Doña Ana County · The Personal Information Questionnaire, or PIQ, is a comprehensive pre-employment requirement for meeting minimum selection and hiring standards. This form is

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Doña Ana County

Detention Center

PE R S O N A L

IN F O R M A T I O N

QU E S T I O N N A I R E ( P I Q )

Doña Ana County Detention Center PERSONAL INFORMATION QUESTIONNAIRE (PIQ) Part 1

2 OF 33 VERIFIED AS COMPLETE

Have Questions? Need Clarification?

Recruiter: Stephanie Johnson-Burick (575) 647-7689 (stephaniej@doñaanacounty.org)

Background Investigator: Andy Luna (575) 647-7608 (andrewl@doñaanacounty.org)

INSTRUCTIONS AND GUIDELINES

----- PLEASE READ CAREFULLY -----

The Personal Information Questionnaire, or PIQ, is a comprehensive pre-employment requirement

for meeting minimum selection and hiring standards. This form is used as a primary source document

for completing background checks of applicants for the Doña Ana County Detention Center.

It is in your best interest to answer EVERY QUESTION HONESTLY and COMPLETELY. Any negative factor in

your background will be evaluated in terms of circumstances, facts surrounding the occurrence and the

degree of relevance to the job.

The statements made herein are subject to verification to determine your qualifications for employment.

Omissions and/or misstatements must be avoided or corrected. Failure to provide a complete and

accurate PIQ may constitute falsification and may result in disqualification from the hiring and selection

process or termination from employment if hired.

PLEASE NOTE THE FOLLOWING

IMPORTANT: Return this document on or before this date:

This PIQ will take 1-2 hours to complete.

Responses must be clear and legible – use ink print or type.

Answer each question completely, accurately and honestly.

If a question does not apply to you, write “N/A” in the space to indicate “not applicable”.

If you do not have sufficient space to respond, extra pages are provided at the end of this document for additional information and detail or you may attach additional typed pages. Include the number of the question you are responding to and please sign and date under your response.

If you are unsure what the question is asking of you, contact our office to clarify prior to answering

or leave the question blank and address it with a member of our staff when you return the document

to our office.

Please note the documents you are required to provide at the time you return this document (listed

on page 3).

Doña Ana County Detention Center PERSONAL INFORMATION QUESTIONNAIRE (PIQ)


The final pages of this document are authorizations to complete a detailed background review including accessing criminal and judicial records by trained Doña Ana County staff and comparing any findings with what you will disclose in this document. DO NOT sign the last pages if not in the presence of a certified Notary Public. The Detention Center has certified Notaries and can assist you with this when you return your PIQ.

Please call the Doña Ana County Detention Center at (575) 647-7608 to schedule a

time to return this document.

WHAT TO EXPECT IN THE RECRUITMENT PROCESS

If you meet the minimum qualifications, our office will email you with a scheduled testing date for

the written exam.

If you pass the written exam, our office will run your NCIC/local law checks and schedule your

polygraph exam.

If you pass your NCIC and polygraph exam, our office will email you with your scheduled interview

date and time.

After the interview, you may be asked to submit your completed PIQ and bring the following

documents. (Documents will be copied to add to your application file. Originals with be returned

immediately.)

• Valid Driver’s License

• High School Diploma or General Education Diploma (GED)

• If college experience, provide transcripts

• DD-214 (if prior military service)

• Academy Completion Certificate (if prior corrections experience)

Doña Ana County Detention Center will verify employment, contact references and run a complete

criminal background check using the information you provide in this document.

If you pass the steps listed above, our office will email you with your contingent job offer letter and

the date and time of your scheduled psychological evaluation.

If you clear the psychological evaluation, our office will email you with your scheduled medical,

physical, drug screen, and Tuberculosis (TB) test.

If you clear the medical, physical, drug screen, and TB test, your completed file will be forwarded to

the Doña Ana County Human Resources Department for final review. You may be given an official



offer of employment, followed by a start date and additional information pending final review and

approval.

PIQ COMPLETION CHECKLIST

Section Page Complete?

