Public Safety Employment Application
Please complete each section of this application.
Incomplete applications may be returned and possibly disqualify you from further consideration.
We are pleased that you are interested in a position with the University of Wisconsin-Green Bay Public Safety Department.
GENERAL INSTRUCTIONS
 Electronic submissions will be accepted and are encouraged.
 Type or handprint (in black ink) an answer to every question. Applications must be legible for full consideration.
 Provide complete and accurate information.
 If a question does not apply to you, mark N/A in the space provided.
 If space provided is insufficient, attach a separate sheet and reference the additional information to the section
title.
 The University of Wisconsin-Green Bay Public Safety Department will verify conviction record, driving records,
places of employment and other information listed on this application.
 If you provide false information, or commit any omissions of fact, either intentionally or unintentionally, you will
not be eligible for University of Wisconsin-Green Bay employment. Failure to admit convictions, and/or any
untruthfulness will result in immediate disqualification.
PERSONAL INFORMATION
Date of Application:
Position Applying For:
Date available for Work:
Full Name:
Last
First
M.I.
Street Address
Apartment #
City
State
Former Name(s), if any:
Address:
Daytime phone:
(
)
Evening Phone:
(
)
ZIP Code
E-mail Address:
Have you ever worked for the State of Wisconsin?
Yes
No
If yes, when and where?
Have you ever worked for UW-Green Bay?
Yes
No
If yes, were you?
Permanent
LTE
Student
If you worked for UW-Green Bay, when and which department:
May we conduct a personal background check including contact of your references and review other records as may be
required for some positions?
If no, explain:
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Yes
No
MOTOR VEHICLE OPERATION
Do you hold a valid driver’s license?
Yes
No
Name on valid driver’s license:
License Number and State:
Has your license been suspended, revoked or placed on negligent operator’s probation (for other than medical reasons)?
Yes
No If yes, indicate all dates, locations, charges and dispositions:
Have you ever been cited for a traffic violation? (Do not include parking tickets):
If yes, indicate all dates, locations, charges and dispositions:
Yes
No
If there is anything you wish to discuss about your driving record, please use the space below.
FORMER ADDRESSES
(Begin with most recent prior to that listed above.) Include all prior addresses within the last TEN years. Attach additional pages if necessary:
Address:
Street
City | State | Zip
From
To:
From
To:
From
To:
From
To:
From
To:
Address:
Street
City | State | Zip
Address:
Street
City | State | Zip
Address:
Street
City | State | Zip
Address:
Street
City | State | Zip
Address:
Street
City | State | Zip
From
To:
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
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EDUCATION AND TRAINING
Check the highest grade completed in school.
K
1
2
3
4
School
5
6
7
8
Name and Location
9
10
11
12
Course of Study
13
14
# of Years
Completed
15
16
Graduate?
Yes No
17+
Degree Received
High School/GED
Vocational/Technical
College and/or Graduate
(Finalists will be required to provide a copy of a High School Diploma, G.E.D. and/or Transcripts).
List all training beyond high school (i.e. college or university, technical or trade school). (Finalists will be required to provide copies of Higher Education
diplomas, certificates, and degrees and/or transcripts of completed coursework).
Name/Location
Credits
Major/Minor
Degree Earned / Date
List any current license or registration as a member of a trade or profession:
List memberships in any professional or technical association:
List Personal Computer Skills/Applications::
List equipment, machinery, or motorized vehicles you can operate:
WORK EXPERIENCE
Begin with your present or most recent employer.
Employer:
Phone Number:
Address:
Dates of Employment:
Starting Wage:
From:
To:
Status:
Full-time
Your Title:
Your Supervisor & their Title:
Your Duties:
Reason for Leaving:
(
)
Ending Wage:
Part-time
Temporary
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
3 | Page
Employer:
Phone Number:
Address:
Dates of Employment:
Starting Wage:
From:
To:
Status:
Full-time
Your Title:
Your Supervisor & their Title:
Your Duties:
Reason for Leaving:
Employer:
Phone Number:
Address:
Dates of Employment:
From:
To:
Status:
Full-time
Your Supervisor & their Title:
Your Duties:
Reason for Leaving:
Employer:
Phone Number:
Address:
To:
Status:
Full-time
Your Title:
Your Supervisor & their Title:
Your Duties:
Reason for Leaving:
Employer:
Phone Number:
Address:
Dates of Employment:
Part-time
(
Starting Wage:
From:
To:
Status:
Full-time
Your Title:
Your Supervisor & their Title:
Your Duties:
Reason for Leaving:
Temporary
)
Ending Wage:
Part-time
(
Starting Wage:
From:
)
Ending Wage:
Starting Wage:
Your Title:
Dates of Employment:
(
Temporary
)
Ending Wage:
Part-time
(
Temporary
)
Ending Wage:
Part-time
Temporary
PRIOR MILITARY SERVICE
(if no Military Service, go on to next section)
Military Branch:
Years of Service:
Rank at time of Discharge:
Type of Discharge:
(Finalists will be required to provide a copy of his/her Form DD214)
Have you ever been charged or disciple under the U.C.M.J.?
