Employment Interest Form

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Important Note:

I understand that positions such as, but not limited to:

  • Law Enforcement Officers
  • Corrections Officers
  • Jail Clerks
  • Communications Operators
  • RTIC Personnel

Do require 12-hour shifts to include nights, weekends, and holidays.


Other positions not listed above may require nights, weekends and holiday hours based on the needs of the agency.

Please type your full name and the date in the box below as acknowledgment that you have read and understand this information.

College, University, Vocation, etc.

Have you ever missed days or been late to work due to drug or alcohol consumption?

Yes:
No:

Has your work performance ever been affected by your use of alcohol or drugs?

Yes:
No:

Refer to the list below of substances as the reference for all questions regarding unauthorized or illegal use of drugs.

For the purpose of responding to the following questions, "Illegal drugs" include the unauthorized use of prescription medications or over-the-counter drugs; it also includes the illegal use of any other substances for the purpose of getting "high."

Your responses should include - but not be limited to - your use of any of the following:

  • Amphetamines / Methamphetamines (Uppers, Speed, Crank, etc)
  • Barbiturates (Downers)
  • Cocaine / Crack Cocaine
  • Designer Drugs (Ecstasy, Synthetic Heroin, etc.)
  • GHB (Date Rape Drug)
  • Hallucinogens (Peyote, LSD, Mushrooms)
  • Hashish / Hashish Oil
  • Heroin / Opium
  • Marijuana (with or without a prescription)
  • Synthetic Marijuana known as K2
  • Mescaline
  • Morphine
  • PCP / Angel Dust
  • Quaaludes
  • Steroids
  • Tetrahydrocannabinal (THC)
  • Glue, paint, or any substance containing toluene

    • Have you ever used any of the above substances?

    Yes:
    No:

    Have you EVER engaged in selling, manufacturing, purchasing, furnishing, cultivating, carrying or holding for another ANY illegal substances, including marijuana, or any other drugs you were not professionally prescribed?

    Yes:
    No:

    Are you now, or have you ever been in ANY branch of the military?

    Yes:
    No:

    Have you EVER been detained by law enforcement for investigation, arrested, indicted, charged, or convicted of any misdemeanor or felony offense in this state or any other legal jurisdiction (including offenses in the Uniform Code of Military Justice)?

    Yes:
    No:

Signature

I agree to the conditions and certify that all statements made by me on this form are true, correct and complete, to the best of my knowledge.