Instructions and Guidelines 2

What to Expect in the Recruitment Process 3

PIQ Completion Checklist 4

Section A-1: Identification Information 5

Section A-2: Contact Information 5

Section A-3: Personal History Information 6

Section A-4: Education & Training 7

Section A-5: Employment History 9

Section A-6: Social History 15

Section A-7: Military Service 16

Section B-1: Criminal & Legal History 17

Section B-2: Specific Information for Detention Center Facilities 20

Section B-3: Drug Activity 23

Section B-4: References 25

Appendix A- Supplementary Applicant Information 27

Appendix B- Detention Center Officer Willingness Checklist 29

Appendix C- Waiver of Rights and Applicant Agreement 30

Appendix D- Affidavit 32

Appendix E- Background Release of Liability 33

4



SECTION A-1: IDENTIFICATION INFORMATION

LAST NAME

FIRST NAME

MIDDLE NAME

OTHER NAMES THAT YOU HAVE USED OR YOU HAVE BEEN KNOWN BY (INCLUDE MAIDEN NAMES, ALIASES & NICKNAMES)

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Enter Last 6 Digits

__ __

__ __ __ __

LEAVE THIS SECTION BLANK Month Date Year

STATEMENT OF WORK ELIGIBILITY

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification documentation form upon hire.

PLACE OF BIRTH (CITY, COUNTY, STATE, COUNTRY) DRIVER’S LICENSE

DL# State Expiration

GENDER HEIGHT HAIR COLOR EYE COLOR WEIGHT

DISTINGUISHING MARKS (LIST & DESCRIBE ALL SCARS, TATTOOS, ETC., INCLUDING LOCATION)

SECTION A-2: CONTACT INFORMATION CURRENT RESIDENCE MAILING ADDRESS IF DIFFERENT STREET ADDRESS STREET ADDRESS or PO BOX

CITY COUNTY CITY COUNTY STATE

ZIP CODE STATE ZIP CODE

NAMES & RELATIONSHIPS OF ALL PEOPLE THAT CURRENTLY RESIDE WITH YOU

TELEPHONE NUMBERS (CHECK THE BEST NUMBER TO REACH YOU)

OTHER HOME PREFERRED CONTACT MOBILE PREFERRED CONTACT PREFERRED CONTACT

EMAIL ADDRESSES



SECTION A-3: PERSONAL HISTORY INFORMATION

1. In chronological order, beginning with the residence preceding your current residence, list EACH and EVERY

place you have lived at for the last ten (10) years. If the space provided is insufficient, please attach additional information.

1 STREET ADDRESS OR PO BOX 2 STREET ADDRESS OR PO BOX

CITY COUNTY CITY COUNTY

STATE ZIP CODE FROM TO STATE ZIP CODE FROM TO

NAMES & RELATIONSHIPS OF ALL PEOPLE THAT YOU RESIDED WITH NAMES & RELATIONSHIPS OF ALL PEOPLE THAT YOU RESIDED WITH









2. List the names of all relatives that currently work for Doña Ana County.

NAME TITLE DEPARTMENT RELATIONSHIP



3. Did you ever have a driver’s license issued by another state? Yes No If yes, provide details:

STATE DRIVER’S LICENSE NUMBER DATES LICENSED

(If space is insufficient, use supplemental space provided in Appendix A)

SECTION A-4: EDUCATION & TRAINING

4. Indicate the highest level of education status you have completed.

Graduated from an accredited U.S. High School

Received a General Education Diploma (GED)

Associate’s Degree or equivalent from an accredited U.S. College or University

Bachelor’s Degree from an accredited U.S. College or University Post

Graduate Degree from an accredited U.S. College or University

5. Please provide details regarding your educational history.

HIGH SCHOOLS (STARTING WITH LAST SCHOOL ATTENDED)

CITY, STATE ATTENDANCE

DATES GRADUATED FROM TO

NAME:

Yes No

NAME:

NAME:


GED TEST DATE TAKEN NAME OF TESTING INSTITUTION LOCATION (CITY, STATE)



6. Please provide details about any professional licenses or certifications that you have obtained.

LICENSE/CERTIFICATION DATE OBTAINED EXPIRATION


7. Have you ever been suspended or expelled from any high school or post-secondary school? Yes No

If yes, please explain:



SECTION A-5: EMPLOYMENT HISTORY

8. List below EVERY place you have been employed at for the last ten (10) years, whether paid or unpaid, beginning with your current or most recent employer. Include part-time employment, volunteer work and internships/externships. Do not omit any employment and give full and complete addresses and phone numbers. List dates and reasons for any periods of non-employment. Attach additional pages, if necessary.

