Application for Employment Evansville, WY Police Department

Transcription

1 Application for Employment Evansville, WY Police Department We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. We are an Equal Opportunity Employer. Part 1. GENERAL INFORMATION Please review all questions carefully before preparing your application. POSITION (Job title) NAME (Last, First, and Middle Initial) SOCIAL SECURITY NO. MAILING ADDRESS (Include apartment number, if any) ADDRESS HOME TELEPHONE CITY STATE ZIP WORK (or message) TELEPHONE Employment Preferences: If you are under 18 years of age, can you provide required proof of your eligibility to YES NO Have you ever filed an application with us before? YES NO If Yes, give date. Have you ever been employed with us before? YES NO If Yes, give date. Are you currently employed? YES NO May we contact your employer? YES NO Are you prevented from lawfully becoming employed in this country because of Visa or YES NO Immigration Status? (Proof of citizenship or immigration status will be required upon employment.) On what date would you be available for work?. Check types of employment you will accept: FULL-TIME PART-TIME TEMPORARY SHIFT WORK Are you currently on lay-off status and subject to recall? YES NO Are you willing to travel as part of this job? YES NO Part 2. BACKGROUND INFORMATION If a driver s license or other license, certificate, or registration is required for this position, please complete the following: Have you been convicted of a misdemeanor or felony within License, Certificate, or Registration License Number Expiration Date Driver s License CDL Other (Indicate type) If Yes please explain: the past seven (7) years? (Answering yes will not automatically bar you from employment). YES NO Other than English, what languages do you speak, read, or write fluently? 1 P a g e

2 Part 3. EDUCATION AND TRAINING Review of education: Have you graduated from high school or passed the GED? YES NO List Elementary, High School, College, business school, military training, and other relevant education. School Name and Address Month and Year Attended 1 From / Quarter Credits Earned Semester Other (Specify) Major Type of Degree Awarded Year degree received To / From / To / From / To / From / To / Describe any specialized training, apprenticeship, skills and extra-curricular activities. Describe any job-related training received in the United States military. Part 4. EMPLOYMENT HISTORY If you need more spaces, please continue on a separate sheet of paper. 1. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years Employed in this Position Total Months Average Hours Last Salary From / To / /Per Week Immediate Supervisor s Name Reason for Leaving Volunteer ( ) Number of Employees Supervised Specific Duties: 2. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years Employed in this Position Total Months Average Hours Last Salary From / To / /Per Week Immediate Supervisor s Name Reason for Leaving Volunteer ( ) Number of Employees Supervised Specific Duties: 3. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years Employed in this Position From / To / Total Months Average Hours /Per Week Immediate Supervisor s Name Reason for Leaving Volunteer ( ) Number of Employees Supervised Last Salary Specific Duties: 2 P a g e

3 4. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years Employed in this Position Total Months Average Hours Last Salary From / To / /Per Week Immediate Supervisor s Name Reason for Leaving Volunteer ( ) Number of Employees Supervised Specific Duties: List professional, trade, business or civic activities and offices held. You may exclude membership, which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status. Part 5. ADDITIONAL INFORMATION Other Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience. Specialized Skills Check Skills/Equipment Operated PC Fax Other (list) Typewriter Microsoft Word State any additional information you feel may be helpful to us in considering your application. Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? YES NO 3 P a g e

4 Part 6. REFERENCES (1) NAME (Last, First, and Middle Initial) MAILING ADDRESS (Include apartment number, if any) ADDRESS (if known) HOME TELEPHONE CITY STATE ZIP WORK (or message) TELEPHONE (2) NAME (Last, First, and Middle Initial) MAILING ADDRESS (Include apartment number, if any) ADDRESS (if known) HOME TELEPHONE CITY STATE ZIP WORK (or message) TELEPHONE (3) NAME (Last, First, and Middle Initial) MAILING ADDRESS (Include apartment number, if any) ADDRESS (if known) HOME TELEPHONE CITY STATE ZIP WORK (or message) TELEPHONE (4) NAME (Last, First, and Middle Initial) MAILING ADDRESS (Include apartment number, if any) ADDRESS (if known) HOME TELEPHONE CITY STATE ZIP WORK (or message) TELEPHONE Applicant s Statement I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. TO BE ACCEPTED, YOU MUST SIGN AND DATE THIS APPLICATION. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that the at will employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. / / Date (Month/Day/Year) Signature 4 P a g e

