/Et

6.

5'/r
ffi

7.

Are you a U.S. Citizen?

8,

Have you cvcl used any other name?

K/4
color

Hair
NO

4e!,
color
DYe

NO

Natural Born

NO

Ton
Nicknam

Aliases Used

name? YES @
If "YES", what was your forme r name?
"/t
44
What Court ordered the name change?

9.

Have you ever legally changed your

il.

MILITARY SERVICE

10.

Complete Military Service:

11.

Tyf"

"f

Dilt*rg"

(tf

"ther

than Honorable' cxplain)

and Unit
of Reserve or Guard Unit, specify Branch

1a

If member

13,

Did you ever receive any type of disciplinary action?

Court Martial?
AWOL?
Reduction in Ranh?

Article
'AnY

14.

Dates Served

Service#

Branch

15?

other?

Namc and phone number of thc last supervisor:

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

24.

Ifyou wear correctivc

if you lost tlpm in :t scuffle

CLD9 NO
ynu still function?

lenses (glasses or contacts) and

rvith an inmate or suspcct,

"uul,l

lv.
25-

List nrcvious law cnforcement cmploymcnt starting with the most recent lirst:
Namc/Addrcss of AgcncY

$*4

Dates of Ernploymcnt

fr;i"8\l::

Lcaving

Name and tclcphone number of immediate supervisor

Job Title and Duties

NO

May we contact this agencY?

26.

nfuc

5"bdz,

d+{"t\p 4t

Name/Addrcss of AgencY

be@^<

t . tl^J
Lfffrrnsil ral t<4'

bil,

qN

for Leaving

Datbs of EmploYment

-b5t?
Nnme and telephone num

of immediate suPervisor

r,

fl rI"ll +hq faservA't;6nl

Ya+rcI Ull;ce
job Title and Dutie-s Lrtt'rt't
J d e+a,n

?t+v+ntson

May we contact this

agencY?

4r
l,
No We u*-e nof a oll

,1
Narnc/Address of AgencY
Rcason for Lenving

Dates of EmploYment

Narn" ottd telephone number of ilnmediatc supervisor

.Iob Title nnd l)rttics

M:ry we contact this agcncY?

YES

NO

OR HAVE BEEN A
COMPLETE THIS SECTION ONLY IF YOU ARE CURRDNTLY
pops NoT INCLUDE SllcuRlTY AND/OR
LAW DNITORCEMIINT Onnt6En--ruls
CORRECTIONS EXPERIENCE.

28.

Are you currcntlY a Pcace Officer?

29.

If "YES", Statc of Certification:

30.

Certification Date:

31.

you have?
How many years Law Enforcement experience do

32.

Have you ever been the subject of an internal investigation?

Certification

#:

Name of Police Acade mY:

/.s
YES

giving full details'

If*YES', attach an explanation to this application

JJ.

Have you ever qualified with a weapon?

tno

-).t.

1{

(10) vears beginning r.r'ith thc most rocent

List previous ernploymcnt fot' the past ten

t55ror

Name/Addlcss of AgencY

atuq

flz- xqq'4q67

Ileason

Dates of EmPIoYment

Pa-il ?s-'3q?'Llqa7
Gil^*t t"t.ph;e number of immediatc
S"bs
.Iob Title and

Name/Address of AgencY

7fu

4
Da{es of EmPloYment

t"t.pLt. "fiber

Job Title and Duties

'e

c.nlNo*'*r66nt'gW w6 lt""i,'l 4n be",*p af"Aol t*v

lrs* 4t norsuC [a"rt lrvtl
^oA.
Reason for leaving

of imrnediate supervisor

l-t

4 a,J ()dnr*L)

itt*.1j'h" pl nok

5k)lok

a'tnb*' Crnu'+ pt<vt"t

a&l/141t/-

Name/Address of AgencY

S/zalzat

,t4160

5l-

rel

ffiffi

supcrvisor

es

36.

I(forelcaving

,rtl

Sbkl '

Dates of EmPloYmcnt

- 105'7lrv
N"rneind

b"r of immcdiatc supen'isor

t"l-pltt

.Iob Titlb and Dutics

38.

Narne/Addr'css of AgencY

b$k

ut\

Dates of DrnPloYurcnt

o*
I{cason foi' leavirlg

irnr',t.as

i la,ri<+

4vg

Cr4t)
Namc and telephone number of immediatc supervisor

6rt*wrwh

$up,vr*co(

3e. Pq4 Gln"(s noo I

az.rc

lw

l+6(t1s

ft"r^ en t'tw

Name/Address of AgcncY

*ilq/alor

lC,?d)b 0t"
Dates

Reason for leaving

Employment

ffiffi..tTGph"t"
Job Title and Duties

""mber

of immediate supervisor

;rtd"[b.
f49l'*i'It\'

f, o1- lil u,6fu'' Sr,wi lur,|t,ps

vI.

4t.

of
Have you ever been arrested, charged, convicted
a felony offense?

YES

42.

of
Have you ever been arrested, charged, convicted
a firearms or exPlosives charge?

YES

dD

43.

Are there currently any charges pending against

you for anY criminal offense?

YES

44.

of
Have you ever been arrestedt charged, convicted
ony oif"rrt", related to alcohol or drugs?

NO

of
Have you ever becn arrested, charged, convicted
any typc of offcnsc (inctuding traffic citations'
warrants. or misdcmcanors)?

@No

45.

fl{-whnt6,

YES

JL.

Havc vou ever becn relused a licensc by any statc?

53.

Givc details of any motor vehicle accitlents you have bcon involved in'

VIII.
f,{.

Personal references (other than family members)

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Name:
Addrcss:
Telephone:

x.
f,J.

l/t*

Name:
Address:
Telephone:
Type of Account:

Name:
Address:
Telephone:
Type of Account:
Narne:
Address:
'felephone:
Type of Account:

,^^

/'6nnlt o" htaan

X.

50.

Marital Status:

Married_

Single-}|-

Separated

Divorced

Widowcd

57,

Spouse:

(First/Middle/Maiden/Last)
58.

Spouse's place of

Spouse's date of birth

birth

59.

Spouse's occupation

Date of marriage
60.