UNEMPLOYMENT DATES REASON FOR UNEMPLOYMENT

FROM:

TO:

1 EMPLOYER ADDRESS

START DATE END DATE PHONE NUMBER

POSITION HELD (JOB TITLE) STARTING PAY ENDING PAY EMPLOYMENT TYPE

FULL TIME PART TIME VOLUNTEER IMMEDIATE SUPERVISOR / TITLE SUPERVISOR PHONE NUMBER

BRIEF DESCRIPTION OF DUTIES

DETAILED REASON FOR LEAVING (EVEN IF STILL CURRENTLY EMPLOYED)


FROM:

TO:

2 EMPLOYER ADDRESS





DETAILED REASON FOR LEAVING




FROM:

TO:

3 EMPLOYER ADDRESS







FROM:

TO:

4 EMPLOYER ADDRESS









FROM:

TO:

5 EMPLOYER ADDRESS







FROM:

TO:

6 EMPLOYER ADDRESS









FROM:

TO:

7 EMPLOYER ADDRESS







FROM:

TO:

8 EMPLOYER ADDRESS








9. Have you ever been involuntarily terminated, asked to resign from employment or resigned in lieu of

termination? Yes No

If yes, please provide details below:

EMPLOYER DATE REASON


10. Have you ever been or are you currently the subject of any investigation, formal or informal, connected

with any employment? Yes No

If yes, please explain:

11. Have you ever received disciplinary action including, but not limited to, verbal warnings, written warnings,

corrective action, administrative leave, suspension or termination? Yes No


EMPLOYER DATE REASON




12. Have you ever applied for employment with any government agency? Yes No


AGENCY DATE STATUS OR DISPOSITION OF APPLICATION




SECTION A-6: SOCIAL HISTORY

13. Please list all clubs, societies and organizations of which you are or have been a member; include civic, gang,

party crew, car club, fraternity, and athletic).

NAME ADDRESS, CITY AND STATE DATE TYPE OF ORGANIZATION

_______________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

_________________________________________________________________________________

14. Are you now or have you been a member of any foreign or domestic organization, association, movement,

group of combination of person which is totalitarian, fascist, community, subversive, or which has adopted,

shows a policy of advocating the commission of acts, force or violence to deny other persons their rights

under the Constitution of the United States, or which seeks to alter the form of Government of the U.S. by

unconstitutional means? If yes, please explain fully.

________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________



SECTION A-7: MILITARY SERVICE

15. If applicable, did you register for selective service (military draft) when you turned 18? Yes No

If no, please explain:

16. Please list your service in the armed forces, National Guard and/or military reserves. Provide details concerning all periods of service below (include drafts, enlistments and recall to service).

BRANCH SERVICE DATES SERIAL # RANK AT EXIT


17. What type of discharge or separation did you receive? ______________________________________

If not honorably discharged, please provide a detailed statement concerning your discharge/separation,

including branch, dates, location and circumstances using space provided in APPENDIX A of this document.

18. Were you ever the subject of a Court-Martial, tried on any charges, the subject of a summary court, deck

court, Captain’s Mast, company punishment, Article 15, Page 11 written counseling or any other disciplinary

action during your military service? Yes No

If yes, please provide a detailed statement concerning the disciplinary action, including branch, dates,

location and circumstances using space provided in APPENDIX A of this document.

19. Were you ever declared unaccounted for (UA), absent without leave (AWOL), missing ships movement or

other similar status? Yes No If yes, please explain:



PART B

SECTION B-1: CRIMINAL & LEGAL HISTORY

20. Have you ever been arrested, taken into custody, charged, detained, summoned, subpoenaed, cited,

convicted, questioned by law enforcement or had to appear in court for any criminal or civil offense in the

state of New Mexico or in any other location? Yes No

If you answered yes, please list EACH incident below. Refer to APPENDIX A to complete a detailed statement

of each listed incident, including the ultimate determination of the case.

DATE

VIOLATION/CHARGE

LOCATION (CITY/STATE)

DISPOSITION OR

SENTENCE

POLICE OR CIVIL AGENCY


21. Have you ever failed to appear/pay for arrests/citations/speeding tickets or violated the terms of any court

order or judgment, including probation, restraining orders, programs, fines, etc.? Yes No

If yes, explain: DATE

VIOLATION/CHARGE


DISPOSITION OR SENTENCE


22. Are you currently pending prosecution for any crime (felony or misdemeanor) including traffic violations

(regardless of the expected outcome)? Yes No If yes, explain:

23. List ALL traffic citations (including speeding tickets, warnings and dismissed citations) you have received and/ or traffic accidents that you had and whether they have been dismissed/deferred or not.

