PERSONAL HISTORY STATEMENT
CLUTE POLICE DEPARTMENT
104 EAST MAIN STREET
CLUTE, TX 77531
979-265-6194
APPLICANT: ____________________________
DOB: ________________
Received: __________, 20__
Received: __________, 20__
POSITION APPLIED FOR:
TELECOMMUNICATIONS OFFICER: ______ (RESERVE TCO ______)
PATROL OFFICER: ______ RESERVE OFFICER: ______
JAILER: ______
HUMANE OFFICER: ______
OTHER: ______
FULL TIME: ______
PART TIME: ______
1
CLUTE POLICE DEPARTMENT
APPLICANT AGREEMENT FORM
I, ________________________ have applied with the Clute Police Department as one of the following:
(check appropriate box)
(
(
(
(
)
)
)
)
Full Time Police Officer
Reserve Police Officer
Telecommunications Officer
Other
Being a full time/reserve police officer or member of a police department often requires a dedication
above and beyond a normal person’s job requirements, and at times may demand sacrificing time with
your family during emergency situations. Although the Clute Department encourages its members to
maintain a healthy family life, there will be times when this time must be sacrificed in order to fulfill
your job requirements.
By signing this document, I state that I have read, understand and agree to the following:
As a full time/reserve police officer or dispatcher with the Clute Police Department, I will be subject to
call outs, working different shifts as assigned (days/nights), weekends, and holidays. I also understand
that if normally assigned to work a holiday, I may not be given permission to take off that holiday. My
shifts will be subject to change at anytime, for the benefit of the department.
During times of emergency, such as hurricanes, I will be expected to remain at the police department
after citizens have been evacuated in order to maintain order. This will require me to stay at the police
station 24 hours a day until released by the Chief of Police. I will be given time to tend to my family’s
evacuation if needed and to secure my home and property.
ALL SWORN OFFICERS/TELECOMMUNICATIONS OFFICERS WILL BE REQUIRED TO STAY DURING A
HURRICANE OR OTHER MAJOR NATURAL DISASTER, UNLESS APPROVED BY THE CHIEF OF POLICE.
Reserve Officers will not be required to stay for a hurricane or other natural disaster.
I also understand that I may be required to help in any other disasters, such as plant explosions, train
derailments, terrorist acts, or any other emergency requiring police action, and to provide assistance to
other law enforcement agencies if needed during an emergency, which may entail staying past my
normal work hours or being called out while off duty to assist. Reserve officers may be contacted to
assist if possible.
2
I also understand that I may be required to work city functions, such as festivals, parades, or other city
functions as required, and these functions may require me to work past my normal working hours or
being called in on my day off for said functions. Example: All full time/reserve officers are required to
work the Mosquito Festival in July, except those officers working night shift on the days of the festival.
I understand that this document does not cover all instances in which I may be subject to call out or
staying after normal duty hours. I also understand that being a sworn police officer or member of a
police department requires dedication to a profession that is often thankless as well as demanding.
By signing this document I indicate that I understand and I agree to the conditions set forth in this
document.
(THIS DOCUMENT MUST BE SIGNED, NOTARIZED, AND TURNED IN WITH APPLICATION. FAILURE TO DO SO WILL
RESULT IN AUTOMATIC DISQUALIFICATION FOR EMPLOYMENT WITH THE CLUTE POLICE DEPARTMENT.)
________________________________
Signature of applicant
________________
Date
SUBSCRIBED AND SWORN BEFORE ME on this _____ day of ________, A.D., 20___
________________________________
NOTARY PUBLIC
STATE OF TEXAS
MY COMISSION EXPIRES:
3
ATTENTION: THIS RELEASE MUST BE NOTARIZED PRIOR TO YOUR SUBMITTING THE
APPLICATION
CLUTE POLICE DEPARTMENT
AUTHORITY TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN:
I hereby authorize the CLUTE POLICE DEPARTMENT and its authorized representatives bearing this
release, or a copy thereof, within one year of its date, to obtain any information in your files pertaining
to my employment, military, credit, education or medical records, including but not limited to academic,
achievement, attendance, athletic, personal history, and disciplinary records, medical records, and credit
records.
I hereby direct you to release such information upon request of the bearer. This release is executed with
full knowledge and understanding that the information is for official use. Consent is granted to all parties
to furnish such information, as described above, to third parties in the course of fulfilling its official
responsibilities. I hereby release you, as custodian of such records, and any school, college, university, or
other educations institution, hospital or other repository of medical records, credit bureau, lending
institution, consumer reporting agency, or retail business establishment including its officers,
employees, or related personnel, both individually and collectively, from any and all liability for damages
of whatever kind, which may at any time result to me my heirs, family or associates because of
compliance with this authorization and request to release information, or attempt to comply with it.