Spouse's employer
61.
Spousets employer address

62.

Spouse's length of emPloYment

Spousets employer's Phone

63.

Is your spouse in favor of you becoming a

Law Enforcement Officer?

64.

Father's full name:

Address:
Living

Deceased

Mother's full name:

Address:
Living

Deceased

65.

66.

Brothers:
Narne:
Address:
Name:

Address:

YES

NO

67.

Sisters:

Namc:
Address:
Name:

Address:

68.

Father-in-law's full name:

Address:

69.

Mother-inJaw's full name:

Address:

'10.

Closest living relative:

Address:

71.

List every child born to You:

Child's Name

Date of Birth

Address where child resides

11

Are you supporting all chiltlren born to you or adopted by you?

/J.

Are you related to any Chatham County employee?

If "YES",

@No
YES

G}

please name the emPloYec:

What department do theY work in?

ni

Do you l<now any employees of the Sheriff s Department?

If "YES",

please give

thcir names:

60

XI. OTHBR INFORMATION

75.

76.

This position may require you to:

Wear a uniform.

Do you object to doing so?

YES

Work rotating shifts.

Do you object to doing so?

YES

Work overtime.

Do you object to doing so?

YES

7'7.

fub, Tn;tr*l nfivu^a*

than for an arrest'

have ever been fingerprinted by a policeagency other
agencies'
give details below. Your inswer will be checked with FBI and other

Ifyou

Agency

Prrnot' (ny'a{nqt

Agency

Yurpor"

78.

.f
Do you drink alcoholic beverag
""? I ,/",^,1
,,VES",
time?
last
the
was
when
If

79.

Have you ever used marijuana?

If ,,YESt'. when was the last time?

),. ,
^ afu{
WfgIvY

80.

pills' etc'?
Have you ever used any other illegal drugs, opiates,
What werc the circumstances?

81.

Do vou now or have you cver associated with an;one.that

82.

83.

@no

Have you ever hnd experience working shift work?

Ifso,whereandwlren:

@
@

u/u'r@
nO

YES

u'"td"98t@E
If ,,VES",who werethey? il4q ntr/lvv tit (ah4arnn {'5b{ nazbrt

@
NO

for breach of trust'

Have you ever been fired or permitted to resign employment
YES N(
--i-^',
^iL^-r crime?
embezzlemcnt, theft, or othe
If "YES", what werc the circumstances?
for abuscof
Have you ever been fired or perrnitted to resign cmployment
or for any disciPlinary rcasons?
If "YES", What were thc cit'cutnstanccs?

3,'Kbt

84.

necessary in the course of policc duties to take a human Iifc, wouJ!.you

YEs /drD
have any reluctancy to do so becausc of religious or othcr beliefs?

If it became

If "YES", give details:

85.

In the space provided below, givc a bricf biography or history about yourself' This
must be in yout otn'n handwriting. Begin with your past, bring yourself into thc
present, and project yourself into the futurc. Tcll whcre you werc born, where you
g."rn up, significant experiences, and accomplishments in your life' Tell something
i5out yourlofbies, special interest, and any othcr subject wlticlt "zeros" in 'n your
indiviiualify. Dcscribe your reasons for a position in Chatham County Law
Enforcement.

mc is true and correct

attest I)y my signaturc that all thc information supplicd by
orvlcd ge.
to th

zs//

Signaturo

Datc

WILLINGNESS CHECKLIST

|nthepast,manypeoplehavetakenthejobofCorrectionaIofficerWithoutcarefu||y
consideringtherequirementsofthework.|tisinyourbestinteresttoanswereachquestion
honestly.Foreachjobrequirementonthe|istbelow,circ|e,,YES,,ifyouarewi|lingtodoit,or
"NO" if vou are not willing.

Do you believe an inmate can be rehabilitated?

personal prejudices and be

Do you believe that you can set aside any
fair in dealing with inmates convicted of serious crimes?

Are you willing to work a twelve (12) hour shift?

Are you willing to work alternating weekends?

your regular days

Are you willing to work all holidays which are not on
off?
are you willing
ln the event of an emergency, such as a shift vacancy'

to work on Your

daY(s)

6.)
@
@>

e@

NO
NO

NO
NO
NO

NO

C9

NO

off?

day?
Are you willing to wear a uniform to work every

Are you willing to work in a tobacco free environment?

develop
Are you willing to participate in training to learn and
officer?
techniques and skills required of a Correctional
such as
Are you willing to use reasonable force when necessary'
controlling disturbances, breaking up fights, etc"?

to inmates who are ill or

Are you willing to give first aid, including CPR,
injured?

of their sEx and

Are you willing to search (frisk) inmates regardless
the same sex
visually search (strip search) the body cavities of inmates
to have?
as you for things that they are not allowed
of tlreir sex' while they
Are you willing to supervise inmates, regardless
are in the bathroom or shower area?

@
@

NO
NO

v$/

NO

NO

NO

'uFi

NO

ADDITIONAL INFORMATION SHEET

APPLICANT:
Social Securily

5r,t,6.r'

Ilow long at curretit

addres

"l

4!:L

PLEASE L]ST ALL CITIES LIVED OVER TI]E PAST 15 YEARS:

STATE

CITY
&cl,$r'r/i

lhor^,tx!114

?rwic
UnG'!

UtI**

{'i'd, (wo,r*
Itn(nJ

?;urnlt

fa/tlw,'"
(

Qfnlun tt arr/*"+q
ilslwr tt t lu[uu
?/7/?do +o tto/uoX

kru nn

Qe.oroti,,'

114 {l

FROM (MM/YY)
TO (MM/YY)

COUNTY

f?t'0,,.4t

(2ft'oz*

G' St*' 1",;

a(i tail-4.

U,v,n
I aA tr t-144

Qa Ao.n'J,*

312/ntt

9^ 6/rdb'

1/zlt{

a/tfzot,

+t

Qol,nz

iF/rtn

(ID: GOOD BEH{Y|OR'

ANY ARRFIST, CONVICTIONS, WARRANTS ISSUED
CnIlo sut't'oRT, woRTHLuss CITECKS, AND ANY TRAFFIC TICKIITS)

CHARGE

DA'TE

CITY

{\tt r
<alkli

7s6b

fe-w9

f"lnh-d*A^l

7@x

("trvis

lc{((?