Yes
No
If so, explain. Include dates:
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
4 | Page
PROFESSIONAL REFERENCES
Name:
Employer & Address:
Position Title:
Phone:
(
)
(
)
(
)
CHARACTER REFERENCES
List three people, not related to you or past employers, who know your strengths and weaknesses
1. Name:
Last
First
Street
City | State | Zip
Address:
Profession/title:
Home Phone:
(
)
Work Phone:
(
)
2. Name:
Last
First
Street
City | State | Zip
Address:
Profession/title:
Home Phone:
(
)
Work Phone:
(
)
3. Name:
Last
First
Street
City | State | Zip
Address:
Profession/title:
Home Phone:
(
)
Work Phone:
(
)
NEIGHBORHOOD REFERENCE
List a person who is not related to you who is a current or recent neighbor of yours and is familiar with you.
Name:
Last
First
Street
City | State | Zip
Address:
Profession/title:
Home Phone:
(
)
Work Phone:
(
)
Name:
Last
First
Street
City | State | Zip
Address:
Profession/title:
Home Phone:
(
)
Work Phone:
(
)
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
5 | Page
RELEVANT VOLUNTEER ACTIVITIES
List any volunteer organizations that you have been a member or actively involved with: Attach additional sheets if necessary.
Agency or Entity:
Address:
Street
Phone Number:
(
City | State | Zip
)
Contact Person:
Describe Activities and/or Responsibilities:
Agency or Entity:
Address:
Street
Phone Number:
(
City | State | Zip
)
Contact Person:
Describe Activities and/or Responsibilities:
YES OR NO QUESTIONS
Have you ever been convicted of, or received a citation for an offense other than traffic violations? (Convictions are not necessarily a bar from
employment)
Yes
No If yes, indicate all dates, locations, charges and dispositions:
Do you have any current pending charge?
Yes
No If yes, indicate all dates, locations, charges and dispositions:
Have you ever been placed on court probation as an adult?
If yes, indicate all dates, locations, charges and dispositions:
Yes
No
Are you now or have you ever been involved as a plaintiff or defendant in any civil court action other than bankruptcy?
If yes, please give details, (include when, where, name and location of court circumstances):
Have you ever been fired or asked to resign from a job?
Yes
If yes, indicate all dates, locations, charges and dispositions:
Yes
No
No
Do you know anything (except medically related information) that might disqualify you for appointment to or prevent the full discharge of the duties of
the position for which you are applying?
Yes
No
If yes, indicate reason(s) in full detail:
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
6 | Page
Are you certified or certifiable by the Wisconsin Law Enforcement Standards Board, or by any other state?
Yes
No
If so, indicate where and when you attended this training. (Finalists will be required to provide a copy of certification).
Has any other Law Enforcement Agency conducted a background investigation on you for employment purposes?
Yes
No If yes, list agency and date:
Agency:
Date:
Agency:
Date:
Agency:
Date:
List all law enforcement or security agencies for which you complete an employment application within the past 12 months:
Attach additional sheets if necessary.
Agency:
Month/Year:
Agency:
Month/Year:
Agency:
Month/Year:
Are you willing to work various shifts and weekends on a regular basis?
Are you willing to work overtime?
Yes
Yes
No
No
SHORT ANSWER QUESTIONS (200 words or less per question.
Anything greater than 200 words will not be read)
Please describe your experience working with others in a team setting, training presentations to groups, working with supervisors and/or employees to
resolve complex issues
Please describe your experience working with high school/college age populations, community groups, businesses and non-profit groups to provide
service delivery/outreach programming, including your experience with those from diverse backgrounds (Paid or volunteer experience included).
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
7 | Page
Please describe in your own words what community policing means to you.
Our core values of the department are integrity, respect, service, and excellence. Please explain which one is most important to you and why as it
relates to law enforcement.
DRUG/NARCOTICS USE
It is not the intent of the UW Green Bay Public Safety Department to use any of this information for criminal prosecution.
Have you ever used or experimented with marijuana?
If yes, date first used:
Yes
No
Date last used:
Have you ever sold, cultivated, or supplied marijuana?
Yes
No
Have you ever used or experimented with any form of drugs such as Cocaine, Speed, PCP, Heroin,
Ecstasy, LSD, Hashish, Opiates, Psilocybin “mushrooms”, or another drug/narcotic not listed?
Yes
No
If yes, please provide details based on your best recollection, include name of drug/narcotic, estimated use, date first used and date last used:
Have you ever sold any form of drug or narcotic?
Yes
No
Have you ever manufactured any form of drug or narcotic?
Yes
No
If yes to either of the above explain:
It is the policy of the University to provide reasonable accommodation for qualified individuals who are employees or applicants for employment. If
you need assistance or accommodation for the application process because of a disability, please contact the Human Resources Office. Employment
opportunities will not be denied to anyone because of the need to make reasonable accommodation for an individual’s disability.
By submitting this document, I hereby certify that there are not willful omissions from misrepresentations in, or falsifications of, the above statements
and answers to questions. I am aware that should investigation disclose such omissions, misrepresentations or falsifications, my application will be
rejected, or if hired, I may be discharged immediately upon discovery of such false statements or omissions. I authorize the University to make an
investigation of any of the facts set forth in this application. I hereby consent the University to obtain necessary information from those individuals
noted as part of this application. In addition, I release the University, my former employers & all other persons, corporations, partnerships &
associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation. I understand that this
application does not constitute an employment contract of any kind.
University of Wisconsin Green Bay Office of Public Safety
2420 Nicolet Drive, Green Bay, WI 54311-7001
Phone : (920) 465-2300 Fax: (920) 465-2558
Revised 12/3/2012
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