DATE

VIOLATION/CHARGE


DISPOSITION OR SENTENCE

POLICE OR CIVIL AGENCY




24. Has your driver’s license ever been restricted, suspended or revoked either criminally or administratively?

Yes No

DATE CITY, STATE REASON


25. Do you have any active felony or misdemeanor warrants for your arrest? Yes No If yes, explain:

26. Are you currently or have you ever been on formal or informal summary or court probation including deferred sentencing, pre-prosecution programs or early intervention programs- supervised or unsupervised?

Yes No If yes, explain:

27. Do you currently or have you ever had a restraining order against you (including those incorporated into a

divorce decree)? Yes No If yes, explain:

28. Have you ever been arrested, booked or convicted of any misdemeanor or felony crime as a juvenile?


29. Have you ever been fingerprinted? Yes No If yes, provide details:

DATE CITY/STATE REASON




30. Have you ever been bonded? Yes No If yes, provide details:

DATE BONDING AGENT & LOCATION REASON


31. Have you ever been refused a bond? Yes No If yes, provide details:

DATE BONDING AGENT & LOCATION REASON




SECTION B-2: SPECIFIC INFORMATION FOR DETENTION CENTER POSITIONS

(Any previous experience in a Detention Center, Correctional Setting or Similar Institution)

32. Have you ever been employed with the Doña Ana County Detention Center (DACDC) or any predecessor

organizations at any time in the past? Yes No

If yes, provide details below:

POSITION HELD FROM TO REASON


33. Have you previously submitted an application to the Doña Ana County Detention Center or any other law


34. Have you completed a Detention Officer Training Academy? Yes No If yes, provide the details:

FACILITY LOCATION

(CITY & STATE) ATTENDANCE DATES

GRADUATED? FROM TO

Yes No

Yes No

Yes No (If space is insufficient, use supplemental space provided in Appendix A)

__________________________________________________________________________________________



Sexual Harassment and Misconduct:

A. Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile

facility, or other institution? (As defined in 42 U.S.C. 1997) Yes No

B. Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was

unable to consent or refuse? Yes No

C. Have you ever been civilly or administratively adjudicated to have engaged in the acts or behaviors described

in A or B above? Yes No

D. Have you ever resigned in lieu of or been terminated for a PREA allegation? Yes No

35. Have you ever brought any contraband of any type into any jail or correctional facility? Yes No

If yes, explain:

36. Have you or any immediate family members or friends been incarcerated in any corrections facility NOW or

ever? Immediate family members include the following: parents (in-law and step), siblings (in-law, half or step),

children (in-law and step), spouse (ex-spouse), and boyfriend/girlfriend (fiancé/fiancée) and/or significant others.

Friends include any close associates. Yes No

If yes, provide details below:

NAME RELATIONSHIP FACILITY (NAME/LOCATION) REASON

NAME RELATIONSHIP FACILITY (NAME/LOCATION) REASON




37. Are you or any immediate family members or friends currently associated with or have ever been associated

with a social club, car club, group or street/prison gang that have been involved with or are suspected of being involved with criminal activity of any type? Immediate family members include the following: parents

(in-law and step), siblings (in-law, half or step), children (in-law and step), spouse (ex-spouse), and boyfriend/girlfriend (fiancé/fiancée) and/or significant others. Friends include any close associates.

Yes No

If yes, please provide a detailed statement concerning the relationship, including group name, dates, location and circumstances of involvement using the space provided in APPENDIX A of this document.

38. Are you now or have you ever been a member of a radical organization or any other similar organization that

targets ethnic, racial or religious groups? Yes No

If yes, please provide a detailed statement concerning the relationship, including group name, dates, location and circumstances of involvement using the space provided in APPENDIX A of this document.

39. Are you now or have you ever been a member of any party or organization, political or otherwise, that now

(or in the past) advocates the overthrow of the government of the United States, the state of New Mexico or

other state by force, violence or other unlawful means? Yes No

If yes, please provide a detailed statement concerning the relationship, including group name, dates, location and

circumstances of involvement using the space provided in APPENDIX A of this document.