I\J V J'

COUNTY

STATE
(ABV.)

DISPOSITION

tpl

{;;,#:;';;rL*

hp,+tu

CGl

ga4

LutrO,/A

Crl

po.il o' Gw

8Wcho1*,r

a#ne

Review of Application
Professional Standards Unit

, reviewed

I,

my apPlication

with
for employnent with tlte Chatham County Sheriff s Departrnent

or,

lL

& -?ntl. I attest that all information submitted is co'ect and trutSful I understaud

may result itr a termination of my

that any false statements made klowing or willingly by me'
application with this Depalttneut.

., f)

/r<o /)l

h A-!//'(^'of

Sigriature

-#

APPlicant

Ddte

Signatule of Investigator

tAlSDltl
Nctary Public

LAML0lFlt 'q
NOTMYNruC

cHAnNl couffix GE0mn

l{Y C0Uul$KN DfrRES i,tARCil 17, mfi

Date

t.

:i@Fso,s )

ii6|,'./

{c"..'Y--:!*'
(i!!1!Lt)!Y'e
'J

LAUTENBERG SCREENING FORM

frorn owning'
NOTICtr! Congrcss cnactcd lcgislation that prohibits ccrtain pcrsons
or thcil'componcnt parts' For tltis
possessing' storing, or tr'lnsporting firearms, ammunition
(antl in somc cascs our curlcnt
reason, it is neccssary to screcn all cmploymcnt canditlatcs
..for causc,, circumstances) to t|etertninc if they fa|l witlrin thc prohibited group of
enlployees in
Codc' Section 922) ft'ottt possessing
pcruons cxcmpted by the Lautcnberg Act (18 Unitccl Statcs
for any person in the
fi..u.rn, and/or anrmunition. The Lautcnbcrg Act makes it a felony
Also' Lautenberg makcs it a felonious
prohibited gro[p to won or possess firearms or antntunilion'
to any pel'son who falls within the prohibited
act for any person 10 providc lircarms or ammunition
to "arm" a pelson who falls within this
group. Therefore it lYould be unlarvful fol thc department
categoly.

officers must be capablc of carrying and

is, or shoultl be obvious, that larry enforcement
to perform their routine duiies in this state'
being proficient with the use offirearms to be able

It

kno\Y all candidates and currcnt

For these reasons' it is essential for the department to
Tlterefore' it is ncccssaty and imperatiYc that
employees are free from the Lautenberg prohibition
oath' Yottr written responses and
you urr.r""r tlte following questions truthfully while under
sign.ture must be witnesscd by a rcpresentative of this department'

to completc this lorm but in so doing' they

Canditlates for employment may choose to rcfuse

nrustunderstandthattlreywilleffectivelyrvitlrdrarvtheirapplicationfoliemploymentwiththis
depaltment'Candidateswhochoosenottocompletethisforrnanrlthel.ebywishtowitlrdllawtheir
applicationfromconsitlerationforenrploynrentshouklwrite..refuset|''ontheform,signit,antl
(lcpartnlent repr.escntativc. crtr'rent cmployees undergoing atlministralive
have it.ryitnesse(l b), a

subiecting themselves to
inquiry may not rclusc to completc the form under oath without
rliscipIinaryaction}Yhichmayinclutlesuspension,dcnrotion,or.termination.Cur.rentenrployecs
this subject, ate encouraged to consult the
ryho havc qucstions or desirc more information on
Professional Standattls Unit.

ffilrarnCountySIreI.iffsDePartment,voluntariIyagrec
rrntlcr onth'
rvhile
an(l conscnt to answer th following questions truthfully,

CHATHAM COUNTY SI{T]RIFF'S DEPAITTMENT

AGREEMENT OF CONFIDENTIALITY

,t t2 l,i ll
, by affixing my.signature
l,
h!/ -klLAUta
to tt i, a*ffint b.low3o signify and agree to the following conditions as
member and employee of the Chatham County Sheriff s Department'

I agree to perform the duties of my position in a confidential manner'

savefort-hatinformationopentopub|icdisc|osureasrequiredbylaw'oras
otherwise authorized by the Sheriff'

I further agree to only discuss the duties, functions' and incidents

and other
involving the Department with fellow members of the Department'
the
public aiencies, and always within the confines as stipulated within
only,
the
procedure
that
policy
I
agree
Manual.
and
bheriff s:Department
permission of the
exception to this agreem"ttt tttutl l. with prior consent or

sheriff or undersherif{, I agree not to possess, distribute, sell, deliver,

duplicate, or carry from the confines of the Chatham County Sheriffs
record' or
Department' any document, duplicate document, or other official
expressed
article which produces records of the Department, without the
permission or consent of the Sheriff or Undersheriff'

Member

/*

1 . It7
'-=

Date

CRIMINAL JUSTICtr I{ELDASE WAIVDIT FOR NEW APPLICANI'S

'l'O: Sl IERIFF AL ST. Ln Wl{llNCt

CI-IA'II IAI\4 COUNTY SI'II]RITI':'S COMPI,EX
I05O CAI{L CRIFFIN DI{IVI]
SAvANNAII, GA 31405

-r'7UF')

Accepllhisis|n|nenl!snr),PersonalIequeslandaulhoriznliontocond0ctaconrprohensivepersollal[)ackgroudi|vesiiga
pendirrgchargeso|arry<|escriplion'aconrp|e|etrnffchislory'crinrinalhislor(ilrc|ll(li]lgfrslob|
repor|,nlcdicalrecords,fUllandconlpleledlsclosureofedjtliona|inslilll
PI-IYSICAL' PSYCIIOLOOICAL'
l'urthennore' lvoltrntarill" FULLY CONSENT TO UNDERGO
thc
irfornralion gathered in lhis
lral
cor)sent
and
psycHoMETR|C, AND URINALySIS DRLIG scREEN TESTINC. I am full)'aware.

complaints or griova ce by or against

nle

screeniDgProce5s,bekDo\Yl|lolheoIfcersl|;e|np|oyeesofChatllanrcou|yshcrjff5Dcparlnrcnl.aswllastl1cofccrs
cha1haD)coul)tJ'Persolluetoepnrtlr.entauorrr"-

rqnired for aPPlicalioll fo

I

cefify lhat

any Person(

hcrbyrclcassaidpcrso"t,laou'*,vo"anrrii.t,iii.y*'''"r.'"yt'"*".,.
Tt,tATTHETNFORMATTONACQUTREDtN,illlsiNVEST|GAfloNBE'USEDFOREMPI-OYMENT'1!RMtNAfloN'o-R...
DlSclPLlNARYD8TERMINA'I.|oNs'a[dllrats0chiDforn)a|io|)beconlcslnratlerofpuhlicinfor

cxisli

g Iaws.