I am furnishing my Social Security Account Number on a voluntary basis with the understanding law or
regulation does not require such. I have been advised that all parties will utilize this number only to
facilitate the location of employment, military, credit, and educational records concerning me in
connection with this application. Should there be any question as to the validity of this release, you may
contact me as indicated below:
Applicant’s Printed Full Name:
Address:
______________________________________
______________________________________
______________________________________
Telephone Number(s)
______________________________________
Applicant’s Signature:
______________________________________
SUBSCRIBED AND SWORN BEFORE ME on this ____ day of ______________, 20____
NOTARY PUBLIC:
__________________________________
MY COMMISSION EXPIRES:
4
INSTRUCTIONS
READ THESE INSTRUCTIONS CAREFULLY BEFORE PROCEEDING
These instructions are provided as a guide to assist you in properly completing your Personal History
Statement. It is essential that the information be accurate in all respects. It will be used as the basis for a
background investigation that will determine your eligibility for employment. Failure to completely and
properly fill out this application will result in your disqualification for consideration for employment.
1. THIS APPLICATION MUST BE FILLED OUT COMPLETELY AND PRINTED IN BLACK INK OR TYPED.
Answer all questions to the best of your ability. Your ability to follow directions and properly fill
out this application will be viewed as part of the hiring process and failure to do so will result in
disqualification for employment.
2. Your personal History Statement should be PRINTED legibly in ink or typed. Answer all questions
to the best of your ability.
3. ALL questions must be answered or marked N/A in the space provided. If you check no on an
answer, put N/A in the explanation section.
4. Avoid errors by reading the directions carefully before any entries on the form. Be sure your
information is correct and in proper sequence before you begin. Failure to do so will result in
your disqualification for employment.
5. You are responsible for obtaining correct addresses and phone numbers. If you are not sure of an
address or phone, check it by personal verification. Your local library may have a directory
service or copies of local phone directories.
6. If there is insufficient space on the form for you to include all information required, attach extra
sheets to the Personal History Statement. Be sure to reference the relevant section and question
number before continuing your answer.
7. An accurate and complete form must be submitted for consideration for employment with the
Clute Police Department. Any form not completed correctly will be disqualified for consideration
for employment.
8. REMIT A LEGIBLE PHOTOCOPY OF YOUR DRIVERS LICENSE, BIRTH CERTIFICATE, HIGH SCHOOL
DIPLOMA OR GED, SOCIAL SECURITY CARD, AND DD 214 (IF APPLICABLE) (SEE LAST PAGE).
ALL ITEMS (ORIGINALS AND COPIES) SUBMITTED WITH THIS APPLICATION BECOME THE PROPERTY OF
THE CLUTE POLICE DEPARTMENT.
APPLICATIONS WILL BE HELD FOR A PERIOD OF 6 MONTHS. DURING THAT TIME, IF THE CLUTE POLICE
DEPARTMENT IS HIRING, YOUR PERSONAL HISTORY STATEMENT MAY BE OBTAINED FROM OUR FILES
FOR FURTHER CONSIDERATION. AFTER THE 6 MONTH PERIOD, A NEW STATEMENT MUST BE FILLED OUT
AND RETURNED TO THE CLUTE POLICE DEPARTMENT.
5
PERSONAL HISTORY STATEMENT
A. APPLICANT IDENTIFICATION: Information provided in this section is used for identification purposes
only.
1. NAME:
_______________________________________________________________
Last
First
Middle
2. ADDRESS: ______________________________________________________________
Street
City
State
Zip Code
3. TELEPHONE NUMBER(S): Home: __________________________
Cell: ____________________________
4. EMAIL ADDRESS:
_______________________________
5. DATE OF BIRTH:
_______________________________
Month
Day
Year
6. NICKNAME(S), MAIDEN NAME, OR OTHER NAMES BY WHICH YOU HAVE BEEN KNOWN:
__________________________________________________________________
7. SOCIAL SECURITY NUMBER:
__________________________
8. PLACE OF BIRTH: _________________________________________________
City
County
State
9. ARE YOU A U.S. CITIZEN?
[ ] YES
10. DRIVERS LICENSE NUMBER:
______________________________________
Number
State
11. HEIGHT:
WEIGHT:
____________
12. HAIR COLOR:
_____________
[ ] NO
__________
EYE COLOR:
6
___________
13. SCARS, TATOOS OR OTHER DISTINGUISHING MARKS: _____________________________
_____________________________________________________________________________
_____________________________________________________________________________
B. RESIDENCES: LIST ALL ADDRESSES WHERE YOU HAVE LIVED DURING THE PAST 15 YEARS, BEGINNING
WITH YOUR PRESENT ADDRESS. LIST DATE BY MONTH AND YEAR. ATTACH EXTRA PAGE(S) IF
NECESSARY.
