COLUMBUS POLICE DEPARTMENT. Recruiting Office th Street Columbus, GA 31902

Transcription

1 COLUMBUS POLICE DEPARTMENT Recruiting Office th Street Columbus, GA An Equal Opportunity Employer APPLICATION & BACKGROUND BOOKLET NAME (LAST) (FIRST) (MIDDLE) REFERENCE # (FOR DEPARTMENT USE)

2 READ ALL INSTRUCTIONS ON THIS PAGE BEFORE PROCEEDING Failure to follow instructions, providing incomplete or incorrect information will delay or may disqualify you from the hiring process. 1. Local applicants are required to submit their application in person. Out of town applicants may mail their applications and supporting documentation to the Recruiting Office of the Columbus Police Department. Once your application is received, a background investigator will contact you with further information and instructions. 2. When submitting your application in person you should allow one (1) hour for the completion of the entire procedure. Applications are accepted Monday Friday between 8:30 A.M. and 4:00 P.M. Please do not bring children with you to the office. 3. The applicant must print or type the answers in this booklet legibly in black ink. 4. All supporting documentation must be clear and legible. 5. Complete and accurate address and contact information must be given in all requested areas. Incomplete information will delay your process. 6. All yes/no questions must be answered with either a Yes or No response. N/A stands for Not Applicable. Do not use N/A when No or None is the correct response. Do not leave any blanks. Answer all questions accurately, truthfully and in complete detail. There are additional pages in the back of this booklet if needed. 7. All waivers/forms located in this booklet must be completed prior to submitting your application. 8. If after submitting this booklet there are any changes to your contact information, you must contact the Recruiting Office promptly. 9. If at anytime during the application process you are involved in an accident, issued a traffic citation, have criminal or civil charges brought against you, or become part of a criminal investigation, you should contact your background investigator promptly. 10. If you have any questions contact the Recruiting Office at It is necessary that all information be complete, truthful and accurate. Georgia Peace Officers Standards and Training (P.O.S.T) council, chapter : The council shall deny certification to any applicant supplying false information or the use of fraud in securing employment. Discovery of deliberate omissions, intentional misrepresentations, or any falsified information will be basis for the termination of the application process or employment and could result in criminal prosecution under Georgia Law Section It is imperative any conviction be listed in a criminal proceeding, regardless of whether the judgment of guilt or sentence is withheld or not entered thereon, this includes first offender status. All information will be subject to verification through polygraph and administrative investigation. I understand the above instructions. I also understand that if I do not wish to answer a question in this booklet, I may not choose to do so and my application will be terminated. (SIGNATURE) (DATE) 2

3 APPLICATION PROCESS START Application Received Initial Interview Process Stops Physical Qualifications Fail 2 nd Attempt State Examination Background Investigation Polygraph Psychological Exam Pre-Interview with Personnel Director Interview with Command Staff Fail Pass HIRED 3

4 APPLICANT DISQUALIFICATIONS The following conditions shall result in the immediate disqualification of an applicant from consideration in the hiring process for police officer: Any adult conviction of a felony. Juvenile adjudications will be reviewed on a case by case basis. Dishonorable discharge from any branch of the armed services. Any adult conviction, misdemeanor or city ordinance, involving family violence. Juvenile adjudications will be reviewed on a case by case basis. Any disclosure involving the sale or distribution of an illegal substance shall be reviewed on a case by case basis. Use of Marijuana within two (2) years of the date of application. Use of any Schedule II, III, IV or V Narcotics within five (5) years of the date of application. Use of any prescription medication not used as prescribed or intended will be reviewed on a case by case basis. Any use of a Schedule I narcotic (Ecstasy, Heroin, GHB, LSD) within ten (10) years of the date of application. Prior use will be determined on a case-by-case basis Any illegal use of steroids within three (3) years of the date of application. All Misdemeanor and City Ordinance convictions not included in the above categories will be reviewed on a case by case basis. Making any false statements or knowingly providing false information on the application or any document related to the application process. WE NEED CLEAR COPIES OF THE FOLLOWING DOCUMENTS: 1. Copy of your Birth Certificate. 2. Copy of your High School Diploma or GED. 3. ALL High School Transcripts must be mailed to our office from the high school by U.S. mail. No exceptions. 4. College Diploma(s) (if applicable). 5. ALL College Transcripts must be mailed to our office from the college by U.S. mail. No exceptions. 6. Copy of your DD214 (if applicable). Any discharge other than Honorable will require a separate statement that must be signed, witnessed and notarized. 7. A copy of your Valid Driver s License and Social Security 8. Record of any legal name change (excluding marriage). We will also need court documentation. 9. An Original and Certified ten (10) year driver s history from ALL the states in which you have been issued a driver s license within the last 10 years, except for Georgia. You must check with that state for their procedure to obtain your driver s history. 10. Separate statement(s) for any arrest(s) or military disciplinary action(s) must be signed, witnessed and notarized. We will also need court related documentation and all police reports relating to the incident(s). 4