:l
n N I) A LL o f l lEI{
ogt"" o HoLo ileRNa l-I;ss' sl lDlu l:f AL s I LAwRENCE
to all lcnrcnls of lhis rcle as" .vaivcr' and li''tli"r
ANY CIVIL LIABILITY
rnOM
couNTY'
AND
Ct.lATIl'{M
MEN1,
IrMpLoyuEs ol; .rE Ct.lAl.t.tAM COUN ;ly s;tiRltrF.s DEpAI{1
COMMISSION'
OR
OMISSION
ANY KIND OR DESCRIPTION, INCLUDINC ACT OF

OI'

lcmrs rrrd conscqtlcnccs of nl)' action

sisDattlrc

SNoar ill {Ic Ifcscrlcc ol

l{cvkcd.luly !2, )001

JAYDA JAOKSOI'I

Notarv Plrblrc, I rberlY CounlY GA

My Comn,'sslon E\prres Augl,5l I J 2013

CHATHAM COUNTY SHERIFF'S DEPARTMENT

Inundertakingthisagreement,Iunderstandthatlhavecertainrightsunderthe
the following;
Fair Credit Reporting Act which include but are not limited to

against you'
You must be told information in your file has been used

You can find out what is in Your file'

CRA'
You can dispute inaccurate information with the
Inaccurate information must be corrected or deleted'

information'
You can dispute inaccurate itens with the sources of
Outdated infornation nay not be reported'

Your

consent is required

that
for reports that are providecl to employers, or reports

contain medical information'

You may seek damages from violates'

Ifyoudesireamoredetailedexplanationofyourrights,youmayrequestacopyofa
no cost

on request and at
ofyour rights under the Fair Credit Reporting Act
fron the department legal office or from the Training Unit'
Credit Reporting Act' I hereby
Being knowledgeable of my rights under the Fair
to order and obtain a Consumer
authorize the Chatham County Sheriff s Department
purposes'
Report to be used for employment consideration

,u*-ury

/*2a-

Signature

zarz-

CRIMINAL JUSTICE REI,EASE WAIVDR TOR NDW APPLICANTS

'l'O: SIilllllFF Al- S'l', LAWRIINCE

cl.lATlIAM COUN I'Y Sl'lllRlIl?'s coMPl-llx
t050 cAI{l- GltlFF|N DRlVll
sAvANNAll, CA I l40s

NUMB

,(

Accspl this irlslruDlert

as

pendillgchargesor{nydescriptiotl,lconp|ele1;m|trisror,c,irninattrisror(iDclr|digfrsloffenderslatt$,i|npp|icable)
report,Dedic!trecords,fullandconp|etodisc|osureofeducationalinstittltiolls,fi[a|lciatslnlentenls.
admil|islra|io[;entp|oymcn|andpre-en]pIoyn1el]|records')cludilgb8ckgro
FULLY coNsENTTo UNDERGo PHYSlcAL' PsYcHo]-oclcAL
i
complairts or grievance by or sgaiisl nre. a",ti'i-lo", ""lu"otiril"
gnlhered in lhis
I 0n tulty awsre' srd co,rsent lhal lhe irfornulion
TESTING.
SCREEN
psl,cHoMETR!C, AND URINALYSIs DRU6
screeDiDgprocess'beknovnlolheofllcersand;nrployecsofchalhan)cotlllq,Sheri'l-sDepar|lnenl'[s\v

c|ra|hnIIcou0|yPersoDl'"|D"p",tn,"ntor'.ltt"ceirleel.eorficerssla
rc*rired for applicstion fo

Icefli$,lhalanyperso[(,1'*l'ou'oyrrr,ni.tl"u"i,i.

herebyreleasesaidperson1s1fronranyanaatttiatliiiq,;I'ij'*.yr'"i""i'"ed0siJestlofffl|d]i
TFrAT TI.rE INFORMATTON ACQUTRED IN

iiJiSitluesTlcalott

nu usED FOR EMPLOYMENT' TERMINATIoN' oR

D|sclPL|NARYDETERM|NATloNs,arr<rrrrars.."t,inro,n,.'ioui,""on'".nntlt|crofp[b|ici|ifont1ntio8ndis8ocessiblcl
exisling l[$'s.

lo all elerrtctrls

oIlIis

releasc rvaiver. and turttrer'agrec TO

.1.r,lE
cr.rATr.rAN,{ couNr\. s;ERrFF,s
coMMlssloN'
oo ,escRlPlloN' INCLUDINC ACTOr o[4lssloN ol{

EMpLoyEEs or,

ot'nn,v rtnn

OTllER
l-lol-D llARMI-ESS' Sl lERlFf Al' ST t-AWRENCE' AND ALIl' I-lABll'l'rY
clvl
ANY
I'RoM
l'l',
N4
couN
DETAR T-N4ENr', AND cttAll t

lcfl rs an(l conscqucllccs of nry aclnn

siAnrltrc'

Swon

irr lhc prcscnoc

l{evised Joly 12,2001

oI

JAYt]A JACKSON

Notafl lrtrblir;, trbelty Courrly, GA

My Comrnissiorr lirpites Au1]u;l llJ' 2013

gr"f+'*f*:
b:*:rrn

\C

CHATHAM COUNTY SHERIFF'S DEPARTMENT

In irnt|ertaking this agrcement, I understanr] that I havc certain rights undcr the
Fair credit Reporting Act which include but are not limitcd to thc following;

you'
You must be told information in your file has been uscd against
You can find out what is in Your file'
You can dispute inaccurate information with the CRA'
Inaccurate information must be corrected or deleted'

You can dispute inaccurate items with the sources of information'

Outdated information may not be reported'

or reports that
Your consent is required lbr reports that are provided to employers,
contain medical information.