FROM
TO
ADDRESS
_______________
_______________
____________________________________
_______________
_______________
____________________________________
_______________
_______________
____________________________________
_______________
_______________
____________________________________
_______________
_______________
____________________________________
_______________
_______________
____________________________________
_______________
_______________
____________________________________
C. WORK HISTORY - BEGINNING WITH YOUR PRESENT OR MOST RECENT JOB, LIST ALL EMPLOYMENT
OVER THE LAST 15 YEARS, INCLUDING PART TIME, TEMPORARY OR SEASONAL EMPLOYMENT.
INCLUDE ALL PERIODS OF UNEMPLOYMENT. ATTACH EXTRA PAGES IF NECESSARY.
FROM ______
ADDRESS
TO
_______
EMPLOYER
_______________________________
_________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
_______________________________
DUTIES ______________________________________________________________________
____________________________________________________________________________
SUPERVISOR ________________
REASON FOR LEAVING
NAME OF CO-WORKER
_________________________
_____________________________________________________
7
FROM ______
ADDRESS
TO
_______
EMPLOYER
______________________________
________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
_______________________________
DUTIES ______________________________________________________________________
____________________________________________________________________________
SUPERVISOR ________________
NAME OF CO-WORKER
_________________________
REASON FOR LEAVING
_____________________________________________________
FROM ______
_______
ADDRESS
TO
EMPLOYER
_______________________________
_________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
_______________________________
DUTIES ______________________________________________________________________
____________________________________________________________________________
SUPERVISOR ________________
NAME OF CO-WORKER
_________________________
REASON FOR LEAVING
_____________________________________________________
FROM ______
_______
ADDRESS
TO
EMPLOYER
______________________________
________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
______________________________
DUTIES _____________________________________________________________________
___________________________________________________________________________
SUPERVISOR ________________
REASON FOR LEAVING
NAME OF CO-WORKER
________________________
____________________________________________________
8
FROM ______
ADDRESS
TO
_______
EMPLOYER
_______________________________
________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
______________________________
DUTIES _____________________________________________________________________
___________________________________________________________________________
SUPERVISOR ________________
NAME OF CO-WORKER
________________________
REASON FOR LEAVING
____________________________________________________
FROM ______
_______
ADDRESS
TO
EMPLOYER
______________________________
________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
______________________________
DUTIES _____________________________________________________________________
__________________________________________________________________________
SUPERVISOR ________________
NAME OF CO-WORKER
________________________
REASON FOR LEAVING
____________________________________________________
FROM ______
_______
ADDRESS
TO
EMPLOYER
______________________________
________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
______________________________
DUTIES _____________________________________________________________________
___________________________________________________________________________
SUPERVISOR ________________
REASON FOR LEAVING
NAME OF CO-WORKER
________________________
____________________________________________________
9
FROM ______
ADDRESS
TO
_______
EMPLOYER
______________________________
_______________________________________________________________
PHONE NUMBER
____________
JOB TITLE
_____________________________
DUTIES ____________________________________________________________________
__________________________________________________________________________
SUPERVISOR ________________
NAME OF CO-WORKER
_______________________
REASON FOR LEAVING
___________________________________________________
FROM ______
_______
ADDRESS
TO
EMPLOYER
______________________________
________________________________________________________________
PHONE NUMBER
____________
JOB TITLE
______________________________
DUTIES _____________________________________________________________________
___________________________________________________________________________
SUPERVISOR ________________
NAME OF CO-WORKER
________________________
REASON FOR LEAVING
____________________________________________________
FROM ______
_______
ADDRESS
TO
EMPLOYER
_____________________________
_______________________________________________________________
PHONE NUMBER
____________
JOB TITLE
_____________________________
DUTIES ____________________________________________________________________
__________________________________________________________________________
SUPERVISOR ________________
REASON FOR LEAVING
NAME OF CO-WORKER
_______________________
______________________________________________________
10
D. MILITARY RECORD
1. HAVE YOU SERVED IN THE U.S. ARMED SERVICES?
[ ] YES
[ ] NO
2. DATE OF SERVICE FROM
_______
TO
_________
(PLEASE ATTACH COPY OF DD FORM 214)
3. WERE YOU EVER DISCIPLINED WHILE IN THE MILITARY SERVICE? [ ] YES [ ] NO
(INCLUDE COURT – MARTIAL, CAPTAINS MAST, COMPANY PUNISHMENT, ETC.)
