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HOUSTON COUNTY SHERIFF'S OFFICE RESERVE UNIT
Membership Application
DIRECTIONS
1. Type or print your responses in black ink.
2. If you need additional space, attach separate sheets of paper.
3. Do not leave any spaces blank. If a question does not apply, so indicate with the letters “N/A.”
4. Provide complete detailed responses for all questions.
5. Mail completed application to: HCSO Reserve Unit, 144 N. Oates St., Dothan, AL 36303.
Although members of the HCSO Reserve Unit are not paid employees
of the Houston County Sheriff, the Unit is an equal opportunity
organization. The Unit does not discriminate on the basis of race,
color, sex, religion, national origin, handicap, or age if over 23.
I. PERSONAL INFORMATION
1. Name in Full (First, Middle, Last, Suffix)
2. List all other names you have used including nicknames. If female, furnish your maiden name. If you have used a surname,
other that your true name, give the time period and the circumstances under which you used this name. If you legally changed your
name, give the date, place, and court in which this occurred.
3. Preferred Mailing Address (Street or Post Office Box, City, State, Zip Code)
4. Home Telephone Number 5. Work Telephone Number 6. Cellular Telephone Number
7. Other Telephone Number 8. E-Mail Address 9. Driver’s License State/Number
10. Birth Date 11. Birthplace (City, State)
12. Age 13. Sex 14. Social Security Number
15. Marital Status
Never Married Engaged Married Separated
Legally Separated Divorced Widowed Cohabiting
a. Give spouse’s name(s) and marriage date(s) and place(s) (City, State).
b. Give the date(s), place(s) (City, State), and reason for all separations, divorces, or annulments.
16 Citizenship
Country of current citizenship: Citizenship acquired by:
□ Birth □ Naturalization
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II. RESIDENCES
List all places where you have lived and account for all time periods for the past ten years. Begin with your most recent place of
residence and work backward. Be sure to indicate the actual physical location of your residence. Do not use a post office box as an
address, and do not list a permanent address when you were actually living at school. For residences during military service, you
may simply list your base or ship/home port. Note: If you need additional space, attach an additional sheet of paper.
Month/Year – Month/Year Street Address Apt. # City (County) State Zip Code
1. to Present
Month/Year – Month/Year Street Address Apt. # City (County) State Zip Code
2.
Month/Year – Month/Year Street Address Apt. # City (County) State Zip Code
3.
Month/Year – Month/Year Street Address Apt. # City (County) State Zip Code
4.
Month/Year – Month/Year Street Address Apt. # City (County) State Zip Code
5.
III. EDUCATION
1. High School
Name of High School from Address (City, State) From To
which you graduated Month/Year Month/Year
2. College or University
Names of all Colleges Attended Subject From To Degree Received GPA
Major Minor Month/Year Month/Year
a.
b.
c.
3. Specialized Schools
Name of School Study or Specialization Certificate/ From To
Degree Received Month/Year Month/Year
4. Was any disciplinary action taken against you while you were in school or were you dismissed or suspended from school for
academic reasons? □ Yes □ No If yes, provide the name of the school, the action, and the date of action below.
School Action Date
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IV. EMPLOYMENT
List your employment activities for the past ten years. You should list all full-time and part-time work, self-employment, other paid
work, and all periods of unemployment. If you need additional space, attach another sheet.
1. Month/Year to Month/Year Employer Your Position
Address of Employment City State Zip Code Telephone Number
Immediate Supervisor Reason for Leaving Work Description
2. Month/Year to Month/Year Employer Your Position
Address of Employment City State Zip Code Telephone Number
Immediate Supervisor Reason for Leaving Work Description
3. Month/Year to Month/Year Employer Your Position
Address of Employment City State Zip Code Telephone Number
Immediate Supervisor Reason for Leaving Work Description
4. Month/Year to Month/Year Employer Your Position
Address of Employment City State Zip Code Telephone Number
Immediate Supervisor Reason for Leaving Work Description
5. Has any of the following ever happened to you? □ Yes □ No If Yes, begin with the most recent occurrence and go
backward, providing the date fired, quit, or left, and other information requested. Attach additional sheets as necessary.