5 INTERNATIONAL HIGH SCHOOL OR COLLEGE DIPLOMAS All international transcripts and diplomas must be evaluated by an approved evaluation service and sent directly to the Columbus Police Department. This is the applicant s responsibility. The following agencies are approved and recommended for diploma and transcript evaluations: Josef Silny & Associates, Inc SW 102 Avenue Miami, FL Telephone: (305) Fax: (305) info@jsilny.com Lisano International P.O. Box 404 Auburn, AL Telephone: (334) LisanoINTL@AOL.com World Education Service Bowling Green Station P.O. Box 5087 New York, NY Telephone: (212) info@wes.org 5

6 P.O. Box Tenth Street Columbus, Georgia Recruiting Office Phone: Fax: DECLARATION I hereby certify that there are no willful misrepresentations or falsifications in the foregoing statements and answers to questions. I am aware that should investigation disclose any such misrepresentations or falsifications, my application will be rejected, or if already employed, my employment may be terminated. I also understand that a failure to answer each question will cause my application to be disqualified. Signature of Applicant Date Signature of Recruiter Date ***UPON SUBMISSION THE APPLICANT AND THE RECRUITER WILL REVIEW THE APPLICATION. ONCE THE APPLICATION HAS BEEN REVIEWED AND DEEMED COMPLETE, THE APPLICANT WILL SIGN AND DATE THIS FORM INDICATING THAT ALL INFORMATION PROVIDED IS TRUE AND CORRECT. THE RECRUITER WILL SIGN AND DATE THIS FORM AS A WITNESS. 6

7 P.O. Box Tenth Street Columbus, Georgia Recruiting Office Phone: Fax: TO WHOM IT MAY CONCERN I,, having submitted an application to the Columbus Police Department for the position of Police Officer, agree to participate in all phases of the applicant screening process to determine my suitability for employment. I fully understand that a Physical Qualifications Test is required and that my participation in said test is a personal choice. In doing so, I hereby relieve the Columbus Police Department, Columbus Consolidated Government, and their representatives of any and all liability for personal harm or injury resulting from my participation. Signed: Date: Witness: Date: Notary Signature: My Commission Expires: (Stamp Only Not Hand Written) Notary Seal: 7

8 TO WHOM IT MAY CONCERN: P.O. Box Tenth Street Columbus, Georgia Recruiting Office AUTHORITY TO RELEASE INFORMATION I hereby authorize any Officer or other authorized representative of the Columbus Police Department bearing this release, or copy thereof, within one year of its date, to obtain any information in your files pertaining to my military or employment history and educational records (including, but not limited to: academic, achievement, attendance, athletic, personal history and disciplinary records); medical records; and credit records. Further authorization is extended to all Police Departments, Sheriff's Departments, Juvenile Courts and Clerks of Courts, to furnish the bearer with information, reprints, photographs and any other record containing information relating to criminal history or activity. I hereby direct you to release such information upon request of bearer. I hereby release you, as the custodian of such records, and any employer, school, college, university, or other educational institution, hospital, or other repository of medical records, credit bureau of consumer reporting agency, 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 any attempt to comply with it. I further authorize the acceptance of a copy of this original to be used as authorization to release any and all information in lieu of the original which remains on file with this investigating agency. Should there be any questions as to the validity of this release, you may contact me as indicated below. Full Name: (Printed) Full Name: (Signature) Date of Birth: Social Security Number: Current Address: Witness: Telephone Number: Date: Notary Public: My Commission Expires: (Stamp Only Not Hand Written) Notary Seal: 8