You may seek darnages from violates'

a copy ofa
Ifyou desire a more detailed explanation ofyour rights, you may request
Act on request and at no cost
summary ofyour rights under the Fair Credit Reporting
from the department legal office or from the Training Unit'

Reporting Act' I hereby

Being knowledgenble of my rights under the Fair Cretlit
and obtain a Consumer
authorize the Chatham County Sheriffs Department to order
Report to be uscd for employment consideration Purposes'

CHATHAM COUNTY SHEIIIFIi'S DEPAIITMtr]NT

EMPLOYEtr DATA SHEET

Nanre

s"*. hM{

*lnto

Poc": Blacb
Marital Slatus:

egc:

S V

4l
D_.-

Physical Ilome Add

MailingAddr.ess: aiia;ifuh(e trfup

a;i;El;l;

zi;

Work TelePhone:

Horne Telephotte:

(aren codc)

Spouse's Nanre:

IN CASE OF EMERGENCY, PLEASE NOTIFY:

check:
Professional Standards Urrit conducted a critniual history

NCrc/GCrc

l-46-A)n-

orlrerAgency:

l-+o'AE'i>

o
? ,/,
fr,y* C{\('O;'

C.C.P.D.

Date Conducted:

TL,tn^*ilt-31

Corrducled:

Polygraph Exatninarion:
Signature of Invcstigatorl

Yes

Date Conducted:
Date Conducted:

=l--No-=-

Date Conducted:

t",

-No/

for
The above llame person has been reviewed by r{iyselfand:
Chalharn Cotlnly Shcriffs lD carcl

.lail Adrnil1istratol

Maior'

No

Date

Other Agency:

Equifax

S.p.D.

Yes

I - d{2 ''Od i"I'

rik

F.r"rdFf
}: S-*_ryf.c

u-s...=qtf

rnrrr

Ei-tF-t

,&1:

OFFICE OF THE SHERII

\-HATHAM COUNTY, GEORGTA
En ht@ n e. t OP. ratio 6 Adn n is Id I o.
Col, John wilch6r

A$ L Enfo r. e n e n I

Ope B I io

^.

A CIE i.Di. I @l Ol

Majo. B an Counihan

J.il ope6tb6 Malol

Meior Thoma3 Gilbq

Major &mbny Middlelon

AugnsI24,2012
MR. BURT AMBROSE

R]CHMOND HILL,

A, 3 1324

MR. AMBROSE:

"rt

LIKE TO WELCOME YOU AS YOU

ON BEHALF OF SHERIFF AL ST. LAWRENCE' I WOULD
srAFF'
cAREER AS oNE oF THE NEwEST MEMBERS oF ouR

irenr voun

YoUAREToRxPoRTToTHETRAININGLTNIToNWEDNESDAY,AUGUST29TH'2012AT
PHYSICAI- AND RECEIVE YOUR
8:30 AM TO PROCESS PAPERWORK, COMPLETE
UNITORMS.

4TH,2o|2 AT 0730 HOU^RS.-YOU

YoUR START DATE WILL BE TUESDAY, SEPTEMBER
(THE RANGE)' YOU WILI- BE
WILL REPORT TO THE RECRUIiMT'NT NNO TANTNING UNIT
ADVISED OF YOUR ASS]GNMENT AT THAT TIME.
EMPLOYEE AND WILL BE
PLEASE REMEMBER THA'I'YOU ARE A PROBATIONARY
NOT BE ABLE TO TAKE AT{Y
PLACED ON PROBATION I''OR-ONE YEAR. YOU WILL
ANY LEAVI YOU TAKE
LtrA!'E UI,{TIL YOUR I'ROBiTION I{AS BEIIN COMPLETED'
NO PAY"'
WITIIIN THE FIRST SIX (6) NNONTHS WILL BE CONSIDERED "LEAVD
ONCE AGAIN, CONGRA

NS

WELCOME ABOARD.

HARLEY/DIRECTOR
CAPTAIN
RECRUITMENT AND TRAINING LII\IT
THE CHATHAM COLINTY SIIERIFF'S OFFICE

(]A
Enforcenrent Burcau - P O- IloY 1 0026 - Savannah'
31405
CA
Savannah,
Drive'
Cliffin
Carl
Jail - 1050

3 14 l

TclcDhone (9l?.) 652-?634 - Fax (ql2) 052-7660

't clcphonc (91 I I 652-7152 - Fr:\ (912) 652-11'15

)FFICE OFTHE SHERIF

CnATHAM COUNTY, GEORGIA
Ealo.@danl aatu1tsl.Eld
Ll. Coloml

En t@E n En I

Thmd Sl@k

Ope tatb ns Adntnl isl Bto

Co[ Jorn Wikh.r

Aetl. Jail AatnhElt tott

Molor Howlrd tlE n

Mrior Kinbenv MEdl6ton

May 14,2012

MR. BURT AMBROSE

ItRICHMOND HILL,
_

A, 31324

MR. AMBROSE:

DEPARTMENT' WE WOULD
ON BEHALF OF THE CHATHAM COIJNTY SHERIFF'S
DEPUTY CORRECTIONS
LIKE TO THANK YOU F6il-'OUR APPLICATION FOR
STAFF VACANCIES' WE CANNOT
OFFICER, AND DUE TO TTTS iTMITEO NUMBER OF
OFFER YOU A POSITION AT THIS TIME.

AN ELIGIBILiTY LIST' YOU DO

HOWEVER, YOUR NAME HAS BEEN PLACED ON
WE WILL REVIEW THE
NOT NEED TO CALL, EEaAUiE A'S OPENINGS OCCUR,
YOU TO SEE IF YOU ARE STILL
STATUS OF OUR ELIGINTT.iiV TiSTMD CONTACT
INTERESTED IN EMPLOYMENT.