CHARGE
AGENCY
DATE
AGE
DISPOSITION
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4. IF YOU RECEIVED A DISCHARGE OTHER THAN HONORABLE, GIVE COMPLETE DETAILS
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
E. EDUCATIONAL HISTORY
1. SCHOOL
CITY/STATE
FROM
TO
GRADUATE?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. COLLEGE OR UNIVERSITY ATTENDED __________________________________________
CITY/STATE
_______________________
UNITS COMPLETED
________
DEGREE AND DATE RECEIVED
DATES ATTENDED
MAJOR/MINOR
____________
________________________
_______________________________________________
11
COLLEGE OR UNIVERSITY ATTENDED
CITY/STATE
_________________________________________
_______________________
UNITS COMPLETED
________
DEGREE AND DATE RECEIVED
DATES ATTENDED
MAJOR/MINOR
_____________
________________________
______________________________________________
3. LIST OTHER SCHOOLS ATTENDED (TRADE, VOCATIONAL, BUSINESS, ETC). GIVE NAME AND
ADDRESS OF SCHOOL, DATES ATTENDED, COURSE OF STUDY, CERTIFICATE, AND ANY PERTINENT
INFORMATION
______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
F. SPECIAL QUALIFICATIONS & SKILLS
1. LIST ANY SPECIAL LICENSES YOU HOLD (SUCH AS PILOT, RADIO OPERATOR, SCUBA, ETC.)
SHOWING LICENSING AUTHORITY, ORIGINAL DATE OF ISSUE, AND DATE OF EXPIRATION
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. LIST ANY SPECIALIZED MACHINERY OR EQUIPMENT WHICH YOU CAN OPERATE
______________________________________________________________________________
3. IF YOU ARE FLUENT IN A FOREIGN LANGUAGE, INDICATE EACH AREA YOUR DEGREE OF FLUENCY
(EXCELLENT, GOOD, FAIR)
LANGUAGE
READING
SPEAKING
UNDERSTANDING
WRITING
_______________________________________________________________________________
_______________________________________________________________________________
4. LIST ANY OTHER SPECIAL SKILLS OR QUALIFICATIONS YOU MAY POSSESS
_______________________________________________________________________________
_______________________________________________________________________________
12
G. ARREST, DETENTIONS AND LITIGATION
1. HAVE YOU EVER BEEN ARRESTED, DETAINED BY THE POLICE, OR SUMMONED INTO COURT?
[ ] YES
[ ] NO
IF YES, COMPLETE THE FOLLOWING:
OFFENSE
AGENCY
CITY/STATE
DATE
DISPOSITION
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. HAVE YOU EVER BEEN INVOLVED AS A PARTY IN CIVIL LITIGATION?
[ ] YES [ ] NO
(IF YES, GIVE, GIVE DETAILS)
____________________________________________________________________________
____________________________________________________________________________
H. TRAFFIC RECORD
1. HAS YOUR DRIVERS LICENSE EVER BEEN SUSPENDED OR REVOKED?
[ ] YES
[ ] NO (IF YES, GIVE DATE, LOCATION AND DETAILS)
__________________________________________________________________________
__________________________________________________________________________
2. WITH WHAT COMPANY DO YOU CARRY INSURANCE?
_______________________
3. LIST TO THE BEST OF YOUR MEMORY ALL TRAFFIC CITATIONS YOU HAVE RECEIVED,
EXCLUDING PARKING TICKETS.
MO/YR
CHARGE
CITY/STATE
DISPOSITION
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. DESCRIBE IN A BRIEF NARRATIVE ANY TRAFFIC ACCIDENTS IN WHICH YOU HAVE BEEN
INVOLVED, GIVING APPROPRIATE DATES AND LOCATIONS.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
13
I.
MARITAL AND FAMILY HISTORY
1. ARE YOU: [ ] SINGLE [ ] ENGAGED
[ ] ANNULLED [ ] WIDOWED?