9 PERSONAL DATA 1. NAME (FIRST) (MIDDLE) (LAST) D.O.B (MONTH/DAY/YEAR) SSN GIVE ANY OTHER NAMES YOU HAVE USED OR BEEN KNOWN BY AND GIVE REASONS FOR THOSE NAMES. IF NONE, STATE NONE. 2. RACE SEX HEIGHT WEIGHT HAIR EYES 3. LIST ANY SCARS MARKS OR TATTOOS 4. NATURAL BORN CITIZEN [ ] OR NATURALIZED [ ] CERTIFICATE # / COUNTRY 5. LOCATION OF BIRTH (IF NATURAL BORN) (CITY) (STATE) (COUNTY) 6. YOUR MAILING ADDRESS (DO NOT USE A P.O. BOX) 7. HOME PHONE ALTERNATE PHONE ADDRESS 8. WITH WHOM DO YOU RESIDE (FULL NAME) 9. LIST ALL ORGANIZATIONS, CLUBS AND ASSOCIATIONS WHICH YOU ARE OR HAVE BEEN A MEMBER OF OR ASSOCIATED WITH 10. WHAT ARE YOUR HOBBIES, SPECIAL SKILLS AND ABILITIES (INCLUDE SPEAKING ANY FOREIGN LANGUAGES) 9

10 MARITAL INFORMATION 1. IF YOU ARE MARRIED, SEPARATED OR DIVORCED, COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR CURRENT SPOUSE AS WELL AS ANY FORMER SPOUSE(S). IF YOU NEED MORE SPACE, USE THE ADDITIONAL PAGES IN THE BACK OF THIS PACKET. CHECK ANY/ALL BOXES THAT APPLY: SINGLE [ ] MARRIED [ ] WIDOWED [ ] SEPARATED [ ] DIVORCED [ ] NAME (FIRST) (MIDDLE) (MAIDEN IF APPLICABLE) PHONE NUMBER OCCUPATION & EMPLOYER DATE MARRIED DATE SEPARATED / DIVORCED FAMILY INFORMATION 2. LIST ALL OF YOUR DEPENDENTS (EXCLUDE CURRENT SPOUSE) NAME DATE OF BIRTH RELATIONSHIP 3. LIST ALL LIVING MEMBERS OF YOUR IMMEDIATE FAMILY. INCLUDE FATHER, MOTHER, SIBLINGS, MOTHER-IN-LAW AND FATHER-IN-LAW. NAME RELATIONSHIP CITY/ST PHONE # 10

11 RESIDENCES LIST ALL RESIDENCES YOU HAVE LIVED IN THE LAST TEN (10) YEARS. THIS SHOULD INCLUDE TEMPORARY ADDRESSES, PART-TIME ADDRESSES, MILITARY ADDRESSES, PERMANENT ADDRESSES, AND SCHOOL ADDRESSES. START WITH YOUR CURRENT ADDRESS. FROM TO STREET # STREET NAME CITY ST ZIP COUNTY 11

12 EDUCATION 1. IF YOU GRADUATED HIGH SCHOOL, COMPLETE THE FOLLOWING (NAME OF SCHOOL) (DATES ATTENDED) (ADDRESS) (CITY, STATE) (ZIP) (PHONE NUMBER) (DATE GRADUATED) 2. IF YOU OBTAINED A G.E.D CERTIFICATE, COMPLETE THE FOLLOWING (NAME OF SCHOOL/ORGANIZATION) (DATES ATTENDED) (ADDRESS) (CITY, STATE) (ZIP) (STATE G.E.D. OBTAINED) (DATE OBTAINED) 3. HAVE YOU EVER BEEN EXPELLED, SUSPENDED OR DISCIPLINED BY A SCHOOL OFFICIAL? IF YES, EXPLAIN. 4. LIST BELOW ANY COLLEGES, UNIVERSITIES, TECHNICAL OR GRADUATE SCHOOLS YOU HAVE ATTENDED. SCHOOL ATTENDED CITY / STATE DATE FROM DATE TO AREA OF STUDY DEGREE OBTAINED 12