5 PERSONAL HISTORY STATEMENT Rev. 05/26/2016 Instructions to the applicant: The information you provide in this personal history statement will be used in the investigation into your background to assist in determining your suitability for the position. Please fill out the questionnaire completely and accurately. Keep in mind that: 1. The completion of this form is mandatory for all applicants. 2. All statements are subject to verification. 3. Deliberate inaccuracies or incomplete statements may bar or remove you from employment consideration. 4. All time periods in your background must be accounted for. 5. All addresses must be complete. Include City, State and Zip Code. 6. All phone numbers requi re an area cod e. 7. Your ability to complete this document as requested will be evaluated and used as one basis for employment decisions. It is to your advantage to respond openly. Any negative factor in your background will be evaluated in terms of the circumstances and facts surrounding its occurrence and its degree of relevance to the job. For example, being fired from a job or having an arrest record is not in itself grounds for disqualification. During the investigation, the investigator will inquire into the facts surrounding such an occurrence. An evaluation will then be made on the relevance of these facts to the requirements of the job. Deliberate omissions or deliberate misstatements of required information are grounds for rejection. Failure to properly complete this document may also result in rejection of your application. PLEASE PRINT IN INK MUST BE HANDWRITTEN IN YOUR OWN HANDWRITING. If a question does not apply to you, write N/A (not applicable) in the space provided for your answer. If you need more space to respond to a question, use additional pages and identify the additional information by page number. For Police Department Use Only Applicant: Position: Upon initial review: PHS appears complete, continue in process PHS incomplete, action taken: Rejected, action taken: Reviewer: Date: 1 P a g e

6 Date of Application: PERSONAL HISTORY STATEMENT PERSONAL INFORMATION Legal Name: LAST FIRST MIDDLE Position(s) Applied For: Sex: Male Female (circle one) Age: Height: Weight: Hair Color: Eye Color: Social Security Number - - Date of Birth (M/D/Y): Phone Number(s) List Aliases, Nicknames, Maiden Name: U.S. Citizen: Yes No (Circle one) Place of Birth: CITY COUNTY STATE Motor Vehicle License #: Expiration Date: Motor Vehicle License State: Emergency Contact Information: NAME ADDRESS TELEPHONE # RELATIONSHIP List all Scars, Tattoos, & Distinguishing Marks, and their locations: 2 P a g e

7 FAMILY HISTORY List relatives in the following order: Mother (include Maiden name), Father, Mother-in-law, Father-in-law, Step Father, Step Mother, Foster Mother, Foster Father, Legal Guardian(s), siblings, and brothers & sisters in-law. RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # 3 P a g e

8 RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # RELATIONSHIP AGE LAST NAME FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE BIRTHPLACE OCCUPATION HOME PHONE # WORK PHONE # 4 P a g e

9 MARITAL INFORMATION Marital status: Annulled Single Married Widowed Divorced Separated Name of present spouse: Last First Middle Place of Marriage: City County State Zip Code Date of Marriage: Spouse address (if different than applicant): Address City State Zip Code Telephone Numbers: Home Work Cell Phones CHILDREN INFORMATION List all of children (includes Step Children, Adopted Children, Etc.) Name (Last) (First) (Middle) Sex Relationship Living With You (Y/N) Name (Last) (First) (Middle) Sex Relationship Living With You (Y/N) Name (Last) (First) (Middle) Sex Relationship Living With You (Y/N) Name (Last) (First) (Middle) Sex Relationship Living With You (Y/N) Name (Last) (First) (Middle) Sex Relationship Living With You (Y/N) 5 P a g e

