Fifth Judicial District - Department of Correctional Services

Online Intern/Volunteer Application

Read the Following Before Signing the bottom of the application

I certify that this application (and any copy or facsimile of same) and applicant survey contains no willful misrepresentation and that the information is true and complete to the best of my knowledge. I understand that:

Application

* denotes a required field

  • * Last Name:
  • * First Name:
  • Middle Name:
  • * Address:
  • * City:
  • * State:
  • * Zip Code:
  • County:
  • Phone Number: (ex. 555-555-5555 12345)
  • Business Number: (ex. 555-555-5555 12345)
  • Cell Number: (ex. 555-555-5555)
  • * Email Address:

Internship

  • [ The questions between the lines are only required for those looking into an internship ]
  • College Attending:
  • Advisor Name:
  • Advisor Phone: (ex. 555-555-5555 12345)
  • College Major:
  • Credit hours to date:
  • Number of internship hours needed:
  • What area of Corrections are you interested in?
  • What days and times are you available to complete your hours:
  • Employment Experience (if you have a resume attach it below):
  • Attach your Resume - (the file must be in Microsoft Word format or PDF format)
  • Advertising Source - (where did you hear about this position(s)?)

Background Waiver

  • Social Security Number: (ex. 000-00-0000)
  • Date of Birth: (ex. mm/dd/yyyy)
  • Driver's License Number:
  • Other Names:
  • Have you ever been arrested? Yes No
  • If yes, please explain:
  • Have you ever been convicted of a criminal charge and/or been on probation or parole? Yes No
  • If yes, please explain:

I understand that individuals employed with the Fifth Judicial District Department of Correctional Services, including interns and volunteers, are subject to law enforcement checks through the National Crime Information Center (NCIC). I have been informed that I will be terminated from Internship or volunteer for any false information that I provide. I further understand that any and all information received through an NCIC background check will remain confidential

In addition, my signature hereon will release other agencies, employers, and schools, their employees and/or agents from liability for supplying background information to the Fifth Judicial District Department of Correctional Services. I realize that if I do not allow this release of information, this refusal shall be grounds for denying employment.

In accordance with the Iowa Code, Title XIII Commerce, Chapter 554D, Uniform Electronic Transactions Act, 554D.108, my typed signatures below serve as my legal written signatures for this Electronic Employment Application and Background Waiver.

* SIGNATURE      DATE  

(TYPE YOUR NAME TO SERVE AS YOUR SIGNATURE)

Read Carefully Before Signing:

I certify the statements I have made above are true and realize that falsification of information on this form may be grounds for disqualification of my application or dismissal from employment. Employment with the Fifth Judicial District Department of Correctional Services is subject to successful completion of a physical examination and alcohol and drug testing through the Polk County Health Center. Results will be held in confidence by the department except where information is required by law.

* SIGNATURE      DATE  

(TYPE YOUR NAME TO SERVE AS YOUR SIGNATURE)

Thank you for completing this application for employment. You can be assured that our review of your job qualifications will be based solely on merit and a final determination reached as soon as possible.

NOTICE: This is an Electronic Employment Application form. Submitting a false Electronic Employment Application form is a criminal act.

** The transmission of the application is not through a secured site **   



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