13 OTHER LAW ENFORCEMENT APPLICATIONS / CERTIFICATIONS 1. LIST ALL OTHER LAW ENFORCEMENT AGENCIES WITH WHICH YOU HAVE APPLIED FOR EMPLOYMENT. INCLUDE CONTACT INFORMATION. AGENCY PHONE # CITY STATE DATE APPLIED STATUS OF APPLICATION 2. LIST ANY LAW ENFORCEMENT ACADEMIES YOU HAVE ATTENDED. ACADEMY CITY STATE DATES ATTENDED CERTIFICATION # 13

14 EMPLOYMENT HISTORY LIST IN DESCENDING ORDER ALL EMPLOYMENT FOR THE LAST TEN (10) YEARS TO INCLUDE: CURRENT, PART-TIME, SEASONAL/TEMPORARY AND VOLUNTEER. PLEASE PROVIDE ALL INFORMATION AS IT IS REQUESTED BELOW. FAILURE TO PROVIDE COMPLETE AND CORRECT INFORMATION WILL DELAY THE BACKGROUND PROCESS. 1. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING MAY WE CONTACT YOUR CURRENT EMPLOYER? YES NO A NO ANSWER WILL NOT AFFECT YOUR CONSIDERATION FOR EMPLOYMENT 2. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 14

15 EMPLOYMENT HISTORY CONTINUED 3. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 4. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 15

16 EMPLOYMENT HISTORY CONTINUED 5. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 6. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 16

17 EMPLOYMENT HISTORY CONTINUED 7. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 8. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 17

18 9. NAME OF CURRENT OR MOST RECENT EMPLOYER EMPLOYMENT HISTORY CONTINUED ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING 10. NAME OF CURRENT OR MOST RECENT EMPLOYER ADDRESS JOB TITLE START DATE END DATE SUPERVISOR S FULL NAME SUPERVISOR S PHONE # JOB DESCRIPTION REASON FOR LEAVING IF YOU NEED MORE SPACE, CIRCLE CONTINUED AND USE THE ADDITIONAL PAGES IN THE BACK OF THIS PACKET. PROVIDE THE SAME INFORMATION AS REQUIRED ABOVE. ***CONTINUED*** 18

19 EMPLOYMENT QUESTIONAIRE 1. HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT WITH THE COLUMBUS CONSOLIDATED GOVERNMENT? YES NO IF YES, WHEN, WHAT POSITION AND WHAT WAS THE OUTCOME? 2. HAVE YOU EVER WORKED FOR THE COLUMBUS CONSOLIDATED GOVERNMENT? YES NO 3. DO YOU OBJECT TO WEARING A UNIFORM? YES NO 4. DO YOU OBJECT TO SHIFT WORK? YES NO 5. DO YOU HAVE EXPERIENCE WITH SHIFT WORK? YES NO 6. HAVE YOU HAD ANY DISAGREEMENTS CONCERNING JOB DUTIES OR WORKING CONDITIONS? YES NO 19

20 EMPLOYMENT QUESTIONAIRE CONTINUED 7. HAS ANY SUPERVISOR EVER REPRIMANDED YOU FOR BEING LATE FOR OR ABSENT FROM WORK? YES NO 8. HAVE YOU HAD ANY DISCIPLINARY ACTION, TO INCLUDE VERBAL, WRITTEN WARNINGS, REPRIMANDS, SUSPENSIONS, OR COUNSELINGS, TAKEN AGAINST YOU FOR ANY EMPLOYMENT OR POSITION YOU HAVE HELD? YES NO 9. HAVE YOU EVER BEEN DENIED EMPLOYMENT, FOR ANY REASON, BY ANY LAW ENFORCEMENT AGENCY? YES NO 10. CIRCLE THE NUMBER OF TIMES IN THE LAST TEN (10) YEARS YOU HAVE LEFT A JOB WITHOUT GIVING NOTICE. IF ANSWER IS OTHER THAN 0 PLEASE PROVIDE AN EXPLANATION IN THE BACK OF THIS BOOKLET CIRCLE THE NUMBER OF TIMES IN THE LAST TEN (10) YEARS YOU HAVE BEEN ASKED TO RESIGN, BEEN FIRED, OR LEFT A JOB IN LIEU OF TERMINATION OR DISCIPLINARY ACTION. IF ANSWER IS OTHER THAN 0 PLEASE PROVIDE AN EXPLANATION IN THE BACK OF THIS BOOKLET