2. IF ENGAGED:
NAME OF FIANCEE
ADDRESS
PHONE NUMBER
[ ] MARRIED
[ ] SEPERATED
[ ] DIVORCED
___________________________________________________
___________________________________________________
___________________________________________________
3. IF MARRIED:
DATE
___________________________________________________
CITY/STATE
___________________________________________________
SPOUSE MAIDEN NAME
_____________________________________________
4. IF SEPARATED, DIVORCED, ANNULLED OR WIDOWED:
DATE OF MARRIAGE ___________________________________________________
CITY/STATE
___________________________________________________
SPOUSES MAIDEN NAME
_____________________________________________
PRESENT ADDRESS/PHONE _____________________________________________
DATE OF ORDER OR DECREE _____________________________________________
COURT/STATE ISSUED
_____________________________________________
5. LIST ALL CHILDREN RELATED TO YOU OR YOUR SPOUSE (NATURAL, STEP – CHILDREN,
ADOPTED & FOSTER CHILDREN)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6. LIST ALL OTHER DEPENDANTS:
NAME
RELATION
AGE
ADDRESS
PHONE
_________________________________________________________________________
_________________________________________________________________________
14
7. LIST OTHER RELATIVES IN THE FOLLOWING ORDER: FATHER, MOTHER (MAIDEN NAME),
BROTHER, SISTER
NAME
ADDRESS
PHONE
RELATION
AGE
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
J. FINANCIAL HISTORY
1. WHAT IS YOUR PRESENT SALARY OR WAGES?
______________________________
2. DO YOU HAVE INCOME FROM ANY SOURCE OTHER THAN YOUR PRINCIPAL OCCUPATION?
[ ] YES [ ] NO (IF YES, GIVE DETAILS: AMOUNT, FREQUENCEY, SOURCE) __________
_______________________________________________________________________
_______________________________________________________________________
3. DO YOU OWN ANY REAL ESTATE? [ ] YES [ ] NO VALUE: _____________________
IF YES, LOCATION: ________________________________________________________
_______________________________________________________________________
4. DO YOU OWN ANY CORPORATE STOCK?
[ ] YES
[ ] NO VALUE: ____________
5. DO YOU HAVE A BANK ACCOUNT?
SAVINGS: [ ] YES
[ ] NO AVERAGE BALANCE: __________________________
NAME AND ADDRESS OF BANK: __________________________________________
CHECKING: [ ] YES [ ] NO AVERAGE BALANCE: _________________________
NAME AND ADDRESS OF BANK: __________________________________________
FINANCIAL OBLIGATIONS:
GIVE NAMES AND ADDRESSES OF THE INDIVIDUALS, COMPANIES, OR OTHERS TO WHOM YOU ARE
INDEBTED, AND THE EXTENT OF YOUR DEBT, INCLUDE RENT, MORTAGE, VEHICLE PAYMENTS, CHARGE
ACCOUNTS, CREDIT CARDS, LOANS, CHILD SUPPORT PAYMENTS, AND ANY OTHER DEBTS AND
PAYMENTS. INCLUDE ACCOUNT NUMBER.
15
TYPE NAME/ADDRESS OF CREDITOR
REASON
ACCT#
BALANCE/PAYMENTS
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
TOTAL: _____________________________________
(IF YOU NEED MORE ROOM, LIST ON A SEPARATE SHEET AND ATTACH)
K. MEDICAL HISTORY
1. LIST THE FOLLOWING INFORMATION CONCERNING ALL DOCTORS CONSULTED WITHIN
THE LAST THREE YEARS AND ALL PERIODS OF HOSPITALIZATION WITHIN THE LAST 5 YEARS
CONSULTATION, ILLNESS
MO/YR
#DAYS
NAME/ADDRESS PHYSICIAN
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. DO YOU HAVE ANY PHYSICAL HANDICAPS, CHRONIC DISEASES OR DISABILITIES?
[ ] YES [ ] NO (IF YES, GIVE DETAILS)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. HAVE YOU EVER RECEIVED WORKERS COMPENSATION OR ANY OTHER DISABILITY
INSURANCE PAYMENTS?
[ ] YES
[ ] NO (IF YES, GIVE DETAILS)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. ARE YOU CURRENTLY TAKING ANY MEDICATIONS PRECRIBED BY A PHYSICANS?
