STUDENT APPLICATION FOR (CSO, CADET, and PARKING MONITORS)
COLORADO SCHOOL OF MINES POLICE DEPARTMENT
1812 Illinois Street
Golden, Colorado 80401
Telephone: (303) 273-3333 – Facsimile (303) 273-3361
Please TYPE or PRINT legibly all requested information in black ink.
Name (Last, First, Middle)
Date of Birth
Social Security Number
Street Address
City, State, Zip
Home Phone
Work Phone
WORK EXPERIENCE
Complete the requested information for your current or most recent position in the first section and work backwards, providing information for all
positions you have held for the last ten years, including part-time jobs and all periods of unemployment. (Attach additional sheets if necessary.)
Name of Employer/Organization
Mailing Address (Street P.O. Box, City, State, ZIP)
Employed From (Month/Year):
Salary
Position/Title
Employed To (Month/Year):
Name of Immediate Supervisor
Supervisor’s Telephone Number
Number of Hours Worked Per Week
Reason for Leaving (or wanting to leave)
Duties/Responsibilities:
Name of Employer/Organization
Employed From (Month/Year):
Mailing Address (Street P.O. Box, City, State, ZIP)
Salary
Position/Title
Employed To (Month/Year):
Name of Immediate Supervisor
Supervisor’s Telephone Number
Number of Hours Worked Per Week
Reason for Leaving
Duties/Responsibilities:
Name of Employer/Organization
Employed From (Month/Year):
Mailing Address (Street P.O. Box, City, State, ZIP)
Salary
Position/Title
Employed To (Month/Year):
Name of Immediate Supervisor
Supervisor’s Telephone Number
Reason for Leaving
Duties/Responsibilities:
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Number of Hours Worked Per Week
Please explain why you believe you would be a good fit with the Colorado School of Mines Police Department
Please list the various states in which you have held a driver’s license. Also include the license number and
approximate date of issue:
State
License Number
Issue Date
Please list, in chronological order, all addresses that you have used or lived at within the past 3 years. You must
include the physical street address (not PO Box) along with the city, state and zip code. If necessary, attach
additional sheets.
From
To
Physical Street Address / City / State / ZIP Code
Have you ever been convicted of, or arrested for, a felony? Yes No If yes, provide the dates for and describe
the incident, including the charge, jurisdiction, disposition and date of disposition:
ATTACH ADDITIONAL SHEETS IF NECESSARY
Please review and complete each box below to the best of your knowledge. Failure to complete each box may result in
disqualification. Have you been convicted of any misdemeanors, including but not limited to:
Harassment
Yes
No
Disorderly Conduct
Yes
No
Domestic Violence
Yes
No
Trespassing
Yes
No
Theft Under $400
Yes
No
Criminal Mischief
Under $400
Yes
No
Assault without Deadly
Weapon
Yes
No
Possession, Use or
Sale of Marijuana or
its Derivatives
Yes
No
Violating a Restraining
Order
Yes
No
Child Abuse
Yes
No
Indecent Exposure
Yes
No
Other
Yes
No
If yes, describe nature and date of the incident, and the jurisdiction where it occurred:
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Have you been convicted of any traffic violation in the past 5 years?
convictions and assigned points.
Date (Month/Year)
Yes
No If yes, please list the dates,
Conviction and Jurisdiction
Points
Has your driver’s license been revoked or suspended?
the action.
Yes
No If yes, describe the reason for and date of
Have you ever been involved in any traffic accidents, including a hit and run?
and describe the incident:
Yes
No If yes, give the date(s)
Have you ever tried or used any illegal drug, including marijuana or its derivatives? Yes
the type of substance and the last date (month/year) of usage.
Have you ever used force to take something from someone? Yes
incident:
No If yes, indicate
No If yes, give the date and describe the
Have you taken anything, including money and merchandise, from a place where you worked without
permission? Yes No If yes, what was taken, from where, and when?
Have you ever used company materials (tools, supplies, equipment, facilities, etc.) for personal gain?
Yes No If yes, what was it, and when?
Have you ever purposefully damaged or destroyed company, public or private property?
Yes No If yes, give the date and describe the incident:
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Have you ever taken anything from a person, business, vehicle, etc. without permission? Yes
what did you take, and when?
No If yes,
Have you ever knowingly or purposefully written any “bad” checks when you knew you didn’t have enough
money in your account? Yes No If yes, give reason and date.
Have you ever been delinquent on income or other tax payments? Yes
Have your wages ever been garnished? Yes
No If yes, give reason and date:
No If yes, give the reason and date of action:
Have you ever falsified an official report or statement? Yes
No If yes, give the date and describe the incident:
Have you ever had a complaint made against you by a customer, child, parent, citizen, neighbor or co-worker?
Yes No If yes, give the date(s) and describe the incident:
REFERENCES
List at least one individual who has known you for at least one year, not including relatives or current supervisors, and who know your qualifications and your capability for the job.
Name
Address (Number, Street, City, State, ZIP)
Phone Number
SIGNATURE, CERTIFICATION AND RELEASE OF INFORMATION
I certify that the information in this supplement and all attachments is true and complete. I understand that false statements, misrepresentations or
omissions of information in this application, supplement attachments, or other CSM Police Department applications or forms, may result in rejection of
this application, removal from an eligibility list, or other disciplinary action. The CSM Police Department is expressly authorized to investigate all
statements contained in this application, supplement or attachments. I consent to the release of information about my ability and suitability for
employment by current and previous employers, schools, law enforcement agencies, and other individuals and organizations to investigators, recruiters,
and other authorized employees of the Colorado School of Mines. Further, I understand that my association with the CSM Police Department is
conditional upon the successful completion of an investigation into my background, and my motor vehicle record. In the event that the CSM Police
Department accepts me as an employee, I agree to comply with all ordinances, rules and regulations. Further I understand and agree that my
association with the CSM Police Department does not grant me any right of employment.
Signature
Date (Month/Day/Year)
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