21 MILITARY 1. HAVE YOU EVER ATTEMPTED TO JOIN ANY BRANCH OF THE UNITED STATES ARMED FORCES AND BEEN DENIED? YES NO 2. HAVE YOU EVER SERVED IN ANY BRANCH OF THE UNITED STATES ARMED FORCES? THIS INCLUDES RESERVES, NATIONAL GUARD AND COAST GUARD. YES NO IF YES, PROVIDE THE BELOW INFORMATION. BRANCH OF SERVICE ENLISTMENT PERIOD HIGHEST RANK HELD TYPE OF DISCHARGE 3. HAVE YOU EVER BEEN COURT MARTIALED, TRIED ON CHARGES, SUBJECT OF AN ARTICLE 15, COMPANY PUNISHMENT, OR ANY OTHER DISCIPLINARY ACTION WHILE A MEMBER OF ANY BRANCH OF THE ARMED FORCES? YES NO IF YES, PROVIDE THE BELOW INFORMATION. TYPE OF ACTION BRANCH OF SERVICE DATE OF ACTION DISPOSITION ***OUR AGENCY REQUIRES A TYPED STATEMENT DETAILING ANY AND ALL COURT MARTIALS, MILITARY CHARGES, ARTICLE 15s, COMPANY PUNISHMENTS OR OTHER DISCIPLINARY ACTIONS. ALL STATEMENTS MUST BE SIGNED AND NOTORIZED PRIOR TO BEING SUBMITTED TO THIS OFFICE*** 21

22 ILLEGAL DRUG USE 1. IN THE SPACES BELOW INDICATE WHEN YOU FIRST USED AN ILLEGAL DRUG, THE LAST TIME YOU USED AN ILLEGAL DRUG AND THE APPROXIMATE NUMBER OF TIMES YOU USED A PARTICULAR ILLEGAL DRUG. IF YOU HAVE NEVER USED A DRUG LISTED BELOW, WRITE NEVER IN THE FIRST COLUMN. TYPE OF DRUG MARIJUANA/HASHISH APPROXIMATE DATE FIRST USED APPROXIMATE DATE LAST USED NUMBER OF TIMES COCAINE/CRACK COCAINE METHAMPHETAMINE (ICE, ANGEL DUST, CRANK, CRYSTAL METH, ETC) ECSTASY ACID/LSD/PCP MUSHROOMS HEROIN OPIUM STEROIDS PRESCRIPTION DRUGS NOT PRESCRIBED SYNTHETIC DRUGS (SPICE) ANY OTHER ILLEGAL DRUGS 2. HAVE YOU EVER SOLD ANY TYPE OF ILLEGAL DRUG, DELIVERED ILLEGAL DRUGS, OR DIRECTED ANOTHER PERSON WHERE TO OBTAIN DRUGS? YES NO I UNDERSTAND THAT ANY CHANGES / FALSIFICATIONS TO THIS INFORMATON MAY TERMINATE THE APPLICATION PROCESS (APPLICANT SIGN AND DATE) (RECRUITER SIGN AND DATE) 22