IN THE CHATHAM COUNTY

ONCE AGAIN, THANK YOU FOR YOUR INTEREST
SHERIFF'S DEPARTMENT.

srNcERELY,,,//

M,ru

C,{PT. HERBERT HARLEY/ DIRECTOR

RECRUITMENT AND TRAINING UNIT
CHATHAM COLINTY SHERIFF'S DEPARTMENT
CC: FILE

llox 10026 - Savannah' GA 31412

Savannah, CA 31405
Drive,
Grif{in
Carl

Enforcemcnt Bureau - P.O.

Jail - 1050

Te leDho ne ( 9 f 2

i"t"i,trun"

io

) 652-

'1

634 - F^x

(912) 652-7 660

zi csz-7'ts2' Fax 19t2) t)52-7-l't

OFFICE OF THE SHERII

CHATHAM COUNTY, GEORGIA
nenl Ad nhtshatol
Major Thomas Smoak

E nlat@

E n lorce ne nl O pe I a I io n s ad mi nisl rcto r

Col. John Wilcher

Assl. Jail Ad nntsttabts

Malor Hwad Ham

Major Thomas Gilberg

Aprrl 18,2012

Mr. Burt A. Ambrose

Richmond Hill, GA. 31324

Mr. Ambrose:
Recently, you

inte

iewed for the position of Depufy Corrections

Officer with the

ChathamCorrntySlrerif|soffice.Afterreviewingyourqualificalionsandtheresultsofyour
initialinterview,youhavebeenselectedforthefinalinterviewwiththeAdministratorsofthe
Jail.

at10:00 a'm'
Your interview has been scheduled for Thursdal" April26th,20l2
Pleasedressintheappropriateinten'iewattire'Malesaretowearasuitandiieordressshirt'
slacksandtie.FemalesaretowearaSkirtSuitolpantsuit,dress,orslacksanddressblouseand
orskirtarrddressblouse.InterviewsessionswillbeheldattheChathanrCourrb,Slrerif|s
Department(Jail),l050CarlGriffinDrive.Pleaseentertlreflontlobbyofthejailandremarn
seatea uotit You a:'e called

Ifyouareunabletoattendyourinterviewsession,pleasecontacttheTrairringUnitat
(9|2)652-7795'Interviews"'-otb".",.h"duledrrrrtiltlrenexthi-r.ingrorrnds.Ifyoudonot
Training Unit' your appiication will be filed
attend and fail to contact The Recruitment and
your application'
and no further consideration will be given to

eyl Director
s Depatltnent
Sheriff
Chatham County
Recntihlent and Training Unit
cc: tilc
Er)lbrce errlBltreau - P.O. Box l(tl)26 - Savannrrir'
Jail - 1050 Ctrrl Crifin Drile, Savilnnah, CA 3l'105

(iA

31412

Ielcolronc r9

'fcleplro'rc

L')

652-'1634 - l:a\ (91? l ('5 2-7 660

l?) 052 '1152 - F:tx (t]12) '\t2"1'115
| 2J

(lhatham County'$hcriJl's Dt:partmcnt

enf
Conditional Off'er of Ernplo)'n'r

you
fifness test and oral interview'
physical
lJpon successful conpletion
polygraph test' Af
Stanriarcls Unit for a
Professional
tlre
to
will be foru'ardecl
is offering you a
Department
s
Sheri{f
Counf'1'
fhis time, flre Chatham
successful
This offer is contingent upon
empiol'nrent'
of
offer
conclitional
complete background
test' final interview' and
polvgraph
fhe
of
completion
o1'fJre

in'r,esfigation.

If

this
your current emplol'ment at
fl'om
resign
nof
you
-do
is important fhat

time,

. : ,

-. .: -

Allplicanf Signature

2-,

,41-

./'o</

lla it

/?,'--

CHATHAM COUNTY SHERIFF'S DEPARTMENT

trMPLOYEtr DATA SHDtrT

MTDDLE

LAST

sEX

nacn-

/il 4 {-(

"ETGHT

5'

AcD L{l

d,l/Lzfzo
HAIR /3lL
nvrs 4t-rl/
f\
MARITAL STATUS S I/ IT

-rB1!--

wucur-!?f-

lf"

SSN#

DRIVER'S LICENStr NUMBER

pHysrcAl, HoM t,

oov

,ffi

CLASS:

^DDRDSFI?4!,

tzqAw'l l:!!

(NO P.O. BOXDS)

MAILING ADDRBSS
STREET/P.O.BOX

kA

4(23:t4

ZIP

STATE

CITY

A B O@

CURRENT HOMtr PHONE #

EMAIL ADDRESS
TELEPHONE # AT WORK

SPOUSE'S NAME

NAME OFHIGH SCHOOL:

DO YOU HAVE A G.tr.D.

CERTIFICATE? YTS X

NO

CIRCLD HIGHEST LEVEL OF EDUCATION:

HTcHScHooLDIPLoMA

IN CASE OF EMERGENCY, PLEASE

r tf e-\ U2fi t.U-et

t' ' '

/-'t

NAME
I}ENEFICIARY
ADDRESS

RI',t,ATIONSHIP

BACHELOR'S DEGRED

NOTIFY:
T..A
6/tl ?st'-tYqi '''

MASTDR'S DEGITED

'/z

6'?-/@

TDLEPHONE #/ALTERNATIVE #

aHr*Hr
r:lr..llrrng

L+Ill|?ft{ds-"{tFrtt

dEErI+G.E=rir6--Ep
"

