Instructions to the Applicant

The information you provide in this application will be used in the background investigation to assist in determining your suitability for the non-sworn position of Custody Assistant.

• It is your responsibility to complete this form and provide all required information.
  
  
• This document must be filled out electronically and printed.
  
  
• You must respond to all items and questions. If a question does not apply to you, write “D.N.A.” (does not apply) in the space provided for your response.
  
  
• Send the completed form to your background investigator or the agency to which you are applying.

Disqualification

There are very few automatic bases for rejection. Even issues of prior misconduct, such as prior illegal drug use, driving under the influence, theft, or even arrest or conviction are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent job-relevant information from their prospective employer.

1. FIRST NAME

• Samantha

2. MIDDLE NAME

• Josephine

3. LAST NAME

• Hayes

4. DATE OF BIRTH

• Month: 04
  Date: 27
  Year: 1997

5. PLACE OF BIRTH

• Buffalo, New York City

6. GENDER

• [—] Male
  [X] Female
  [—] Other

7. RACE

• [X] White
  [—] Black or African American
  [—] Hispanic or Latino
  [—] American Indian or Alaska Native
  [—] Asian
  [—] Flippino American
  [—] Native Hawaiian or Other Pacific Islander
  [—] None of the Above
  [—] Two or More Races

8. HEIGHT

• In feet: 5
  In inches: 5

9. WEIGHT

• In pounds: 160

10. MARITAL STATUS

• [X] Single
  [—] Married
  [—] Divorced
  [—] Widow
  [—] Legally Separated
  [—] Unknown/Not Applicable

11. ADDRESS OF PRIMARY RESIDENCY

• Street Number & Name: #1 Tug Street, Floor 2 (Room 8)
  City: Los Santos
  State: San Andreas
  Zip: 86345

12. PRIMARY PHONE NUMBER

• 18844401

13. EMAIL ADDREESS

• [email protected]

14. LEVEL OF EDUCATION

• [—] Some High School
  [X] High School
  [—] Some College
  [—] Technical College
  [—] Associate's Degree
  [—] Bachelor's Degree
  [—] Master's Degree
  [—] Doctorate

15. SCHOOL OF ATTENDANCE

• School Name: Davis High School
  Enrollment Term: 09/01/2011 to 07/01/2015
  Course of Study: General

16. FIRST PLACE OF EMPLOYMENT

• Company/Agency Name: Port of Los Santos - CONTRACT
  Position: Contract Delivery Driver
  Duties Summary: Provided (on contract) deliveries of goods, services, and excellent logistical support. Delivering products all over the State.
  Employment Term: 08/11/2022 to Current
  Reason for Leaving: I am still working contract work at this time. In the event of being accepted into the process, I would divert my attention to the Sheriff's Department completely.

17. SECOND PLACE OF EMPLOYMENT

• Company/Agency Name: D.N.A
  Position: D.N.A
  Duties Summary: D.N.A
  Employment Term: D.N.A
  Reason for Leaving: D.N.A

18. THIRD PLACE OF EMPLOYMENT

• Company/Agency Name: D.N.A
  Position: D.N.A
  Duties Summary: D.N.A
  Employment Term: D.N.A
  Reason for Leaving: D.N.A

19. I HAVE A VALID SAN ANDREAS DRIVER LICENSE

• [X] Yes
  [—] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

20. I AM LEGALLY ABLE TO WORK IN THE UNITED STATES OF AMERICA

• [X] Yes
  [—] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

21. I HEARD ABOUT THIS POSITION THROUGH

• [X] LSSD Website
  [—] Sheriff's Station Website
  [—] Social Media
  [—] College Campus
  [—] Career Fair or Seminar
  [—] LSSD Employee
  [—] LS County Employee
  [—] Family Member
  [—] Friends or Neighbors
  [—] Radio
  [—] Billboard
  [—] Other

22. IN ADDITION TO ENGLISH, I KNOW THE FOLLOWING LANGUAGE(S)

• D.N.A

23. I AM A PERSON WITH A DISABILITY

• [—] Yes
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

24. I AM A CURRENT OR FORMER MEMBER OF THE UNITED STATES MILITARY

• [—] Yes, I currently serve
  • I currently serve in the: D.N.A
  [—] Yes, I have formerly served
  • I have formerly served in the: D.N.A
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

25. I AM CURRENTLY ON CRIMINAL PROBATION OR PAROLE

• [—] Yes
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

26. I HAVE PRIOR CONVICTIONS FOR DRIVING UNDER THE INFLUENCE OF ALCOHOL OR OTHER INTOXICANTS IN SAN ANDREAS AND/OR ANOTHER STATE

• [—] Yes
  • Indicate which state(s) and year(s) convicted: D.N.A
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

27. I HAVE PREVIOUSLY USED MARIJUANA WITHIN THE LAST YEAR

• [—] Yes
  • Indicate the previous month(s) and year(s) you have used marijuana: D.N.A
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

28. I HAVE PREVIOUSLY USED OTHER ILLEGAL SUBSTANCES WITHIN THE PAST YEAR

• [—] Yes
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

29. I HAVE COMMITTED THEFT, OR HAVE EMBEZZLED, AN AMOUNT AT LEAST $950.00

• [—] Yes
  [X] No
  [—] Unknown
  [—] Not Willing to Answer
  [—] Other

I, the undersigned, do herein agree that the information aforementioned is true and complete to the best of my knowledge under the penalty of perjury. I further agree and understand that the information provided will be utilized by the Los Santos County Sheriff's Department for the purposes of employment & preliminary background investigation for the position of Custody Assistant. I further understand that the Los Santos County Sheriff's Department employs candidates with no regard to race, religion, sexual orientation, creed, ethnicity, veteran status, or disability. I agree that if selected to move forward with the hiring process, I will abide by the hiring standards as prescribed by the Sheriff of Los Santos County and his designated deputies.

30. SIGNATURE

• Samantha Hayes

31. DATE

• Month: 09
  Date: 12
  Year: 2022

32. MY TIMEZONE

• GMT -05:00 (Central Standard Time)

33. MY USER CONTROL PANEL USERNAME

• Krisseh

34. MY UNEDITED SCREENSHOT OF MY USER CONTROL PANEL ADMINISTRATIVE RECORD

• https://i.imgur.com/VX6nHvM.png

35. MY GTAWORLD FORUM ACCOUNT

• Krisseh

36. MY DOUBLE FACTION PERMISSIONS

• D.N.A

37. HAVE YOU EVER BEEN DISCHARGED OR BANNED FROM A LEGAL FACTION? IF SO, ELABORATE

• [—] Yes
  • Elaboration: D.N.A
  [X] No

38. DO YOU CONSENT TO YOUR CHARACTER ICLY PROVIDING FINGERPRINT SAMPLES AND A MUGSHOT AS PART OF THE APPLICATION PROCESS?

• [X] Yes
  [—] No

39. ATTACH AN IMAGE OF YOUR CHARACTER FROM THE SHOULDERS UP CLEARLY SHOWING THEIR FACE WITH NOTHING COVERING THE FACE

• SPOILER: show