10 IF DIVORCED, WIDOWED, OR ANNULLED (List Prior Marriages in order of occurrence) Name of Former Spouse Telephone # Address Date Final Divorced Filed Name of Former Spouse Telephone # Address Date Final Divorced Filed Name of Former Spouse Telephone # Address Date Final Divorced Filed Amount of Alimony or Child Support Ordered: Have you ever been delinquent in these payments: Yes No If you have been delinquent, please explain circumstances: IF UNMARRIED, COMPLETE THIS SECTION List name of boyfriend, girlfriend, or significant other: List his/her Date of Birth: List his/her occupation: List his/her employer: List his/her Business Address: List his/her Business Phone #: List his/her home address: List telephone number: Social Security Number: 6 P a g e

11 EDUCATION HISTORY List all high schools, colleges, technical or trade schools you have ever attended, regardless of whether or not you graduated. If you are listing colleges/universities and you did not graduate, indicate the actual number of credit hours you earned. If you attended a technical or trade school, indicate your course of study and whether you received a diploma or certification. NAME AND TYPE OF SCHOOL LOCATION (CITY AND STATE) DATES ATTENDED DEGREE AND/OR CREDITS EARNED Were you ever expelled or suspended from school? If yes, please complete below: Yes No SCHOOL DATES REASON Have you ever been placed on academic probation? If yes, please complete below: Yes No SCHOOL DATES REASON 7 P a g e

12 If you have obtained a G.E.D. High School level equivalent, indicate test scores & U.S. Percentile. Test Scores Standard Scores U.S. % Correctiveness & Effectiveness of expression Interpretation of reading materials in Social Studies Interpretation of reading materials in Natural Science Interpretation of Literary Materials General Mathematical Ability Average Where Taken When Taken Clubs, sports, etc: SCHOOL ACTIVITIES Leadership positions: indicate positions/organizations/dates held: Community activities: Awards, commendations or items of special recognition: Current hobbies and activities: 8 P a g e

13 List your past and present memberships in groups, associations, and/or clubs: TYPE: SOCIAL, ORGANIZATION FRATERNAL. PROFESSIONAL, ETC. OFFICES HELD DATES FROM/TO Are there any incidents in your life not mentioned herein which may reflect upon your suitability to perform the duties which you may be called upon to perform? Yes No If yes, please explain: EMPLOYMENT HISTORY Have you ever been fired/discharged from a job? Yes No Have you ever been forced to resign from a job? Yes No Have you ever resigned to avoid being fired? Yes No If yes to any questions above, please explain in detail the circumstances surrounding your termination/request to leave. Please include dates, name, address and phone number of employer, supervisor's name and all of the facts. Specifically, what was the allegation(s) made against you by your employer? If you have been fired/requested to leave more than once, please list each incident separately (attach additional pages if necessary): 9 P a g e

14 DRUG USAGE Have you ever illegally used, possessed, bought, sold or delivered any of the following drugs? Drug Marijuana / THC Methamphetamine Cocaine LSD or other hallucinogens Hashish Amphetamines (stimulants) Barbiturates (depressants) Heroin PCP (angel dust) Opium, Morphine Steroids Any designer drug MDMA (Ecstasy), GHB, Ketamine Peyote Mushrooms Have Used? Yes No Within last 24 months Last Time Used Within last 2-5 years More than 5 years ago Number of Times 1 to 2 3 to 10 More than 10 Activity* Details Last Date Used *Please indicate in this column whether you used, possessed, bought, sold or delivered the substance indicated. Have you ever intentionally inhaled with the intent to get high any paint, glue or other chemical vapors found in household products? Yes No If yes, describe your involvement (include dates): Do others use illegal drugs in your presence? Yes No If yes, how often? When was the last time? Have you used cough medicine or any other over the counter drug to get high? Yes No If yes, explain: Have you ever used legitimate pharmaceuticals not prescribed for you or abused medicine prescribed for you? Yes No If yes, explain: 10 P a g e

