YORK COUNTY SHERIFF'S OFFICE

PERSONAL HISTORY STATEMENT

Kevin R. Tolson
Sheriff of York County
1675-3A York Highway
York, South Carolina 29745-7431
(803) 628-3080

Sworn Detention Officer

Part I

Applicant's Name: ______________________________________

Date Submitted: ________________________________________

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 YORK COUNTY SHERIFF'S OFFICE

PERSONAL HISTORY STATEMENT

Part 1

Sworn Detention Officer

EQUAL EMPLOYMENT OPPORTUNITES: It is the policy of the Sheriff of York County to maintain a
systematic, consistent recruitment program, to promote equal employment opportunity, and to identify and attract
the most qualified applicants for all, present and future vacancies. This intent is achieved through consistency in
announcing all positions, evaluation of all applicants on the same criteria, and by applying accepted testing and
evaluation methods. Equal employment opportunities are allowed without regard to sex, race, religion, color,
national origin, age or non-disqualifying handicap.

EDUCATIONAL REQUIREMENTS: High School Diploma or GED.

RESIDENTIAL REQUIREMENTS: You must reside within a fifty mile radius of York County to be considered
for a position. Relocating will be taken into consideration.

TERMS OF EMPLOYMENT: The Office of Sheriff is the oldest public office in the United States. The Sheriff
and all of his employees must adhere to the Law Enforcement Code of Ethics and must hold themselves to a higher
standard of morality than others. This is the premier law enforcement agency, the only full service law enforcement
agency, and the Sheriff answers directly to the people of our County. Sheriff's employees answer to the Sheriff
through an established chain-of-command.

The Sheriff is a Constitutional Officer and the Chief Law Enforcement Officer of the County. He is civilly
responsible for the acts, commissions and omissions of his employees. Employment by the Sheriff is a political
appointment and service is at the will and pleasure of the Sheriff.

APPLICATION PROCESS: Hundreds of applications are currently on file and are maintained for one (1) year.
Yours and all others will be reviewed by the Sheriff, Chief Administrator, and the senior staff (Captains) as
vacancies arises. A background investigation may be initiated. (A copy of the following will be required for
background investigation purposes: high school diploma or GED certificate, valid driver's license, and social
security card.) You must be completely thorough and honest in completing this document. Falsified or incomplete
information will result in immediate termination of this application. If you have a question regarding the
information requested, please call the Detention Division Administrative Offices at 803-628-3080.

If an interview is necessary, the senior staff will schedule it. PLEASE DO NOT CALL THIS OFFICE
SEEKING TO BE INTERVIEWED.

INSTRUCTIONS: Using a typewriter or legibly printing in black ink fill out this form completely and accurately.
If you need extra space, add additional pages and identify the information by item number. If an item does not apply
to you, indicate by entering N/A in the blank.

Note: All statements are subject to verification and any incorrect statements or omissions may bar or remove you
from consideration. Truthful statements to any item requested will not necessarily exclude you from consideration.

THIS FORM MUST BE NOTARIZED UPON COMPLETION.

* This form must be completed and returned on the day of your scheduled pre-employment testing.

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 PERSONAL INFORMATION

1. Name ______________________________________________________________________
First Middle/Maiden Name Last

2. Nickname __________________________________

3. SSN ___________/_________/_____________

4. Present Address ______________________________________________________________

Number & Street City State Zip

Permanent Address ___________________________________________________________

Number & Street City State Zip

Home Phone Number __________________ Work Phone Number ____________________

5. Date of Birth ______/______/______

6. Place of Birth _______________________________________

7. Citizenship: US Born ________ US Naturalized ________ Other __________

8. Eye Color ________ 9. Hair Color ________ 10. Height ________

11. Weight ________ 12. Sex ________

13. Do you possess a Valid SC Driver's License?  YES  NO

If YES, License # ____________________

14. Have you ever been licensed in another state?  YES  NO

If YES, list state and license # __________________

15. Has your license ever been suspended or revoked?  YES  NO

If YES, give details ___________________________________________________________

16. Have you previously submitted an application with this agency?  YES  NO

Date Submitted: ____________________________________

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EDUCATIONAL BACKGROUND

17. List all high schools attended. Attach transcript from last high school attended (if within five
years of date of application date).