40. Are you aware of anything that may potentially disqualify you from being hired to a position in a Detention

facility or that prevents you from discharging the duties of such a position? Yes No If yes, explain:



B-3: DRUG ACTIVITY

41. Have you ever used, thought you were using, tasted, sniffed, smoked, ingested, inhaled, injected, swallowed,

attempted to use or experimented with, possessed, sold, offered for sale, cultivated, manufactured,

transferred, transported or engaged in any other illegal activity with any illegal substances or prescription

medications not prescribed to you? Yes No

If yes, please complete the following and attach a statement fully explaining your usage.

TYPE OF DRUG DATE FIRST USED DATE LAST USED # OF TIMES USED

Marijuana (Pot, Grass, Reefer, Weed, etc.)

Spice (Synthetic marijuana, K2, Black Mamba, etc.)

Wax (BHO, etc.)

Hash (Hashish, Hash Oil, etc.)

Unprescribed Pain Killers / Psychotherapy Medications (Oxy, Vicodin, Ritalin, Ativan, Valium, etc.)

Cocaine (Crack, Rock, Blow, etc.)

Barbiturates (Downers, etc.)

Amphetamines (Meth, Uppers, Speed, Bath Salts, etc.)

Heroin (Black Tar, H, Horse, etc.)

Ecstasy (Molly, X, etc.)

PCP / Angel Dust / 2C-P / Krokodil

Mushrooms / Peyote

Steroids (Oral or Injected)

LSD (Acid, Blotter Acid)

Opium / Morphine

Suboxone / Methadone (unprescribed)

Inhaled Drugs (Paint, Glue, Solvents, Gases, Poppers)

Any Other Unprescribed Drugs / Medications:



Any Other Illegal Substance:

Any Other Illegal Substance:

42. Have you been present when illegal substances or prescription medications that were not prescribed have

been used? Yes No If yes, explain:

43. Have you ever used any illegal drugs, narcotics, and prescription medications not prescribed to you, or

alcohol on any job or gone to work under the influence of any illegal drug, narcotic, alcohol, or prescription

drug not prescribed to you? Yes No If yes, explain:

44. Have you ever purchased narcotics, illegal drugs, steroids or marijuana without a doctor’s prescription? This includes, but not limited to, giving someone else money to purchase any of them for you or to defray the

cost, chip in, etc. Yes No If yes, explain:

45. Have you ever sold, exchanged or given away any illegal or counterfeit drugs or narcotics?


46. Have you ever sold or traded anything of value, OTHER THAN MONEY, to purchase any illegal drugs or

narcotics? Yes No If yes, explain:

47. Have you ever participated in the manufacture, i.e. help make, produce, supply or packaging of any illegal

drug, narcotic, or counterfeit drug? Yes No If yes, explain:



B-4: REFERENCES

Provide the names and contact information of a MINIMUM of SEVEN (7) character/personality references. Listed individuals MUST NOT be family members (parents, siblings, aunts/uncles, cousins, etc.) or friends.

Listed references must include a combination of individuals who can speak to your character in the areas of employment (supervisor, business owner, etc.), military (if applicable) (CO, ranking officer, etc.) Academic (teacher, principal, tutor, counselor, professor), and community (mentor, coach, pastor/priest, volunteer associate, etc.).

1. NAME & TITLE RELATIONSHIP YEARS KNOWN

ADDRESS PHONE ALT PHONE

Comments:


ADDRESS PHONE ALT PHONE

Comments:


ADDRESS HOME PHONE ALT PHONE

Comments:



Comments:





Comments:



Comments:



Comments:



Comments:



Comments:

10.

NAME & TITLE RELATIONSHIP YEARS KNOWN


Comments:



APPENDIX A – SUPPLEMENTARY APPLICANT INFORMATION

This space is for providing additional, complete and accurate information to any personal information question

required in the above document. Please reference the section and question number for each added response. If

applicable, provide the date and location of the incident. Written statements should completely describe events/incidents, circumstances, actions, and outcomes.

Supplemental

Response to Section:

DATE OF INCIDENT

(if applicable):

LOCATION

(if applicable):

Question #:

Supplemental


DATE OF INCIDENT

(if applicable):

LOCATION

(if applicable):

Question #:

S t a teme n t:

S t a teme n t:



Supplemental


DATE OF INCIDENT

(if applicable):

LOCATION

(if applicable):

Question #:

Statement:

Supplemental


DATE OF INCIDENT

(if applicable):

LOCATION

(if applicable):

Question #:

S t a teme n t:



APPENDIX B – DETENTION CENTER OFFICER WILLINGNESS CHECKLIST

Many people have accepted the job of Detention Officer without carefully considering the requirements and demands of

the job and the work environment. Please carefully consider each job requirement listed below. Initial in the respective

column whether you are willing and able to meet each requirement

Yes No

Are you willing to attend a paramilitary style-training academy to learn and develop the skills necessary to perform the role of Corrections Officer?