15 PERSONAL REFERENCES List five (5) persons who know you well enough to provide current information about you. Do not list relatives or past/present employers! REFERENCE #1 Name: Occupation: Home Address: _ Home Phone #: Work Phone #: How long have you known this person? Briefly describe your relationship with this person: REFERENCE #2 Name: Occupation: Home Address: _ Home Phone #: Work Phone #: How long have you known this person? Briefly describe your relationship with this person: REFERENCE #3 Name: Occupation: Home Address: _ Home Phone #: Work Phone #: How long have you known this person? Briefly describe your relationship with this person: REFERENCE #4 Name: Occupation: Home Address: _ Home Phone #: Work Phone #: How long have you known this person? Briefly describe your relationship with this person: REFERENCE #5 Name: Occupation: Home Address: _ Home Phone #: Work Phone #: How long have you known this person? Briefly describe your relationship with this person: 11 P a g e

16 RESIDENCES List all addresses where you have lived during the past ten (10) years, beginning with your present address. List date by month and year. Attach an additional page if necessary. Include landlord names and telephone numbers. Have you ever been evicted? Yes No If yes, please explain: DATES FROM COMPLETE STREET ADDRESS TO CITY STATE ZIP LANDLORD LANDLORD PHONE ( ) DATES FROM COMPLETE STREET ADDRESS TO CITY STATE ZIP LANDLORD NAME LANDLORD PHONE ( ) DATES FROM COMPLETE STREET ADDRESS TO CITY STATE ZIP LANDLORD NAME LANDLORD PHONE ( ) DATES FROM COMPLETE STREET ADDRESS TO CITY STATE ZIP LANDLORD NAME LANDLORD PHONE ( ) DATES FROM COMPLETE STREET ADDRESS TO CITY STATE ZIP LANDLORD NAME DATES FROM COMPLETE STREET ADDRESS TO CITY STATE ZIP LANDLORD NAME LANDLORD PHONE ( ) 12 P a g e

17 Are you: Living with a friend or relative? Yes No Living with your parents? Yes No Own? Yes No Rent? Yes No Residence Phone Number: Business Phone Number: Cell Phone Number: Other Phone Number: Mailing Address: Number and Street City State Zip Code If renting, give name, address, & telephone number of person to whom you pay rent: NAME NUMBER AND STREET ADDRESS City State Zip Code TELEPHONE NUMBER BELOW LIST INDIVIDUAL W/WHOM YOU HAVE RESIDED DURING THE LAST 10 YEARS, EXCLUDE FAMILY MEMBERS. Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known 13 P a g e

18 Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known Name (Last) (First) (Middle) Age Residence Phone # Business Phone # Address City State Zip Code Occupation Yrs. Known DRIVING RECORD How many moving citations have you received since you began driving? List all driving citations and/or summons you have received. DATE RECEIVED TYPE OF VIOLATION ISSUING AGENCY DISPOSITION (FINED, NOT GUILTY, GUILTY) Have you ever been denied a driver's license for any reason? Yes No If Yes, please explain: Have you ever had your driver's license reviewed for receiving an excessive number of traffic violations? Yes No If Yes, please explain: Have you ever had a hearing for the restriction, cancellation, suspension, or revocation of your driver's license? Yes No If Yes, please explain: Have you ever had your driver's license suspended? Yes No 14 P a g e

19 DATE OF SUSPENSION TYPE OF SUSPENSION DATE REINSTATED Have you ever knowingly driven a motor vehicle after your driver's license was suspended or revoked? Yes No What states have you had a driver's license in? How many motor vehicle accidents have you been involved in as a driver? List all accidents that you have been involved in as a driver. DATE LOCATION (City & State) BRIEF DESCRIPTION Is there anything you wish to discuss about your driving record? Yes No Explain: Have you ever been involved in an accident and then left the scene without identifying yourself? Yes No Have you ever been involved in an accident when you were driving after you had been drinking any type of alcoholic beverage? Yes No Have you ever allowed a traffic citation to go to warrant because of your failure to appear in court? Yes No Explain: Have you ever operated a motor vehicle while under the influence of an intoxicating beverage or controlled substance? Yes No If yes, explain: Have you ever been placed as an assigned risk for vehicle insurance? Yes No 15 P a g e