NAME & LOCATION

YEARS GRADUATED
OF HIGH SCHOOLS DATES
COMPLETED YES OR NO

18. Higher Education. List information for all colleges and universities attended. Attach transcript or
Diploma from last institution of higher education attended.

NAME & LOCATION

YEARS GRADUATED
OF COLLEGE OR TRADE SCHOOLS DATES
COMPLETED YES OR NO

19. Other schools or training (trade, vocational, business, military). For each give the name and location
of schools, dates attended, subjects studied certificates, and any other pertinent data.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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 SPECIAL QUALIFICATIONS AND SKILLS

20. Indicate type of special license, such as pilot, radio operator, etc., showing licensing authority, where
the license was first issued, and the date your current license expires (except vehicle operator's
license).
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

21. Special skills you possess; machines and equipment you can use. Example: data entry, computer,
scientific or professional devices, short wave radio, etc.
Typing (wpm) ______________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

22. Memberships in professional associations or organization. __________________________________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

23. List any foreign language that you speak, write, or read fluently. Indicate also if you can use
American Sign Language.

LANGUAGE SPEAK WRITE READ

FAMILY HISTORY
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24. Are you related by blood or marriage to any person(s) now employed by the York County Sheriff's
Office?
YES NO

If yes, give name(s) and details. _______________________________________________________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

RESIDENCES

25. List all of your addresses for the past ten (10) years beginning with your present address:

FROM TO CONTACT/
ADDRESS OF RESIDENCE CITY/STATE
DATE DATE LANDLORD

26. Have you ever been sued with a civil judgement being rendered against you?
Yes No

If yes, give details: __________________________________________________________________

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 WORK HISTORY

27. Have you ever applied with another law enforcement agency? YES NO

If yes, complete the following:

DATE OF
AGENCY NAME POSITION
APPLICATION

28. Have you ever been denied employment by a criminal justice agency? YES NO

If yes, list agency name and give details: ________________________________________________

_________________________________________________________________________________
_________________________________________________________________________________

29. Are you willing and able to wear a uniform? YES NO

30. Are you willing and able to work nights, holidays, and overtime? YES NO

31. Are you willing and able to work both permanent and/or rotating shifts? YES NO

32. Occasionally you may be asked to be away from home overnight and for other periods of time
attending meetings, acquiring training, and otherwise performing official duties. Would you be able
to fulfill these obligations? YES NO

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33. List all jobs you have held in the last ten- (10) years, including temporary and part-time jobs. Put
your present or most recent job first. If you need space, you may attach additional pages. Include
military service in proper sequence.

Employer __________________________________________ Supervisor _________________________

Address ______________________________________________________________________________
Phone ______________________________
Start Date ___________________________ End Date _____________________________
Status FULL-TIME PART TIME If part-time, # hours worked_____________________
Number of employees supervised ____________________________
Start Salary __________________________ End Salary ______________________________
Duties _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Leaving __________________________________________________________________
_____________________________________________________________________________________
Coworker who knows/knew well __________________________________________________________
Day Phone Night Phone Best time to Contact

Employer __________________________________________ Supervisor _________________________

Address ______________________________________________________________________________
Phone ______________________________
Start Date ___________________________ End Date _____________________________
Status FULL-TIME PART TIME If part-time, # hours worked_____________________
Number of employees supervised ____________________________
Start Salary __________________________ End Salary ______________________________
Duties _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Leaving __________________________________________________________________
_____________________________________________________________________________________
Coworker who knows/knew well __________________________________________________________
Day Phone Night Phone Best time to Contact

Employer __________________________________________ Supervisor _________________________