Are you willing and able to participate in demanding physical training (running several miles, weight training, plyometric training and other exercises) on a daily basis?

Are you willing to assist in inmate rehabilitation?

Do you believe that you can set aside your personal prejudices and be fair in dealing with inmates convicted of serious crimes?

Detention Officers may be assigned to work any shift by the department, including Graveyard (5:00 pm – 5:00 am) or Days (5:00 am – 5:00 pm). Are you willing and able to work any shift as needed and as determined by the department?

Are you willing and able to work all holidays, which are not on your regular days off, unless, authorized for leave?

Are you willing and able to work several mandatory overtime shifts in addition to your regularly scheduled hours (up to 24 hours of overtime in a pay period)?

Are you willing and able to work weekends, with your regular days off during the week?

Are you willing to wear a uniform to work every day?

Are you willing and able to work in a tobacco free environment?

Are you willing to use reasonable force when necessary, such as controlling disturbances or breaking up fights?

Are you willing to give first aid, including CPR, to inmates who are ill or injured, given the proper safety equipment and training?

Are you willing to pat search (frisk) inmates?

Are you willing to supervise inmates, regardless of their gender?

Are you willing to work in areas with inmates who are sick and may have contagious diseases?

Are you willing to work in a noisy environment?

Are you willing and physically able to remain on your feet during a twelve (12) hour shift or more?

Are you willing to risk your personal safety to come to the aid of a fellow officer?

Are you willing to work, unarmed, in a locked area, with sixty (60) or more non-confined inmates who may be aggressive?

Are you willing to work in a situation where you may be verbally assaulted and/or threatened?

If it becomes necessary to take a human life in the course of your duties, would you?

I have read the above and believe that I can fulfill the duties of a Detention Officer and would like to continue with the

application process.

Print Name Signature Date



APPENDIX C - WAIVER OF RIGHTS AND APPLICANT AGREEMENT

WAIVER OF RIGHTS TO APPLICATION/BACKGROUND INFORMATION/APPLICANT AGREEMENT

I understand that information regarding every aspect of my background will be used by the Doña Ana County Detention

Center for the purpose of determining my eligibility for the position for which I have applied.

I hereby acknowledge that I understand and agree that all information and materials gathered by the Doña Ana County

Detention Center, either from me or from other sources, is and shall remain the sole and exclusive property of Doña

Ana County. This shall include, but is not limited to, all test instruments, questionnaires, inquiries, acknowledgments,

social media accounts, telephone records, credit reports and any other documentation that might be found in my

background file.

I understand and agree that the Doña Ana County Detention Center may gather confidential information pertaining to

me from a number of sources and that Doña Ana County has my permission to do so as evidenced by my signature on

their form “Background Release of Liability.” I understand that any information gathered regarding my background will

be used for employment purposes only and will not be made available to me or to others outside of Doña Ana County

now or in the future unless required by law.

I further understand and agree that any or all information obtained as part of the investigation of my application will be

considered confidential and will not be released to anyone outside the Doña Ana County Detention Center or Doña Ana

County.

ACCURACY OF INFORMATION PROVIDED

By signing below, you hereby certify that information contained in this Personal Information Questionnaire is truthful,

correct and accurate and that no information has been omitted or misrepresented. You further understand that any

information that is not disclosed in its entirety or is not accurate will constitute a falsification of this questionnaire and

may be deemed sufficient cause to disqualify you from employment or to terminate your employment, if hired.

CONFIDENTIAL INFORMATION AGREEMENT

A thorough investigation will be conducted to determine your qualifications for the position for which you have

applied. Your employment with the Doña Ana County Detention Center, in this capacity, may depend on information

obtained in confidential interviews with persons who you have been associated with. Therefore, such information will

remain confidential and may not be disclosed to you at any point during or after the hiring process.