20 Have you ever had your insurance revoked due to the number of traffic citations you have received? Yes No Within the last three years, have you operated a motor vehicle without having the proper insurance? Yes No With what company do you carry automobile insurance? Company Address: Street Address City State Zip Policy Number: Effective Dates: Name of your local agent: Address: Street City State Zip Phone #: List all vehicles owned by you and your spouse: 1) 2) 3) Year Make Model License Plate# State Issued Year Year Make Model License Plate# State Issued Year Year Make Model License Plate# State Issued Year 16 P a g e

21 CRIMINAL INVOLVEMENT/ARRESTS/DETENTIONS Have you ever used excessive physical force against another person? Yes No If yes, give details: Have you ever taken any property or money from an employer or place of business? Yes No If yes, give details: Have you ever provided alcohol to a minor? Yes No If yes, give details: Have you ever been the subject of or involved in a police investigation? Yes No If yes, give details including agency and date: Have you ever been charged with a crime? Yes No If yes, give details including agency and date: Have you ever been arrested? Yes No If yes, give details including agency and date: Have you ever been adjudicated as a delinquent in juvenile court? Yes No If yes, give details: Have you ever been incarcerated in a jail, prison, or other detention facility? Yes No If yes, give details including agency and date: List all other crimes that you have been involved in (even if not detected.) Explain each incident in detail including final outcome (list juvenile as well as adult occurrences): Have you ever been sued by anyone (civil court)? Yes No If yes, give details: 17 P a g e

22 Has any of your immediate family ever been arrested or charged with a felony? Yes No If the Answer is yes, list their name, relationship, and briefly explain circumstances: (List Law Enforcement Agency, charge, & date) Have you ever had anyone call the police on or about you? Yes No Explain: Have you ever been placed on court probation as an adult? Yes No Explain: Were you ever required to appear before a juvenile court for an act which would have been a crime if committed by an adult? Yes No Explain: Have you ever applied for a permit to carry a concealed weapon? Yes No Explain ( include date, location, L.E. Agency, Status or Permit): 18 P a g e

23 MILITARY SERVICE Have you ever been a member of any branch of the United States Military? Yes No Branch of Service: Date of Discharge: month/day/year Type of Discharge: Awards/Commendations (type and date awarded): Special Schools/Training/MOS: While in the military, were you ever arrested for an offense which did or could have resulted in a trial or hearing? Yes No If yes, give date, place, law enforcing authority or type of court or court-martial, charge and action taken for each incident. Charge: Date: Results: Last duty station and name of commanding officer: Are you currently a member of a United States Reserve or National or State Guard Organization? Yes No Branch of Service: Grade & Service #: Are you: Active Inactive Standby Organization/Station/Unit and Location: List all enlistments in the Armed Forces: Selective Service Number: Enlistment Date Branch of Service Unit Rate/Rank Serial Number Discharge Date Highest rank held discharge Type of discharge Veteran's Claim # Enlistment Date Branch of Service Unit Rate/Rank Serial Number Discharge Date Highest rank held discharge Type of discharge Veteran's Claim # 19 P a g e

24 While in service, were you ever the subject of any disciplinary action such as Court Martial, Captains Mast, Office Hours, Company Punishment, or Article 15? Yes No Explain: If you received a discharge other than Honorable, explain reasons below: List your military reserve status: Active Inactive None Branch of Service: Unit: Unit Address: Date of Enlistment: End of Enlistment: Current Rank: Commanding Officer: Have you ever asked or received Deferment from Military Service: Yes No If yes, Give board number, dates, and full details: 20 P a g e

25 FINANCIAL INFORMATION This section will be used to evaluate the behavior exhibited by you in meeting your financial obligations. Have you ever written a check that was returned for insufficient funds or because the account was closed? Yes No If yes, give details: Have you ever filed for or declared bankruptcy? Yes No If yes, explain: Have any of your bills ever been turned over to a collection agency? Yes No If yes, explain: Have your wages or tax refunds ever been garnished? Yes No If yes, explain: Have you ever been delinquent on income tax or other tax payments? Yes No If yes, explain: Have you ever been denied credit or has your credit been canceled? Yes No If yes, explain: Are you currently delinquent on any financial obligations? Yes No If yes, explain: Have you ever had court action taken against you for failing to pay child support? Yes No If yes, explain: 21 P a g e

