal Offender Record Information (C.O.R.I.) and the Central Registry of Child Abuse/Neglect reports in accordance with M.G.L. Chapter 119, Section 51B.
C.O.R.I Consent Name(Required)
First
Last
PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING NOTICE
PLEASE READ BEFORE SIGNING PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING Consent(Required) I hereby acknowledge that I have read in full and understand the below statement.
If an offer of employment is made to you, the Berkshire County Sheriff’s Office may specify that it is contingent upon the results of a medical exam. I freely and voluntarily agree to submit to a pre-employment physical and/or drug screen, as it relates to the requirements of a specific job, as part of my pre-employment application to the Berkshire County Sheriff’s Office. I understand that either refusal to submit to such screening, or failure to qualify according to the minimum standards established by the Berkshire County Sheriff’s Office for this screening may disqualify me from further consideration for employment. Further, I understand that any positive drug test results will be communicated in a confidential manner.
I hereby acknowledge that I have read in full and understand the above statements.
PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING Consent Name(Required)
First
Last
ENTRANCE REQUIREMENTS Consent(Required) I hereby acknowledge that I have read in full and understand the below statement.
ENTRANCE REQUIREMENTS
1. Must be high school graduate or possess equivalency certificate issued by MA. Dept. of Education.
2. Must be nineteen (19) years of age or older.
3. Must not have been convicted of a felony, or served a sentence in a Jail or House of Correction.
4. Must have a dependable background and pass a background investigation.
5. Must qualify in all phases of testing – written, physical fitness, personal interview.
6. Must meet all qualifying standards to enter the Correction Officers Training Academy and must successfully complete the Academy training as a condition of employment
7. Must have a Massachusetts Drivers license
8. Must pass drug screen testing.
9. Must be legally eligible for employment in the United States. Proof of citizenship or immigration status will be required.
10. Work experience related to criminal justice system preferred.
11. Must be of good character.
12. Must be able to maintain regular and punctual attendance. ENTRANCE REQUIREMENTS Consent Name(Required)
First
Last
Name(Required)
First
Middle
Last
Authorization for Release of Information Agreement
Authorization for Release of Information Agreement Consent(Required) I hereby acknowledge that I have read in full and understand the below statement.
Authorization for Release of Information Agreement
TO WHOM IT MAY CONCERN: I am an applicant for a position with the Berkshire County Sheriff’s Office, Jail and House of Correction. The Sheriff’s Office needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I have applied. It is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the Berkshire County Sheriff’s Office.
I hereby authorize any representative of the Berkshire County Sheriff’s Office bearing this release to obtain any and all information in pertaining to my employment and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof concerning myself by and to any duly authorized agent of the Berkshire County Sheriff’s Office, whether said records are of a 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 Sheriff’s Office 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 financial status, my criminal history record, including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the 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, unless said files are sealed by a court order.
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 damage pursuant to any state or federal laws. I hereby release you, as the custodian of such records, including its officers, 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 request of the duly authorized representative of the Berkshire County Sheriff’s Office regardless of any agreement I may have made with you previously to the contrary.
For and in consideration of the Berkshire County Sheriff’s Office acceptance and processing of my application for employment, I agree to hold the Commonwealth of Massachusetts, the County of Berkshire, the Berkshire County Sheriff’s Office, and all of their officers, agents, employees, representatives and insurers 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 Berkshire County Sheriff’s Office. 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 that my rights under title 5, United States Code, Section 552a. the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those rights with the understanding that information furnished will be used by the Berkshire County Sheriff’s Office 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 copy does not contain an original writing of my signature.
A) this waiver is valid for a period of two years from the date of my signature.
B) Should there be any questions as to the validity of this release, you may contact me at the address listed on this form.
C) I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form.
D) I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request. Address(Required)
AFFIRMATIVE ACTION DATA RECORD
CONFIDENTIAL
The Berkshire County Sheriff’s Office is committed, in spirit as well as in action, to abide by all laws dealing with equal employment opportunity. It is our policy to guarantee equal employment opportunities for all qualified persons without regard to their age, race, creed, color, national origin, ancestry, marital status, gender, military status, sex, sexual orientation, military status, genetic information or disability, which can be reasonably accommodated.
Further, the Berkshire County Sheriff’s Office will act in good faith, to affirmatively recruit and consider for promotion individuals in protected categories. Age, race, creed, color, national origin, ancestry, marital status, gender, military status, sex, sexual orientation, genetic information or disability are not factors in employment, promotion, transfer, compensation, lay-off, discipline and termination.
In order to effectively monitor the success of our recruitment and employment efforts, it is requested that you provide the following information.
The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Affirmative Action Data Records are kept in a confidential file and are not a part of your application for employment or your personnel file. Your cooperation is voluntary. Inclusion or exclusion of any affirmative action data will not jeopardize or adversely affect any employment decision.
Name(Required)
First
Middle
Last
Address(Required)
Untitled(Required) Check one of the following: (Race) Check if the following is applicable: *In order to qualify for Affirmative Action status as a Vietnam Era Veteran, you must apply for Eligibility Certification that is issued by the State Office of Affirmative Action. Forms are available from the State Office of Affirmative Action, (617) 727-7441.
Check if the following is applicable: *If you wish to obtain Affirmative Action status as a Person with a Disability after you have been employed by this agency you may need to submit self-identification and verification of such with the ADA Coordinator if your disability is not obvious. Appropriate forms are available from this agency’s ADA Coordinator.
Wish to obtain Affirmative Action status as a Person with a Disability Name
First
Last
1. Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility or other “institution” within the meaning of 42 U.S.C. 1997(1) (to include State facilities for persons who are mentally ill, disabled, or retarded, or chronically ill or handicapped; residential care or treatment facilities for juveniles; and facilities that provide skilled nursing, intermediate or long-term care, or custodial or residential care)? Choose One:(Required) If yes, please provide full details. (attach additional sheets if necessary)
2. Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Choose One:(Required) If yes, please provide full details. (attach additional sheets if necessary)
3. Have you been civilly or administratively adjudicated to have engaged in the activity described in Section (2) above? Choose One:(Required) If yes, please provide full details. (attach additional sheets if necessary)
4. Have you ever engaged in or been accused of engaging in sexual harassment in any prior employment?(Required) If yes, please provide full details. (attach additional sheets if necessary)
5. Have you resigned from, been terminated from, quit or otherwise separated from any job following allegations that you engaged in sexual harassment or any other form of sexual misconduct? Choose One(Required) If yes, please provide full details. (attach additional sheets if necessary)
PREA National Standards - 28 CFR § 115.17 Consent(Required) I hereby acknowledge that I have read in full and understand the below statement.
I understand that I have a continuing, affirmative duty to immediately report in writing to the Sheriff any such misconduct during the time I am employed by/contract with or volunteer for the Berkshire County Sheriff’s Office.
I further understand that failure to do so may result in disciplinary action up to and including discharge.
I affirm and attest that all statements and answers given by me on this form are true and correct under the pains and penalty of perjury.
PREA National Standards - 28 CFR § 115.17 Consent Name
First
Last