Use the following codes and explain the reason your employment ended:
1 - Fired from a job
2 - Quit a job after being told you’d be fired
3 - Left a job by mutual agreement following allegations of misconduct
4 - Left a job by mutual agreement following allegations of unsatisfactory job performance
5 - Left a job for other reasons under unfavorable circumstances
Month/Year Code Specify Reason Employer’s Name and Address City (County) State Zip Code
a.
b.
c.
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V. MILITARY RECORD
1. Have you served on active duty in the United States Armed Forces? □ Yes □ No If yes, attach a copy of each DD-214
received and proceed to question 2. If no, proceed to Part VI.
2. Branch of Military Service:
3. Dates of active duty (Month, Date, Year) 4. Military Serial Number or SSAN:
From To
From To 5. Are you a member of the Reserve? □ Yes □ No
From To □ Ready □ Standby
From To Branch of Service:
6. Was any disciplinary action taken against you while you were in the service? □ Yes □ No If applicable, be sure to
include non-judicial punishment and Article 15’s. If yes, provide details:
7. Have you ever served in the National Guard? □ Yes □ No If yes, provide dates, unit location, and name of
Commanding Officer:
VI. REFERENCES/SOCIAL ACQUAINTANCES
List four people who know you well and live in the State of Alabama. They should be good friends, peers, colleagues, college
roommates, etc., whose combined association with you covers as well as possible the last ten years. Do not list your spouse,
former spouse, or other relatives, and try not to list anyone who is listed elsewhere on this form.
1. Name
Home Address (Street, City, State, Zip) Home Telephone Number
Work Address (Street, City, State, Zip) Work Telephone Number
DOB or Approximate Age Years Acquainted Occupation
2. Name
Home Address (Street, City, State, Zip) Home Telephone Number
Work Address (Street, City, State, Zip) Work Telephone Number
DOB or Approximate Age Years Acquainted Occupation
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3. Name
Home Address (Street, City, State, Zip) Home Telephone Number
Work Address (Street, City, State, Zip) Work Telephone Number
DOB or Approximate Age Years Acquainted Occupation
4. Name
Home Address (Street, City, State, Zip) Home Telephone Number
Work Address (Street, City, State, Zip) Work Telephone Number
DOB or Approximate Age Years Acquainted Occupation
VII. ASSOCIATION RECORD
1. Have you been an officer or a member of or contributed to an organization that is dedicated to the violent overthrow of the United
States Government and that engages in illegal activities with the specific intent to further that end?
□ Yes □ No If yes, provide details:
2. Have you engaged in acts or activities designed to overthrow the United States Government by force?
□ Yes □ No If yes, provide details:
3. Have you ever been an officer, member, or participant in, or contributed to, any street gang, motorcycle gang, racial supremacist
or separatist group, cult, or militia? □ Yes □ No If yes, provide details:
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VIII. COURT RECORD
1. Have you been a party to a civil court action? □ Yes □ No If yes, provide the requested information below:
Month/Year Nature of Action Result of Action Names of Parties (identify plaintiff and defendant)
the court and address (city, county, state, zip code)
a.
b.
2. Have you ever been arrested or charged with any violation including traffic, but excluding parking tickets?
□ Yes □ No If yes, list all such matters even if not formally charged or no court appearance, or found not guilty, or
matter settled by payment of fine or forfeiture of collateral. Attach additional sheets as necessary.
Date Place and Department Charge Court and Place Disposition Details
a.
b.
c.