26 HAVE YOU OR YOUR SPOUSE YES NO Ever had your wages attached? YES NO Ever been a defendant to a small claims or other civil action? YES NO Ever had a judgment rendered against you? YES NO Any immediate civil action pending against you? YES NO Ever filed Bankruptcy or been declared Bankrupt? YES NO Ever been refused credit? YES NO Ever had any of your property repossessed? YES NO Ever had life, automobile, or health insurance cancelled or been refused insurance? YES NO Ever had a bond refused? YES NO Do you have any income other than present salary? IF THE ANSWERS TO ANY OF THE ABOVE QUESTIONS ARE YES, EXPLAIN IN DETAIL BELOW AND/OR ON A SEPARATE SHEET OF PAPER. INCLUDING DATES, LOCATIONS, AND OTHER PERTINENT INFORMATION. Supply accurate information from all of your credit agencies. A couple of businesses you can get a credit report from are Equifax, Experian, & Transunion. Are you currently an owner, partner, or investor in any business enterprise that requires the attainment of a Federal, State, or Local permit or license to operate? Yes No 22 P a g e

27 ASSET / LIABILITY / INFORMATION Show income, expenditures, assets, & liabilities Current monthly income Monthly Salary Current monthly expenditures Real Estate (Mortgage) Spouse's Monthly Salary Rent Other Monthly Income Other Monthly Payments Estimate monthly cost of living (including Utilities, food, gas, home, vehicle maintenance, entertainment, and any other obligation) Total Monthly Income Total Monthly Expenditures Savings Current Assets Current Liabilities Real Estate Indebtedness Checking Long Term Loans Real Estate Charge Accounts Stocks and Bonds Other Liabilities (Describe): Life Insurance (cash value) Other Assets (Describe): Total Assets Total Liabilities: 23 P a g e

28 MISCELLANEOUS INFORMATION Are you a State certified police officer? Yes No If yes: Issuing State: Date issued: Have you ever filled out an application for employment with this or any other law enforcement or enforcement related agency? Yes No NAME OF AGENCY LOCATION (CITY & STATE) DATE OF APPLICATION STATUS OF APPLICATION: PENDING, REJECTED, WITHDREW, ETC. If there are additional agencies list them on a separate sheet. Have you ever been de-certified as a Peace Officer or Detention Officer: Yes No If yes, please explain: Do you have any prior police experience or training: Yes No Where: Agency: Dates: Address: Phone Number: Contact Person: Do you have any relative currently employed with the City? Yes No If yes, give their name and position and the nature of relationship (i.e. parent, aunt, uncle, brother, etc.) Are you willing to work varied schedules during any hour of the day, all days of the week, including holidays and weekends on a regular basis? Yes No How have you prepared yourself to be an employee of the Police Department? 24 P a g e

29 The following question is to be answered by Police Officer Applicants and Community Service Officer Applicants only. If it should become necessary in the performance of your duties, could you use deadly force in defense of your life or the life of someone else? Yes No Explain: 25 P a g e

30 All applicants for Police Officer and/or Community Service Officer must include a one-page hand written synopsis of why you desire to be a Police Officer and/or Community Serv ice Officer. All applicants will be required to provide the following information with the personal history statement or at the time of testing: Certified Copy of Birth Certificate Copy of Valid Driver's License Copy of Social Security Card Copies of High School and Other Diplomas Copy of Military Records (DD214 and Evaluations) I hereby certify that there are not willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to questions. I understand that any appointment offered me is contingent upon the successful outcome of the background investigation, physical fitness assessment (if required) and oral board recommendation. I also understand that during the entire hiring process, I am required to report any changes in this personal history statement within five (5) working days (defined as Monday through Friday). I am fully aware that failure to report any changes in this personal history and/or any false statements or omissions made on any documentation I provide shall be cause for my name to be removed from the Eligibility List. If appointment is made prior to discovery of these omissions, that discovery will be ground for IMMEDIATE dismissal from this Department. Dated this day of, 20. Applicant's Signature: 26 P a g e