Law Enforcement Operations
6000 W. Olive Avenue
Glendale, AZ 85302
623-845-39
POSITION APPLIED FOR:
Peace Officer Certification I & II
NAME:
DATE OF BIRTH:
PRESENT ADDRESS:
PHONE:
HEIGHT:
EMAIL:
WEIGHT:
HAIR COLOR:
EYE COLOR:
BACKGROUND APPLICATION PACKET
This packet contains the Arizona Peace Officer Standards and Training Board (AzPOST)
Statement of Personal History and Application for Open Enrollment in a Community College
Program, the AzPOST medical history questionnaire, the AzPOST medical examination report, and
the AzPOST physical aptitude test consent form. Further, this packet contains the Glendale
Community College background investigation packet, authorization for release of information, and
a memorandum of understanding.
Your responses on these documents will be verified by the investigators through checks of a
variety of records that include those kept by police agencies, courts, social service agencies, and
by interviews with persons you may have listed on your application packet. Your responses to
these questions and those posed by the investigators will also be verified by a polygraph
examination. If you deliberately give false or misleading information, or omit relevant information,
you will be disqualified from this application process. If misleading information is discovered
after your employment begins, you may be subject to immediate termination.
Once you have completed all documents, you will contact the background investigator to make an
appointment for an interview and review of your documents:
Arizona Investigations & Professional Consultants, PLLC
Sequel Polygraph
2131 E. Broadway Road #12 Tempe, AZ 85282
James Norwood, Private Background Investigator
Phone: (602) 550-4567
Fax: (480) 634-7128
Loren Wunderle, Private Background Investigator
Phone: (480) 766-8313
Fax: (480) 361-6479
DIRECTIONS:
1.
2.
3.
4.
5.
6.
Complete this packet in ink in your own handwriting. Write or print legibly.
Review each answer carefully and ensure your answers can be easily read.
Answer each question completely. Do not omit any information that is requested.
Do not leave any question blank. If it does not apply to you, write N/A in the blank.
Use a continuation form to explain any question.
Before returning this questionnaire, read and have your signature notarized on the Release &
Authorization form.
PERSONAL HISTORY
1. Are you a citizen of the United States of America?
2. Have you ever used a proof of citizenship document not your own?
Explain:
3. Have you earned a high school diploma or G.E.D. certificate?
4. Do you have a valid and current Arizona driver’s license?
5. Have you served in the United States military?
6. If you have served in the United States military, what military discharge did you receive:
Yes □ No □
Yes □ No □
7. Will you be at least 21 years of age when you receive your peace officer certification?
8. Have you submitted your fingerprints for the Glendale Community College to query?
9. Have you previously ever been fingerprinted for any reason?
Explain:
10. Would you be able to follow a legal direct order with which you do not agree?
11. Would you be able to take physical action against another person including taking a life?
12. Have you ever been involved in a physical confrontation?
Explain:
13. Have you ever been involved in a high stress or extreme emergency situation?
Explain:
14. Do you have any difficulty working or dealing with members of the protected class such as gender,
race, origin, religion, ethnicity, or age?
Explain:
15. Have you ever been a member of any foreign or domestic organization, association, movement
group or combination of persons which has adopted or shows a policy of advocating or approving
the commission of acts of force or violence to deny other persons their rights under the Constitution
of the United States or the State of Arizona by any unlawful or unconstitutional means?
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Explain:
16. Have you ever been a member of any organization that was involved in or promoted illegal activity?
Yes □ No □
Explain:
17. Have you ever been accused of violating a person’s civil rights?
Yes □ No □
Explain:
18. Do you have any tattoos on your person that you know or have reason to believe are gang related
or inappropriate for a peace officer?
Yes □ No □
Explain:
19. List any group, organization, club or gang with which you have been associated:
Name:
Location:
Dates Involved:
EMPLOYMENT HISTORY
20. Have you ever applied to or been employed by the Maricopa County Community College District
which includes the Glendale Community College?
21. Do you have any acquaintances or family that has been employed by the Maricopa County
Community College District which includes the Glendale Community College?