Address ______________________________________________________________________________
Phone ______________________________
Start Date ___________________________ End Date _____________________________
Status FULL-TIME PART TIME If part-time, # hours worked_____________________
Number of employees supervised ____________________________
Start Salary __________________________ End Salary ______________________________
Duties _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Leaving __________________________________________________________________
_____________________________________________________________________________________
Coworker who knows/knew well __________________________________________________________
Day Phone Night Phone Best time to Contact

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Employer __________________________________________ Supervisor _________________________
Address ______________________________________________________________________________
Phone ______________________________
Start Date ___________________________ End Date _____________________________
Status FULL-TIME PART TIME If part-time, # hours worked_____________________
Number of employees supervised ____________________________
Start Salary __________________________ End Salary ______________________________
Duties _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Leaving __________________________________________________________________
_____________________________________________________________________________________
Coworker who knows/knew well __________________________________________________________
Day Phone Night Phone Best time to Contact

Employer __________________________________________ Supervisor _________________________

Address ______________________________________________________________________________
Phone ______________________________
Start Date ___________________________ End Date _____________________________
Status FULL-TIME PART TIME If part-time, # hours worked_____________________
Number of employees supervised ____________________________
Start Salary __________________________ End Salary ______________________________
Duties _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Leaving __________________________________________________________________
_____________________________________________________________________________________
Coworker who knows/knew well __________________________________________________________
Day Phone Night Phone Best time to Contact

Employer __________________________________________ Supervisor _________________________

Address ______________________________________________________________________________
Phone ______________________________
Start Date ___________________________ End Date _____________________________
Status FULL-TIME PART TIME If part-time, # hours worked_____________________
Number of employees supervised ____________________________
Start Salary __________________________ End Salary ______________________________
Duties _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Leaving __________________________________________________________________
_____________________________________________________________________________________
Coworker who knows/knew well __________________________________________________________
Day Phone Night Phone Best time to Contact

Attach additional sheets for additional employment data

34. If you have ever been discharged or requested to resign from any position because of criminal or
personal misconduct, or rules violations, please explain in detail.

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 _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

VOLUNTEER SERVICE
35. In the past ten- (10) years, have you served as a volunteer in any capacity? YES NO
If yes, complete the following:

DATES
SUPERVISOR/
AGENCY/ORGANIZATION ADDRESS TELEPHONE OF
COWORKER
SERVICE

MILITARY SERVICE
36. Were you ever in the U. S. Military Service or any other military organization?
YES NO

QUESTIONS 36 THROUGH 46 ONLY APPLY TO VETERANS.

37. What is your service number? ________________________________________________________

38. What is the highest rank you held? _________________________________________________

39. What was the date and location of your first entrance into active duty?
Date __________________________ Location __________________________________________

40. What were your unit assignments in the service?

BRANCH UNIT LOCATION FROM TO

MO/YR MO/YR

41. What was the date and location of your last discharge from active duty?
Date ______________________ Location ______________________________________

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42. Was your discharge:
HONORABLE GENERAL DISHONORABLE BAD CONDUCT

43. Were you ever court-martialed, tried on charges, the subject of a summary court, deck court,
captain's mast or company punishment, or any other disciplinary action while a member of the
armed forces?
YES NO
If YES, explain ____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

44. List any disciplinary action taken against you in the National Guard or other reserve unit.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

45. List all medals and decorations awarded to you during your military service.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

46. If you are presently a member of the National Guard or any other military reserve, give the unit
and location, and describe your obligation.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

47. FOR EX-MILITARY PERSONNEL, attach DD-Form 214.

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 CRIMINAL OFFENSE RECORD

NOTE: Include all offenses other than minor traffic offenses. The following are not minor
traffic offenses and must be listed below: DWI/DUI (alcohol or drugs), failure to stop in the
event of an accident, driving with a revoked or suspended license.