CONSENT TO OBTAIN EMPLOYMENT INFORMATION

In conjunction with the thorough investigation of your background, Doña Ana County Detention Center will verify

employment information provided including dates of hire, position held, current or former employment status, current

or past work performance, disciplinary history and any other information relevant to the determination of your

suitability for employment with Doña Ana County . By signing below, you authorize your current and former employers

to release any and all information concerning your employment to Doña Ana County Detention Center. Further, you

release any current or former employer and any educational institutions you attended and/or graduated from any and

all liability in supplying requested information regarding your employment.



Applicant Signature Date

Applicant Printed Name

State of New Mexico County of Doña Ana

On the day of , 20 before me personal appeared, known to me, to be the person

whose name is subscribed to the above instrument and acknowledged the same to his/her own free act and deed.

NOTARY PUBLIC

My Commission Expires: (seal)



APPENDIX D - AFFIDAVIT

AFFIDAVIT

STATE OF NEW MEXICO

__________________________________, being first duly sworn on oath, states as follows:

1. My name is ____________________________________. I am applying for an employment position with

___________________________________. As part of my background investigation, I have been asked to provide

this sworn affidavit to attest to whether I have any social network accounts. I understand that as a condition of

employment, this background investigation requires that I voluntarily provide access to any such social network

accounts I may have. This is necessary to ensure that I meet the criteria for employments with

___________________________. I understand that this information in itself will not disqualify me from

employment, but will provide the agency with additional information what will assist in a reasonable employment

background investigation. I am aware that access does not include providing my private password for purposed of

this access.

Provide your social network account usernames(s) for the following:

Facebook: ________________________________

Instagram: ________________________________

Twitter: ________________________________

Other(s): _________________________________

2. (Alternative for current employee) My name is _______________________. I understand that my employment

status with _________________________________ can be adversely affected if I engage in any conduct that has

the potential to adversely affect my job performance or ability perform or conduct that has the potential to

adversely affect the agency’s morale, operations or effectiveness. I hereby subscribe that I (do) or (do not) have

any social network accounts. I understand that should I be subject to an administrative investigation by my

agency that will be enhance d by access to my social network accounts, I will be required to provide access to the

assigned investigator. I understand that any such investigation will be strictly limited to my conduct, directly and

narrowly related to my position with this agency that might have the potential to adversely affect my performance

or the operations of my agency. I am aware that access does not include providing my private password for

purposes of this access.

Name: ______________________________ Address:______________________________________________

Signature: _____________________________________ Date: _________________________

Sworn and subscribed before me this____________ day _______________, 20_____

____________________________________________

Notary Public, in and for Doña Ana County, New Mexico My Commission Expires: __________________

(Notary Stamp)



APPENDIX E – BACKGROUND RELEASE OF LIABILITY

To be completed by Doña Ana County Detention center

Printed Name of

Applicant

1. I am applying for employment with a department within the Doña Ana County Detention Center and acknowledge that the

burden of providing my qualifications for such employment is at all times upon me. I further understand that a full investigation

will be made of my background, character and financial responsibilities by the Doña Ana County Detention Center Background

Investigator. I accept any and all risk of adverse public notice, embarrassment, criticism or financial loss, which may result from

actions taken in regard to my application. This authorization is given freely and without duress or promise. I voluntarily waive

any protection against unauthorized disclosure of information. I further understand that information furnished to the Doña Ana

County Detention Center will remain confidential and will not be released to me now or in the future.

2. I respectfully request and authorize you to furnish the Doña Ana County Detention Center with any and all information or

documents concerning me, including information or documents of a confidential or privileged nature, photocopies of same, if

requested.

3. I understand that any offer of employment is contingent upon successful completion of an in-depth background investigation

including, but not limited to, work history, educational verification, personal references, personal reputation and character,

driver’s history, criminal history and civil history and any pre-employment screening as required by the department or Doña Ana County. I understand that a variety of resources may be used by the Doña Ana County Detention Center to collect

this information about me. Further, I understand that my continued employment will depend on information obtained.

4. I request that you allow employees including supervisors and co-workers, to be interviewed by personnel from the Doña Ana

County Detention Center regarding any aspects of employment with you or your organization.

5. I hereby release you, your organization or others from liability for damages, which may result from furnishing any information,

as requested above.

6. A reproduction of this request by Xerox, facsimile, email or similar process shall be for all intents and purposes as the original.

Applicant Signature Date

Applicant Printed Name

Please remit copies of requested documents to: Doña Ana County Detention

Center

Attn: Background Investigator Scan to email:

andrewl@doñaanacounty.org Questions?: Call (575) 647-7608

T o : F r o m:

Name, Address of Former Employer