Name:
Address:
Telephone:
Yes □ No □
Relationship:
22. Has any of your family or friends been employed at any Police Department?
Name:
Address:
Agency:
Telephone:
Yes □ No □
Relationship:
23. Have you ever consumed alcohol or illegal drugs while connected in any way to your job?
Explain:
24. Have you ever been rejected as a job applicant?
Explain:
25. Have you ever left an employment without giving notice?
Explain:
26. Have you ever resigned to avoid discipline or termination?
Explain:
27. Have you ever been disciplined by your employer?
Explain:
28. Have you ever been discharged or asked to resign from any position?
Explain:
29. Have you ever been on extended leave/absent from work for 10 or more working days?
Explain:
30. Have you very been tardy or late for work that negatively affected your employment?
Explain:
31. Have you ever failed a probationary period with your employer?
Explain:
32. Have you ever falsified sick time or vacation time?
Explain:
33. Have you ever falsified an industrial injury claim?
Explain:
34. Have you ever falsified any legal document related to your employment?
Explain:
35. Have you ever had your wages garnished?
Explain:
36. Have you ever collected unemployment?
Explain:
37. Have you ever violated the laws associated with unemployment benefits?
Explain:
38. Have you ever been accused of or taken, borrowed, damaged or given away property or services
belonging to your employer, customer, citizen, or fellow employee that was not authorized or
approved?
Explain including value:
39. Have you ever been accused of or committed any crime against your employer, customer, citizen,
or fellow employee?
Explain including value:
40. Have you ever worked for or participated in an illegal operation?
Explain:
41. Have you ever misappropriated funds belonging to your employer?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
42. Have you ever been involved in any way with sexual harassment at your employment?
Yes □ No □
Explain:
43. Have you ever been involved in any way with a physical confrontation at your employment?
Yes □ No □
Explain:
Law Enforcement Employment History
44. List all law enforcement agencies for whom you have been employed or volunteered in any capacity:
Dates:
Agency and address:
Classification/Title:
Reason for Leaving:
45. Have you ever been accused of or taken, borrowed, damaged or given away property or services
belonging to your employer, citizen, accused, or fellow employee that was not authorized or
approved?
Explain:
46. Have you ever falsified any document related to your law enforcement position?
Explain:
47. Have you ever lied or committed perjury in court testimony or any other official proceeding?
Explain:
48. Have you ever been on the “Brady List” – proven integrity issues based on Brady vs. Maryland?
Explain:
49. Have you ever consumed alcohol or taken illegal drugs without approval while associated with your
employment?
Explain:
50. Have you ever committed a crime while associated with your employment?
Explain:
51. Have you ever used your position of authority to gain services or property that was not authorized
or approved?
Explain:
52. Have you ever used your position of authority to access information that was not authorized or
approved?
Explain:
53. Have you ever used your position of authority to engage in sexual conduct with any person?
Explain:
54. Have you ever committed a sexual act while associated with your employment?
Explain:
55. Have you ever used illegal or prescription drugs while employed or appointed as a peace officer?
Explain:
56. Have you ever failed to report a known violation by a co-worker?
Explain:
57. Have you ever been involved in an illegal action such as search & seizure or false arrest?
Explain:
58. Have you ever been involved with an Internal Affairs investigation as a subject or witness?
Explain:
59. Have you ever been disciplined?
Explain:
60. Have you ever had a citizen complaint reported to your supervisor or filed against you?
Explain:
61. Have your actions ever resulted in injury or death to any person?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
MILITARY HISTORY
62. Have you ever registered with the Selective Service?
Date:
State:
If no, explain:
63. Have you ever been a member of any branch of the United States of America military?
Explain:
Yes □ No □
Yes □ No □
64. Have you ever been a member of any branch of the military of any other country?
Explain:
65. Have you ever failed to complete any term of service for any reason?
Explain:
66. Did any negative actions on your part (poor performance, other) lead to your military discharge?
Explain:
67. Have you ever been involved in a military court martial as a subject or witness?
Explain:
68. Have you ever been accused of or taken, borrowed, damaged or given away property or services
belonging to the military, citizen, or fellow employee that was not authorized or approved?
Explain:
69. Have you ever falsified any document related to your military position?
Explain:
70. Have you ever lied or committed perjury in court testimony or any other official proceeding?
Explain:
71. Have you ever consumed alcohol or taken illegal drugs without approval while on-duty or on military
property?
Explain:
72. Have you ever committed a crime while on-duty or on military property?
Explain:
73. Have you ever used your position to gain services or property that was not authorized or approved?
Explain:
74. Have you ever used your position to access information or relationships that was not authorized or
approved?
Explain:
75. Have you ever committed a sexual act while on-duty or on military property?
Explain:
76. Have you ever failed to report a known violation by a co-worker?
Explain:
77. Have you ever been involved with an Internal Affairs investigation as a subject or witness while in
the military?
Explain:
78. Have you ever been disciplined while in the military?
Explain:
79. Have you ever been incarcerated while in the military?
Explain:
80. Have you ever had a citizen complaint reported to your supervisor or filed against you while in the
military?
Explain:
81. Have your actions ever resulted in injury or death to any person while in the military?
Explain:
82. Have you ever faked an illness or circumstance to avoid deployment, exercises or any duties?
Explain:
83. Have you ever missed ship movement, been absent without leave, or missed formation?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
EDUCATION AND TRAINING HISTORY
84. School /Training Name:
Address:
Dates Attended:
Certificate Received:
Law Enforcement Specific Training
85.