Answer all of the following questions completely and accurately. Any falsification or misstatement of
fact may be sufficient to disqualify you. If any doubt exists in your mind as to whether or not you were
arrested or charged with a criminal offense at some point in your life or whether an offense remains on
your record, you should answer "YES". You should answer "NO" only if you have never been arrested or
charged, or your record was expunged by a judge's court order.

48. Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal
offense?
YES NO If YES, give details below. Attach extra pages if necessary.

DISPOSITION
OFFENSE CHARGED LAW ENFORCEMENT AGENCY DATE
OF CASE

49. Have you ever been charged with, or convicted of, a felony?
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

50. Have you ever been charged with, or convicted of, the crime of domestic violence?
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

51. Have you ever been charged with, or convicted of, a crime involving sexual abuse, sexual
misconduct, or sexual harassment?
YES NO
If YES, give details. ________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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52. Have you ever been involved in a physical confrontation/alteration with a close family member
(i.e., current or former spouse, your child, brother, sister, parent or grandparent?)
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

53. Have you ever been the subject of a restraining order?

YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

54. Have you ever been placed on probation?

YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

55. Have you ever been required to pay a fine in excess of $50.00 (this does not include court costs)?
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

56. In the past (10) years, have you ever stolen from a person or business?
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

57. In the past (10) years, have you ever embezzled from a person or business?
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

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58. Have you ever paid or received anything that could have the appearance of a bribe or
inappropriate gratuity? (A bribe may be defined as accepting anything [e.g., money, drugs,
merchandise, sex] on return for overlooking an actual or anticipated illegal act.)
YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________

59. Have you committed any crimes that you were not charged with? YES NO
If YES, give details. ________________________________________________________________
_________________________________________________________________________________

60. Can you operate a motor vehicle? YES NO

61. Do you possess a valid Driver's License from the State of South Carolina? YES NO
Driver's License Number _________________________
Year Issued _______________________
If CDL, which Class?

62. Do you now possess a driver's license issued by any state(s) other than South Carolina?
YES NO
If YES, explain. ____________________________________________________________________
_________________________________________________________________________________
63. Have you ever possessed a valid driver's license issued by any state or the military?
YES NO
If YES, explain. ____________________________________________________________________
_________________________________________________________________________________

64. Was your license ever suspended or revoked?

YES NO
If YES, explain. ____________________________________________________________________
_________________________________________________________________________________

65. Was your license ever restored? YES NO

If YES, explain. ____________________________________________________________________
_________________________________________________________________________________

66. Have your driving privileges ever been restricted? YES NO

If YES, explain. ____________________________________________________________________
_________________________________________________________________________________
67. Do you currently reside in a home where regular illegal drug use occurs? YES NO
If YES, explain. ____________________________________________________________________

68. SUPPLY A CERTIFIED DRIVING HISTORY REPORT FOR EACH STATE THAT YOU
HAVE HELD DRIVER'S LICENSE. THIS HISTORY MUST COVER TEN (10) YEARS.
*FYI - You must possess a legally issued South Carolina driver's license to be enrolled and begin at the
South Carolina Criminal Justice Academy.

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 REFERENCES

69. Give names of five responsible persons other than relatives or past employers who could provide
information about your character, ability, experience, personality and other qualities.

__________________________________________________________________________________________
NAME ADDRESS HOW KNOWN

__________________________________________________________________________________________
DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT

__________________________________________________________________________________________
NAME ADDRESS HOW KNOWN

__________________________________________________________________________________________
DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT

__________________________________________________________________________________________
NAME ADDRESS HOW KNOWN

__________________________________________________________________________________________
DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT

__________________________________________________________________________________________
NAME ADDRESS HOW KNOWN

__________________________________________________________________________________________
DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT

__________________________________________________________________________________________
NAME ADDRESS HOW KNOWN

__________________________________________________________________________________________
DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT

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To facilitate the background investigation of your application, please forward the following
documents with your PERSONAL HISTORY STATEMENT.

