Fifth Judicial District - Department of Correctional Services

Online 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:

Applicant Survey

The Fifth Judicial District Department of Correctional Services is committed to Equal Employment Opportunity and Affirmative Action. The following information will only be used for program evaluations, reporting requirements and affirmative action referrals. It is deemed confidential and refusal to provide information will not adversely affect you as an applicant. If you are hired, it will become a part of your employee record. This section is removed before your application is processed. Applicants found to have falsified applicant survey information will be subject to the penalties indicated above.

  • Date: 12/03/2008
  • Position(s) Desired: (hold down the "Ctrl" key and click with your mouse to select multiple positions)
  • A. What is your gender? Male Female
  • B. What is your age?
  • C. What is your highest level of education?
  • D. Of which racial/ethic group do you consider yourself a member?
  • E. Do you have a disability that is a physical or mental impairment that substantially limits one or more major life activities: do you have a record of such an impairment; or are you regarded as having such an impairment?
  • Yes No
  • F. Advertising Source- (where did you hear about this position(s)?)
  • If you chose other please state where you heard about the position(s) you are applying for

Application

* denotes a required field

  • * Last Name:
  • * First Name:
  • Middle Name:
  • Maiden Name:
  • Gender: Male Female
  • * Social Security Number: (ex. 000-00-0000)
  • Phone Number: (ex. 555-555-5555 12345)
  • Business Number: (ex. 555-555-5555 12345)
  • Cell Number: (ex. 555-555-5555)
  • * Email Address:
  • * Address:
  • * City:
  • * State:
  • * Zip Code:
  • * County:

  • Previous Addresses/ Counties:
  • 1) Address:
  • City:
  • State:
  • Zip Code:
  • County:
  • 2) Address:
  • City:
  • State:
  • Zip Code :
  • County:
  • 3) Address:
  • City:
  • State:
  • Zip Code:
  • County:

  • Are you a U.S. Citizen? Yes No
  • If not, are you able to provide proof of identity & employment eligibility?
  • Visa Number:
  • Expiration Date:
  • * Referral source: (How did you hear about this position?)
  • Do you have any relatives employed by this Department? Yes No
  • If yes please list them here.
  • Do you possess a valid Driver's License? Yes No
  • * Driver's License Number:
  • If not, do you have means of transportation if travel is required on the job for which you are applying?
  • List any traffic violations you have had within the last five years:
  • Have you ever been convicted of anything other than a minor traffic violation? Yes No
  • If yes, please submit with your application a detailed explanation of charges and the events that led up to the charges:
  • Position Desired In Order of Preference:
  • * 1)
  • 2)
  • 3)
  • Type of Employment Desired: Full-Time Part-Time
  • Typing Speed:
  • Shorthand Speed:
  • Please list other Office Machines with which you are proficient:
  • Starting salary expected:
  • Preferred starting date:
Name and Address of Schools Attended Dates  Attended Grade Diploma/Degree
  From To Point or Hours
   High School
   
   College/University
   
   Graduate School
   
   Other Training/Languages Spoken
   
   
   

If a license, certificate, or other authorization to practice a trade or profession is required for the position for which you are applying, please list:

License Held Expiration Date
  • Employment History
  • Current Employer:
  • Phone Number : (ex. 555-555-5555 12345)
  • Address:
  • Supervisor:
  • Start Date:
  • Base Earnings:
  • Position:
  • Duties:
  • Reason for Leaving:

  • 1) Previous Employer:
  • Phone Number : (ex. 555-555-5555 12345)
  • Address :
  • Supervisor:
  • Dates From: To
  • Base Earnings:
  • Position:
  • Duties:
  • Reason for Leaving:

  • 2) Previous Employer:
  • Phone Number : (ex. 555-555-5555 12345)
  • Address:
  • Supervisor:
  • Dates from: To
  • Base Earnings:
  • Position:
  • Duties:
  • Reason for Leaving:

  • 3) Previous Employer:
  • Phone Number : (ex. 555-555-5555 12345)
  • Address:
  • Supervisor:
  • Dates from: To
  • Base Earnings:
  • Position:
  • Duties:
  • Reason for Leaving:

References: Other than former employers or relatives

Name Address Occupation Phone

Attach your Resume - (the file must be in Microsoft Word format or PDF format)

Veterans Preference

Those veterans honorably discharged from service within the designated periods as established by law. (35C.1 of the Code of Iowa) may claim preference by submitting proof of service along with this application (such as discharge papers that include dates of induction and separation). Please submit a notarized photocopy since the copy cannot be returned.

Background Waiver

I authorize the Fifth Judicial District Department of Correctional Services and its employees and/or agents to check into my background to determine suitability for employment as a Departmental employee. Included herein is the gathering of information relative to violation(s) of law that have resulted in convictions(s).

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 **   



Offices | Services | Offender Resources | Site Map | Links