]t-tF,,o

l.r-..,+"dr.,a

FROM:Richmond Hill Police

Dept.TC :'^706 02/

01

/20121 3:54 40 #30846

P 0n^

/0^j

CRIMINAL JUSTICE RELEASE WAIVtrR FOR NEW APPLICANTS

'l'Or

Sl-lliRlff AL ti'r. LAWI{llNCll

cl.l^ll IAM COUN'ty

Sl.lER rF'S COMpI-DX

Ot{pnN DRIvE
sAvANltArJ,0A 3t405
t0S0 CARL

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Fndln|ihn[c$0|.![yd9scripli0n.ilcon0l0G[0lli6ltlttor',9|ini0!Ihi|lor(inch/l|un/r1dfenuor,{k\|x,i|hiillcnb|0),cldhi||0r
rJpn.nbdim|rc4onj[.l.tl||lIdflpldtqcl'cla,|lroot'cdltctt(io||Dlini|i|u|ioni,|'lllnltlJ|ll||tntsm0n|[ndl

|d[t|||i5|ll0t!lch}t|6yfcntA$d''rj+mpl0y||lcnlrcoldr.inc|udi|]ghlcl8'0|n|t,lt!|'or|i.|ygf0hcxn
conrthifl6 ef r,rlcylnca lry of!$/rinfit n|c. ru(hcrnlorc,l v0lutlurilt, rul.l"Y CoNSh'N'I1'O UNDERoO PllYSlCAl., PSYCiIOLOCICAI,.
pgYCHOM0l'RlC, AND UIIINALYS IS DRUG $cltltBN TEsl'lNg. | 0n l'ully nworc. Nrd 4orflllit tll th$ infcmulion
8ltltctud ii thi3
ttcNc0i0!lrocg6r.boln0wt|lolhuofqcnndc|l|p|oy0uNo|'cllnth!|llc0||,ny6h6d|l.rDupfr|m6n|,llliwc||n$t||o')l(er6!id
lt{nwrll DcFddrlont 0nd th9 Oc0lgiu Pcrec Olllc.B Stdndrrdr nnd l'nri in8 Council. l n u\4oic tlrtl$rqt i4lofnutinn
lo(',iNrt|.0rttm|icnlionf0r|)'o.lj.T.c.finoJt|l0||0,$|uucI1bd.{mcnlollicnr,I0ds|np|oyrnontw]dthec|lnlhU|coul|yshQtlf

Cholittn Co[nl y

ii

|'cn|fyl||!t0ttyF''on(')w|tomuyfmirltsttcltiofonntllionc0[c!nln8nlDE|t0||tul'eh9|dl|cc0unt[blc|aI8ivh|Et|||3hlb.rn[tiqt;0id|d0
||ert||yr|rNcit|idpcnion(')non[nynndu||||0h||l|yt'h/dllmlryboinc!rredtri||rlirll||of|0.n|rhin8suehlflbrdit|oI,Thcrc|hlc,IA6RE
IN TI,IIS INVBSTIOATON BD'U$IID FOR EI\4PLOVIVI'NT. TIIRMINAI1ON. OR
^CQUIRIID
DISCIPI,INARY
DEfBflMtNATloN.$.
'NFORMATION
md thol$udl informntloD bccohlr n dottorofF bli0 irrfom ionrnd i$ rcoq lbls r.r thetublic ndcf

TI.IATll1B

s*iiting lttwx,

|n0ot8idornt|o||of{kh8liJ'Ii.[|ionforlrnn|0ytm|l1.t||td|!omplc|90Id$i
(o0llolsnrcrti 0f{hjrrqhir{ wrriver, md li,nlrcr ngn$ t'O ITOLD HARMLIIS$, $l,lDR lF ALs1'j,AWRdNC8, AND ALLOI ItER
EMI'I,OYEES OP'T[E CI'IAII{AM COUNTY 9IIIRIFT'S DBI'ARTMRNT,
CIIATI,IAM COUNI'Y. FROM NY CIVIL LtABII,IT'Y
^ND
orr
KrNt)o( DEscRrmt0N. rNcLUDtNo AcT orr oMlsstoN oR coMMtsstoN,

^N?

Tl|ixdco|nl[lionirf0dof.gc|y0ndvolutllfri|ywit|QUtfc|tro|pl|nkl|rn0loiF$
lcrrt]l nttd 9oDtrtqu{lou of

lry

uclion.

Ap|Dlocol'yorthu8&|C4|o|or[|wj|lbcv,|idnsnt|ori8i[[llitclGoqcvoitllon8|l|h0[ltidpholuc4pyd
$iSnuturE'

'fl\it

3,O

S\vom

iI

dtty ol

lh0 prc{c||co

ol\

aovked J"ly 12, t00l

JAYDA JACKSON
Notfiry Public, Llborty Counly, HA

' My

6on1rni66l0n Expif6s Augusl 1:i, ?010

.-F

-lrgqr-rd

THIS RECORD IS VALID FOR BIBTH ONLY

636 47

STATE OF LOU IS IA I! A

CERTIFICATE OF

LIVE

BIRTH

'iLi"

tn--se!7ia!l970

AnLhonY
Tlpl.r B

8: 16

orunrurr'

Lake Char le

Calcasleu

ffi

Ye!

St, ?aErickts HosPitaL

2434

cline

Louis ia

Calcasieu

Lrke Charles
''1. HA,,,i-;-;^r

ls ia na

No i-t

o'coronoanr:ro.

"'""" Negro
Po,enr [f

ril 28.

oihe. U

rie

cttne srreet

Loulsiana

'
-

'7lo'zzo

!l-l5iF-.\1. r

CONFtT,F

r!a

Y EAD

L.n

'7n
.7 L'/)
,/

1970

nl':, f r'tqrr

HqA.!.'r!l

UsE

Dul t6r to.r Bnlir)

IS A
A
oF
coPY
to'rr.',r 6 CoRRECT
Docul'4EN"l'
olr
vlrAl"'iilrljrc.rrrE
iEbrS,rrr . D Wt'll t( rH.E._
sl'4111
flll:
REGIsTRY 'f
nidonos
'1-ilrrrirl,r.ln
PLJFISU/ril r' Io LlA
I

1992

L970

JUN

0601

tloi-T-lii"no"a rt'o
.:'"\
oro rho! lh. ch,ld
-or bDrn
rii-i,li'.,'
;;i!o";;;;.
-l-*

06

na

sEree!

s EA

thor
obove !roted
-.1-"rr
--bbn * th"
ono co"ect
'a *t ot true
hy \no.ledge.

IAUG

tr

Yes*-,

LouLs ia na

!434

AM

66- P^FrSB or BrFTa

or

R.lj.