Items marked * are required by South Carolina State Law and Regulations for admittance to the South
Carolina Criminal Justice Academy for training and certification.

Birth Certificate*

GED Certificate (if applicable)*

High School Diploma*

College Diploma or Transcript (certified from school)

Driver's License* (A South Carolina driver's license is required prior to admittance to the South
Carolina Criminal Justice Academy.)

Certified ten (10)-year driver's history from each state where you held a driver's license*

Military discharge papers (DD-214)*

Social Security Card*

Current Photograph

Any certificates received from any Criminal Justice Academy or Law Enforcement Agency (and
transcripts/course curricula if applicable).

*PLEASE NOTE: All of the above paperwork MUST be turned in before completion of background.

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 YORK COUNTY SHERIFF'S OFFICE

DETENTION OFFICER CANDIDATE ADDENDUM

Complete form in your own handwriting.

1. In the space provided below, please tell us why you wish to become a Detention Officer with the
York County Sheriff's Office.

________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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2. Describe how your skills and training would enhance the York County Sheriff's Office.

________________________________________________________________________________
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________________________________________________________________________________
Applicant's Signature: _____________________________________________________ Date: _____/_____/_____

Social Security Number: ___________________________________

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 YORK COUNTY SHERIFF'S OFFICE

YORK COUNTY SHERIFF'S OFFICE

BACKGROUND INVESTIGATION
AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

I, ___________________________________, authorize the York County Sheriff's Office to conduct a

personal investigation in connection with my application for employment.

This investigation may include information from current and/or former employers, educational
institutions, physicians and/or medical records, mental health records, listed personal references, and/or
other appropriate sources.

I authorize the release of any information that the York County Sheriff's Office may request from the
above sources. I further waive all rights to inspect or review of any information obtained pursuant to any
application for employment.

I fully understand all information gained from such an investigation is confidential, and will be released
only to authorized persons in the employment process.

I agree to give any further information, which may be required and hereby certify that there are no willful
misrepresentations, omissions, or falsifications in any of the applications and/or documents furnished for
the position and/or answers to questions. I am aware that should an investigation disclose any willful
misrepresentations, omissions, or falsifications my application may be rejected, or if already employed,
my employment may be terminated.

I hereby release the York County Sheriff's Office, York, South Carolina, and any of its agents or
representatives and any persons so furnishing information from any liability for damages from the release
of records, documents, and other information for the investigation made by the York County Sheriff's
Office.

________________________________________________ _____________________
Signature Date

State of _________________________________________________,
__________________________County

On this ___________, day of ________________, ___________, ________________________________

whose name signed to the foregoing instrument, personally appeared before me, acknowledge the
forgoing signature to be his, and having been duly sworn by me, made oath that the statements made on
said instrument are true.

My commission expires: __________________________

___________________________________________Notary Public

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 DRUG SCREEN AGREEMENT

I freely and voluntarily agree to submit to a urinalysis (drug screen) as part of my

application for employment. I understand that either refusal to submit to the urinalysis screen or
the detection of illegal drugs in this screen may disqualify me from further consideration for
employment.

I further understand that upon commencement of employment with the York County
Sheriff's Office I may again be required to submit to a urinalysis screen. I understand that
refusal to take a requested urinalysis screen, or the detection of illegal drugs in this screen, may
result in immediate suspension or discharge.

I have read in full and understand the above statements and conditions of employment.

______________________________________________ ______________________________
Signature Date

______________________________________________ ______________________________
Witness Date

cc: Employee's Personnel File

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 Authorization for Release of Personal Information

To Whom It May Concern: I am an applicant for a position with the York County Sheriff's Office. The
department needs to thoroughly investigate my employment background and personal history to evaluate
my qualifications to hold the position for which I applied. It is in the public’s best interest that all
relevant information concerning my personal and employment history be disclosed to the above
department.