School /Training Name:
Address:
Dates Attended:
Certificate Received:
86. List any foreign languages you speak and indicate your level of fluency:
87. Have you ever been suspended, expelled or disciplined by any education or training institute?
Explain:
88. Have you ever purchased a degree, term paper, other document of intellectual property from the
internet or from any other source that you claimed as your own work?
Explain:
89. Have you ever had a concealed weapons permit?
If so, list your permit number and date of issuance:
Yes □ No □
Yes □ No □
Yes □ No □
CRIMINAL HISTORY
90. Have you ever committed, been present during, or aware of any activity that may be criminal in
nature or of a suspicious nature that has gone undetected by law enforcement that you have not
already listed?
Explain:
91. Have you ever bought, sold, or do you still have in your possession any item that may be stolen?
Explain:
92. Have you ever had a warrant or summons issued for your arrest or been cited and released?
Explain:
93. Has anyone in your family or relationships ever used narcotics illegally?
Explain:
94. Has anyone in your family or relationships ever been convicted of a crime or imprisoned?
Explain:
95. Has anyone in your family or relationships ever been sued or summoned into court?
Explain:
96. Have you ever paid for or been paid to participate in a sexual act?
Explain:
97. Have you ever participated in or observed sexual conduct with anyone under the age of 18?
Explain:
98. Have you ever intentionally sought out or viewed child pornography?
Explain:
99. Have you ever exposed yourself in public or in a location open to the public?
Explain:
100. Have you ever engaged in, attempted to engage in, or used force to engage in any sexual behavior
with any person without their permission?
Explain:
101. Have you ever engaged in or witnessed any sexual conduct with an animal?
Explain:
102. Have you ever used a fake or altered ID, another person's identification, or have you ever furnished
your identification to another?
Explain:
103. Have you ever possessed or manufactured illegal weapons?
Explain:
104. Have you ever illegally made or detonated or threatened to detonate an explosive device?
Explain:
105. Have you ever illegally sold, produced, cultivated or transported any illegal drug?
Explain:
106. Have you illegally used a prescription drug?
Explain:
107. Have you ever consumed an amount of medication greater than the prescribed amount?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
108. Have you ever forged a prescription for drugs?
Explain:
109. Have you ever provided any illegal or controlled drug to friends or others in exchange for money or
in trade for goods?
Explain:
110. Have you ever tried, used, possessed, purchased, sold, furnished or transported any form of illegal
drugs that you have not previously been asked about?
Explain:
111. Has law enforcement ever been to your residence or place of employment?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
MOTOR VEHICLE HISTORY
112. Have you ever possessed a driver’s license in two states concurrently?
Yes □ No □
What states?
113. Have you ever operated a motor vehicle without a valid driver’s license, registration or insurance?
Yes □ No □
Explain:
114. Do you have valid and current vehicle registration and insurance as mandated by law?
Yes □ No □
Agency:
Policy #:
115. Have you ever had your vehicle registration or insurance cancelled or denied coverage?
Yes □ No □
Explain:
116. Have you ever operated a motor vehicle while under the influence of alcohol or drugs?
Yes □ No □
Explain:
117. You were previously asked to list any moving violations for which you were cited. List all incidents involving motor
vehicle operations for which you were contacted by law enforcement whether cited or not:
Date: Agency or contact location:
Violation:
Disposition:
Collision:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
118. Have you ever had your driver’s license revoked, suspended or in any other way been invalid?
Yes □ No □
Date of Suspension/Revocation/Other:
License # and Type:
State:
Reason invalid:
119. Have you ever attended a driver improvement school to affect the disposition of a citation?
Date of School:
Location/Jurisdiction:
Citation:
Yes □ No □
120. Have you ever been involved in any collision for which you were at fault?
Date:
City/State:
Explain:
Yes □ No □
121. Have you ever been involved in a traffic collision that resulted in serious injury to death?
Date:
City/State:
Explain:
Yes □ No □
122. Have you ever been involved in a traffic collision where injuries or damage occurred and you left
the scene without reporting it as required by law?