[ ] YES
[ ] NO (IF YES, GIVE DETAILS)
_________________________________________________________________________
_________________________________________________________________________
16
L. REFERENCES
LIST AT LEAST FIVE PERSONS WHO KNOW YOU WELL ENOUGH TO PROVIDE CURRENT INFORMATION
ABOUT YOU. DO NOT LIST RELATIVES OR FORMER EMPLOYERS.
NAME: ___________________________
ADDRESS:
_____________________________
PHONE: (HOME)
_______________
WORK:
_____________________________
BUSINESS ADDRESS: _________________________________________________________
YEARS KNOWN:
_______________
NAME: ___________________________
ADDRESS:
_____________________________
PHONE: (HOME)
_______________
WORK:
_____________________________
BUSINESS ADDRESS: _________________________________________________________
YEARS KNOWN:
_______________
NAME: ___________________________
ADDRESS:
_____________________________
PHONE: (HOME)
_______________
WORK:
_____________________________
BUSINESS ADDRESS: _________________________________________________________
YEARS KNOWN:
_______________
NAME: ___________________________
ADDRESS:
_____________________________
PHONE: (HOME)
_______________
WORK:
_____________________________
BUSINESS ADDRESS: _________________________________________________________
YEARS KNOWN:
_______________
NAME: ___________________________
ADDRESS:
_____________________________
PHONE: (HOME)
_______________
WORK:
_____________________________
BUSINESS ADDRESS: _________________________________________________________
YEARS KNOWN:
_______________
M. MEMBERSHIPS IN ORGINAZATIONS (PAST OR PRESENT)
NAME & ADDRESS
TYPE (SOCIAL/PROFESSIONAL)
FROM
TO
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
17
N. PERSONAL DECLARATIONS
1. DESCRIBE IN YOUR OWN WORDS THE FREQUENCY AND EXTENT OF YOUR USE OF INTOXICATING
LIQUORS
______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. HAVE YOU EVER USED MARIJUANA OR ANY OTHER DRUGS NOT PRESCRIBED BY YOUR
PHYSICIANS? [ ] YES [ ] NO (IF YES, GIVE DETAILS) ________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. HAVE YOU EVER SOLD OR FURNISHED DRUGS OR NARCOTICS TO ANYONE?
[ ] YES [ ] NO (IF YES, GIVE DETAILS) ___________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. IF IT BECAME NECESSARY TO TAKE A HUMAN LIFE IN THE COURSE OF YOUR DUTIES AS A POLICE
OFFICER, WOULD ANY RELIGIOUS OR OTHER BELIEFS PREVENT YOU FROM DOING SO?
[ ] YES [ ] NO
IF YES, EXPLAIN: ___________________________________________________________
_________________________________________________________________________
5. DO YOU HAVE ANY RELIGIOUS OR OTHER BELIEFS WHICH WOULD PREVENT YOU FROM FULLY
PERFORMING THE DUTIES OF A POLICE OFFICER, INCLUDING WORKING ON WEEKENDS,
EVENINGS, NIGHT SHIFTS, OR HOLIDAYS? [ ] YES
[ ] NO
(IF YES, GIVE DETAILS)
________________________________________________________________________
________________________________________________________________________
6. HAVE YOU EVER MADE APPLICATION FOR EMPLOYMENT WITH THIS OR ANY OTHER LAW
ENFORCEMENT OR RELATED AGENCY?
[ ] YES [ ] NO (IF YES, GIVE AGENCY, DATES AND
STATUS OF APPLICATION)
AGENCY
DATE
STATUS
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
18
7. ARE THERE INCIDENTS IN YOUR LIFE OR DETAILS NOT MENTIONED HEREIN WHICH MAY
INFLUENCE THIS DEPARTMENT’S EVALUATION OF YOUR SUITABILITY FOR EMPLOYMENT AS A
POLICE OFFICER? [ ] YES
[ ] NO
(IF YES, EXPLAIN)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
O. IN CASE OF EMERGENCY NOTIFY:
_________________________________________________________________________
NAME
ADDRESS
PHONE
DO YOU HAVE ANY ONLINE SOCIAL ACCOUNTS SUCH A FACEBOOK, MY SPACE, TWITTER, ETC. IF SO,
PLEASE GIVE USERNAME AND PASSWORD.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
19
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF
MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS
APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
___________________________________
APPLICANT’S SIGNATURE
PLACE COPY OF DRIVERS LICENSE, BIRTH CERTIFICATE, HIGH SCHOOL DIPLOMA OR GED, SOCIAL
SECURITY CARD, A CURRENT PHOTO, AND DD 214 (IF APPLICABLE) HERE:
20