I hereby authorize any representative of the York County Sheriff's Office bearing this release to obtain
any information in your files pertaining to my employment records and I hereby direct you to release such
information upon request of the bearer. I do hereby authorize a review of and full disclosure of all
records, or any part thereof, concerning myself, by and to any duly authorized agent of the York County
Sheriff's Office, whether said records are of public, private, or confidential nature. The intent of this
authorization is to give my consent for full and complete disclosure. I reiterate and emphasize that the
intent of this authorization is to provide full and free access to the background and history of my personal
life, for the specific purpose of pursuing a background investigation that may provide pertinent data for
the York County Sheriff's Office to consider in determining my suitability for employment in that
department. It is my specific intent to provide access to personnel information, however personal or
confidential it may appear to be.

I consent to your release of any and all public and private information that you may have concerning me,
my work record, my background and reputation, my military service records, educational records, my
financial status, law enforcement or criminal records, including nay arrest records, any information from a
law enforcement agency, any records or recollections of attorneys at law, or other counsel, whether
representing me or another person in any case, either criminal or civil, in which I presently have, or have
had an interest, attendance records, polygraph examination, and any internal affairs investigations and
discipline, including any files which are deemed to be confidential and/or sealed.

I hereby release you, your organization, and all others from liability or damages that may result from
furnishing the information requested, including any liability or damage pursuant to any state or federal
laws. I hereby release you, as the custodian of such records of your organization, including its officers,
employees, or related personnel, both individually and collectively, from any and all liability for damages
of whatever kind, which may at any time result to me, my heirs, family or associates because of
compliance with this authorization and request to release information, or any attempt to comply with it. I
direct you to release such information upon request of the duly accredited representative of the York
County Sheriff's Office, regardless of any agreement I may have made with you previously to the
contrary. The York County Sheriff's Office will discontinue processing my application if you refuse to
disclose the information requested.

For and in consideration of the York County Sheriff's Office acceptance and processing of my application
for employment, I agree to hold both your agency and the York County Sheriff's Office, their agents and
employees, harmless from any and all claims and liability associated with my application for employment
or in any way connected with the decision whether or not to employee me with the York County Sheriff's
Office. I understand that should information of a serious criminal nature surface as a result of this
investigation, such information may be turned over to the proper authorities. Nothing in this
authorization obligates York County or your organization to release any information.

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 Authorization for Release of Personal Information

I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, as
amended, with regard to access and to disclosure of records, and I waive those rights with the
understanding that information furnished will be used by the York County Sheriff's Office in conjunction
with employment procedures.

A photocopy or FAX copy of this release form will be valid, as an original thereof, even though the said
photocopy or FAX copy does not contain an original writing of my signature.

This waiver is valid for a period of one year from the date of my signature. Should there be any questions
as to the validity of this release, you may contact me at the address listed on this form.

I agree to indemnify and hold harmless the York County Sheriff's Office, its agents and employees, and
the person to whom this request is presented and their agents and employees, from and against all claims,
damages, losses and expenses, including reasonable attorney’s fees, arising out of, or by reason of,
complying with this request.

Signature: ______________________________________ Date: _____________________

Name: ___________________________ DOB: _______________ SSN: ______________________

Address: _____________________________________________________________________________

Notarization:

State of: __________________, County of: ________________

On this day, __________________________ personally appeared before me and acknowledged his/her

signature to this above statement.

My commission expires on the _______ day of_______________, 20_____.

________________________________
Notary Public

York County Sheriff's Office Receipt

This form was received by: ____________________________________on________________________

Date
This form will expire on: ______________________________________

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 YORK COUNTY SHERIFF'S OFFICE

CREDIT HISTORY AUTHORIZATION

I authorize the York County Sheriff's Office to obtain a report on my credit history inorder to determine
my suitability for employment.

__________________________ _______________________________________
Date Signature

________________________________________________
Name: Please Print

________________________________ ________________________________________________
Date Witness

For the purposes of obtaining the credit report, I provide the following information:
________________________________________________
Social Security Number

________________________________________________
Date of Birth

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