Explain:
123. Have you ever given false information during a traffic collision investigation?
Explain:
Yes □ No □
Yes □ No □
FINANCIAL HISTORY
124. Given all sources (all salary available to you, pension, disability, interest & dividends, insurance, gambling and
other), what is your total yearly income? __________ List Firm Names or Sources:
125. List all financial obligations (mortgage, rent, utilities, automobile, child support, judgments, etc):
Type:
Name and Address:
Unpaid Balance: Monthly payment:
126. Have you ever been involved in any civil actions?(divorce, bankruptcy, small claims, court, etc)
Explain:
127. Are you current on your financial obligations?
Explain:
128. Have you ever been extensively delinquent on any of your financial obligations?
Explain:
129. Have you ever filed for bankruptcy?
Explain:
130. Has your financial health ever created an issue with your employment or family?
Explain:
131. Have you ever been a party to a small claims or other court action?
Explain:
132. Have you ever had any civil actions pending against you?
Explain:
133. Have you ever had a judgment rendered against you?
Explain:
134. Have you ever been refused credit?
Explain:
135. Have you ever had property repossessed?
Explain:
136. Have you ever knowingly purchased something knowing the funds were not available?
Explain:
137. Have you ever had your financial obligations turned over to a collection agency?
Explain:
138. Have you ever had a gambling debt?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
FAMILY OFFENSES AND DOMESTIC VIOLENCE
139. Have you ever been accused of or caused neglect or injury to a spouse, former spouse,
adult/juvenile cohabitant, former adult/juvenile cohabitant, family member by blood or court order,
person with whom you currently or previously had a romantic or sexual relationship, or person with
whom you have a child?
Explain:
140. Have you ever committed, been charged with, or convicted of a crime of domestic violence?
Explain:
141. Have you ever committed, been charged with or convicted of a felony crime or dangerous crime
against children?
Explain:
142. Have you ever been the subject of a court order of protection or injunction prohibiting harassment?
Explain:
143. Have you ever been the subject of an investigation by a child protective services agency?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
SOCIAL NETWORKS
144. Do you now have, or have you ever had, a business or personal website, a social network page(s),
a business or personal email address, or any chat room identity(s) that you accessed with a
computer?
Yes □ No □
145. Have you deleted, or do you plan to delete, information from these sites, or from your computer,
that you do not want perspective employers to know about or see?
Yes □ No □
Explain:
146. List each online site or identity you used or owned and include the dates when you used it. Do not list any
passwords to these accounts.
Identity:
Web Address:
Start Date:
End Date:
Personal Web Page
Personal Web Page
Personal Web Page
Business Web Page
Business Web Page
Business Web Page
Email Address
Email Address
Email Address
Chat Room ID
Chat Room ID
Chat Room ID
Social Network Page
Social Network Page
Social Network Page
Other
Other
Other
SUMMARY QUESTIONS
147. Have these questions caused you to remember any situations or circumstances not mentioned in
this packet that you would like to bring to our attention at this time?
Explain:
148. Have you deliberately falsified any of your answers or purposely mislead this investigative agency
or GCC at any point during this hiring process?
Explain:
149. Have you omitted, or altered any information during this interview based on advice from an
attorney, judge, a family member, or anyone else?
Explain:
Yes □ No □
Yes □ No □
Yes □ No □
Please note that prior to signing the Affirmation Statement on the next page you may add
explanations and clarifying information to this packet by writing or providing additional
information and inserting any such documents into this packet.
As stated earlier, you will be held responsible for the information contained in this
questionnaire. Having someone assist you who writes answers or provides information
that is not accurate may be held against you and result in your disqualification or
termination of employment.
AFFIRMATION
Under penalty of perjury as enforced under Arizona Revised Statutes 13-2702, I hereby state and
declare the above answers and statements contained in each section of this questionnaire were
furnished directly by me and are true.
I make this declaration fully aware that personnel at the Glendale Community College Law
Enforcement Training Academy or their designee may choose to verify the validity of these
statements and disclosures through a polygraph examination and a full background investigation.
Further, if it is shown I have made a false or misleading statement or omission, I understand this
would be grounds for my dismissal as a student, a peace officer job applicant and potentially the
termination of my employment now and in the future.
I understand that I am not entitled to any information or copies of paperwork obtained by
investigators for the purpose of completing this background investigation. I understand that
background investigation fees are not refundable regardless of the outcome. I understand all
components of the background investigation are the property of the Maricopa County Community
College District – Glendale Community College.
This form must be signed in the presence of the background investigator conducting your
interview.
Applicant’s Name (Printed):
Applicant’s Signature
Date
Reviewed with Applicant:
James Norwood or Loren Wunderle
Date
Private Background Investigators
Arizona Investigations & Professional Consultants, PLLC
Received by Glendale Community College:
Law Enforcement Program Director
Date
Law Enforcement Operations
6000 W. Olive Avenue
Glendale, AZ 85302
623-845-3951
POSITION: _ Peace Officer Certification I & II_ NAME:_________________________________________________
Question #
Explanation:
DOB:_____________
Law Enforcement Operations
6000 W. Olive Avenue
Glendale, AZ 85302
623-845-3951
POSITION: _ Peace Officer Certification I & II_ NAME:_________________________________________________
Question #
Explanation:
DOB:_____________