CtrFITIFY THAT THIS

'1():32, ET SEO'

U-l

rtt^*,.,

l"t /\^,-,r,"^r

STA'IF f U:clsT RAll

DRIVE R'S LICEN

i!?F

.:iuiii,qNI r:0Nv
A

irlStiCsE

sex

j-Hgr 5-11

Eyos BRO
115

Wtl

oo rroraoers:asnorazra

4 A At:---

/'1

SE

8$"lJn'o

r-ltal
IE=Iil
6.3-,i;i-l

.c-r"r+r-ilitr,

uryljuryryrylryryvryryLvrytryrryrvlr

DEPARTMENT

OTT

vvvvwvvvvsvvvvv14

PUBLIC INSl'RUCIION

HIGH SCHOOL EQUIVALENCY DIPLOMA

This cetlilies that

ANTHoNY

iiiliiiiil;i'ffi;;;e;.'
i":i:JH:T:l il,"J-,,n'r,."iJo ini,

B.

AMBROSE

.- .

l'"i"c:"ll!:j:,c:l':T:'ll:i:
.'**"'wi,""",i"
^ !:,:'g';,;'"):li:,il*,:i:i';.,:::1";'"""0""
Hish schoor Equivarencv Diploma.

si"-,"_.

"i

Civen undcr my hand and seal of oflice

in the city of Madison, Wisconsin' this
1

3th

day

of SePtember,

in the year of l9 8o
Er;

Not valid
Pr,17a2

"", '"tt

il name

*,*.

has been changed or

alEted

olficial {isconsin Se3l is aflixed

uivalency Diploma No

1!-1-?25

3D16.72

DL,S lntemet Servrces -

Lrrrvm.,.

I nursday, August JU,

ffiffi"i"ffi,

-ffi-

lull

rage r or l

Driving History (N'[VR)

(Non-CertifiedCopy)

Ot DturtJr Sr:ar'l(Is

MVR Search Results

as

of 08/30/2012

Confirmation#: 13612830866
Driver HistorY Years Requested : 3

DOk04D7ll970

BURT ANTHONY AMBROSE

438 River Bend Rd
Richmond Hill GA31324-4308

Number:I-l

License
Gender: Male

Documents Issued

Type: REGULAR
Restrictions: None,
Endorsements: Not Available

License Class: CM

Issued*
Expires:G

Surrendered: Not Available

Non-Commercial Privitege: VALID

ConnercialPrivilege: NOTLICENSED

Limited Permit:
Current Points:
Original Issue Date:

NA
0

09122/2011

This Concludes Information In The Records For This Driver'

DDS Intemet Services -

Monday, January

!--

O'2, 2tJ 12

Driving History (MVR)

(Non-Certified CoPY)

(;r:ata(;t't LTPAKII||N
Or. Irrur"Jr

Srallclr

MVR Search Results as of 01/02/2012

confirmation#:

iIF

Drivor History YeaB Requeated : 3

DOBt 0412711570

BURT ANTHONY AMBROSE

:-tcense lru,,.,r"tIl
Gender: Male

ffil!ffif?,.o,ou
Documenta lssued

Type: REGULAR

Liconso Class: CM

Reatrictions: None,
Endorsement6: Not Available

la3,uedi 0912212011

Expfie, i 04n712016
Suirendered: Not Available
Non-Commercial Privllege: VALID

CommercialPrivitege:
Limited

Psrmit:

NOTLICENSED
NA

/.,,"anf P^inl.:

Original lssue Date:

0912212011

This Driver'
This Concludes Information In The Record8 For

Page

I ot I

rlnting the Driver Hislory

21112

Report
:

CALIFORNIA DEPARTMENT OF MOTOR VEHICLES

*+ *CUSTOMER RECEIPT COPY*+ +
DRIVER LICENSSIDENTIFICATION CARD

INFORMAT]ON REQUEST
08/27/2012

"

ATE:O 8 - 2'7

- 1 2* TIME: I 2 3

DL/I.IO:86l 10430*
AME'AMBROSE,BURT ANT}IONY*

B/DT-N

IDENTIFYING INFORMATION

*HT:5- I I *WT:1 80*

SEXMALE*HAIRBLACK'*EYES'3RN
*
ID CARD MLD: 01 -24-97 EXP :04-27 -02*
LIC/IS

04-22-

*EXPIRED*CLAS

:C

NON- COMMERCIAL & M 1 MOTORCYCLE*

ENDORSEMENTSNONE*

IIEALTH QIESNONNAIRE EXPIRESNONE*

LICENSE STATUS:
EXPIREDf
SURRENDERED BY SUBJECT TO :GA*

DEPARTMENTAL ACTIONS:
*ORDER MAILED:1 0-2
DRV LIC CANCELLED*EFF:I 0-2 I - 1 1

AUTH:I3100 *
REASON:REGULAR CANC*SERVICEf/1 0-2

CONMCTIONS:
NONE+
FAILURES TO A?PE,,\R:
NONE+

ACCIDENTS:

NONE*
END

1- 1 I

-1I

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CALIFORNIA DEPARTMENT OF MOTOR VEHICLES

* * *CUSTOMER RECEIPT COPY** *
DRIVER LICENSE/IDENTIFICATION CARD
INFORMATION REQUEST
0r/0212012
DATE:01 -02- 1 2*TIME: 14:00*

DLAIO:B6110430t
B lD :04-27 -l 97 0*NAME'AMBROSE,BURT ANTHONY+
IDENTIFYTNG INFORMATION :
*WT: I 80*
SEX:MALE*FIAIR:BLACK*EYES :BRN*HT:5-1 1
ID CARD MLD:01-24-97 * EXP :04-27 -02*
L\CIISS:04-22-11 *E)PIRED*CLASS :C NON-COMMERCIAL & M 1 MOTORCYCLE*
ENDORSEMENTS:NONEt
HEALTH QUESTIONNAIRE E)GIRES:NONE*
LICENSE STATUS:
EXPIRED*
SURRENDERED BY SUBJECT TO:GA*

DEPARTMENTAL ACTIONS:
DRV LIC CANCELLED*EFF: 1 0-2 1 - 1 1 * ORDER MAILED
AUTH:13100 *
t
REASON:REGULAR CANC*SERVICE:T/I 0-21 -1 1

I 0-2

CONVICTIONS:
NONE'i
FAILURES TO APPEAR:
NONE*
ACCIDENTS:
NONE*
END

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