3. Have you ever been the subject of a restraining order or a protection order? □ Yes □ No If yes, provide the following:
Date Court and Place Names of Parties Details
4. Have you ever been accused of racial, sexual or religious harassment or discrimination in any form, regardless of whether a
lawsuit or formal complaint was filed? □ Yes □ No If yes, provide the following:
Date Place Names of Parties Details
IX. FINANCIAL STATUS
1. Have you ever been over 120 days delinquent on any debt(s) or had any debt placed for collection? □ Yes □ No
2. Are you currently delinquent on any debts? □ Yes □ No
3. Have you ever filed a petition under any chapter of the bankruptcy code (to include Chapter 13)? □ Yes □ No
4. Have you ever had your wages garnished or had any property repossessed for any reason? □ Yes □ No
5. Have you ever had a lien placed against your property for failing to pay taxes or other debts? □ Yes □ No
6. Have you ever had any judgments filed against you? □ Yes □ No
If you answered “Yes” to items 1-6, provide the information requested below:
Month/Year Action Taken Amount Name Action Occurred Under Name/Address of Court or Agency City Zip Code
Handling Case
7.
8.
9. Are you current on all federal, state and local tax debts? (Include individual and employer tax debts that apply to you.)
□ Yes □ No If no, provide details.
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X. SPECIAL QUALIFICATIONS AND SKILLS
1. Do you have foreign language abilities? □ Yes □ No If yes, indicate your foreign language proficiency by rating
each category of ability as “slight,” “good” or “fluent.”
Name of Language Speak Understand Read Write
a.
b.
2. a. Are you a licensed automobile driver? □ Yes □ No
b. Are you a licensed motorcycle driver? □ Yes □ No
c. Do you possess a Commercial Driver’s License? □ Yes □ No
If yes to a., b., or c., indicate the following:
State: Expiration Date: License Number:
State: Expiration Date: License Number:
3. Do you have any special skills for which certification or licensing is required? (Nurse, Emergency Medical Technician, Attorney,
C.P.A., Pilot, Doctor, Land Surveyor, Engineer, etc.)
XI. FRIENDS OR ACQUAINTANCES EMPLOYED BY THE HOUSTON COUNTY SHERIFF'S OFFICE
Full Name Position Length of Acquaintance
1.
2.
3.
4.
5.
XII. PHYSICAL DATA
1. Height Without Shoes 2. Weight Without Clothes
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XIII. MINIMUM REQUIREMENTS
1. Do you have a high school diploma or GED? □ Yes □ No
2. If you are not already APOST-certified, are you willing to attend this training at your own expense? □ Yes □ No
3. Are you willing to attend all monthly meetings, unless properly excused for good cause? □ Yes □ No
4. Are you willing to work a minimum of twenty hours during the National Peanut Festival? □ Yes □ No
5. Are you willing to work patrol operations at least eight hours per month? □ Yes □ No
6. Are you willing to attend all mandatory training classes? □ Yes □ No
7.Are you willing to abide by the Procedural General Orders of the Houston County Sheriff’s Office? □ Yes □ No
8. Are you willing to furnish your own weapon and equipment at an estimated cost of $1,000.00? □ Yes □ No
9. Are you willing to maintain the minimum physical agility standards at all times during your membership? □ Yes □ No
VERIFICATION
“I certify that I am 23 years of age or older, of good moral character and reputation, and have never been convicted of a felony or of
a misdemeanor involving force, violence or moral turpitude. I consent to a fingerprint and background search.
I understand that I may be required to submit to a pre-acceptance polygraph examination to assist the HCSO Reserve Unit in
determining my qualifications and suitability for membership.
I understand that all appointments are probationary for a period of one year beyond the basic training period, during which time I
must demonstrate my fitness for continued membership in the HCSO Reserve Unit. If I am dismissed from the Unit at any time, I will
not be entitled to a refund or reimbursement for any equipment I have purchased or expenses I have incurred. I understand that the
Unit is under no obligation to admit me to full membership. The Unit may sever its connection with me at any time, and it is not
required to give me a reason for rejection of my application, or for termination of my membership.
I understand that willfully withholding information or making false statements on this application will be grounds for dismissal from
the Unit and constitutes a felony under § 13A-9-3(a)(3) of the Code of Alabama (1975). I agree to these conditions and hereby
swear that all of my statements on this application are true and complete to the best of my knowledge.”
Printed Name
Signature (as usually written, without nicknames)
Date
ATTACHMENTS
Attach copies of the following records:
1. Your current driver’s license.
2. Your high school diploma or GED.
3. Your DD-214, if you have served in the military.
4. Your APOST certification, if already certified.