23 CRIMINAL HISTORY 1. HAVE YOU EVER COMMITTED OR PARTICIPATED IN ANY OF THE FOLLOWING CRIMES (WHETHER YOU WERE CAUGHT OR NOT)? IF YES, PROVIDE A TYPED STATEMENT DETAILING EACH INCIDENT. CRIME YES NO CRIME YES NO ARSON ASSAULT BURGLARY CHILD ABUSE OR MOLESTATION COMPUTER RELATED CRIME CREDIT CARD / CHECK FRAUD CRUELTY TO ANIMALS DISORDERLY CONDUCT DOMESTIC VIOLENCE DRUG POSSESSION / SALE DUI / DWI EMBEZZLEMENT EXTORTION FORGERY FRAUD - BAD CHECKS GIVING FALSE INFORMATION IMPERSONATING AN OFFICER KIDNAPPING MURDER / MANSLAUGHTER PERJURY PROSTITUTION / SOLICITATION PUBLIC INTOXICATION ROBBERY SEXUAL ASSAULT THEFT THEFT / UNAUTHORIZED USE OF A MOTOR VEHICLE TRESPASSING VANDALISM WEAPONS VIOLATION OTHER 2. HAVE YOU EVER PURCHASED OR PAWNED AN ITEM THAT YOU KNEW OR SHOULD HAVE KNOWN WAS STOLEN? YES NO 23

24 CRIMINAL HISTORY CONTINUED 3. ESTIMATE THE AMOUNT OF MERCHANDISE OR CASH MONEY YOU HAVE TAKEN FROM ALL EMPLOYERS OVER THE LAST TEN (10) YEARS. AMOUNT / EXPLAIN: 4. HAVE YOU EVER BEEN PLACED ON PROBATION OR PAROLE? YES NO 5. HAVE YOU EVER BEEN DETAINED, ARRESTED, INVESTIGATED OR GIVEN A SUMMONS FOR VIOLATING ANY CITY, MUNICIPAL, STATE OR FEDERAL LAW? YES NO IF YES, PROVIDE THE BELOW INFORMATION. CRIME CHARGED DATE CIRCLE: FELONY MISDEMEANOR CITY ORDINANCE POLICE AGENCY CITY / STATE DISPOSITION 24

25 CRIMINAL HISTORY CONTINUED CRIME CHARGED DATE CIRCLE: FELONY MISDEMEANOR CITY ORDINANCE POLICE AGENCY CITY / STATE DISPOSITION CRIME CHARGED DATE CIRCLE: FELONY MISDEMEANOR CITY ORDINANCE POLICE AGENCY CITY / STATE DISPOSITION CRIME CHARGED DATE CIRCLE: FELONY MISDEMEANOR CITY ORDINANCE POLICE AGENCY CITY / STATE DISPOSITION 6. IS THERE ANYTHING IN YOUR PAST, WHICH IF REVEALED AT A LATER DATE, MAY PROVE TO BE EMBARRASSING TO YOU OR THE DEPARTMENT IF HIRED? YES NO 25

26 DRIVING RECORD 1. CURRENT DRIVER S LICENSE # STATE EXPIRATION DATE RESTRICTIONS 2. DO YOU HAVE OR HAVE YOU EVER HAD A DRIVER S LICENSE ISSUED BY ANOTHER STATE? YES NO IF YES, PROVIDE STATE AND LICENSE NUMBER (IF KNOWN) 3. HAS A STATE EVER DENIED YOU A DRIVER S LICENSE? YES NO 4. HAVE YOU EVER OBTAINED A LICENSE UNDER AN ASSUMED NAME? YES NO 5. HAVE YOU EVER HAD YOUR DRIVER S LICENSE SUSPENDED OR REVOKED IN ANY STATE? YES NO (GIVE STATE, DATES OF SUSPENSION AND REINSTATEMENT) 26

27 DRIVING RECORD CONTINUED 6. BELOW LIST ALL TRAFFIC CITATIONS, INCLUDING WRITTEN WARNINGS, YOU HAVE RECEIVED IN THE LAST TEN (10) YEARS. CITY / STATE DATE MM/DD/YY VIOLATION PENALTY 27

28 FINANCIAL INFORMATION 1. DO YOU HAVE ANY BILLS THAT ARE OVERDUE OR IN COLLECTIONS? YES NO 2. HAVE YOU EVER HAD ANYTHING REPOSSESSED? YES NO 3. HAVE YOU EVER DECLARED BANKRUPTCY? YES NO 4. HAVE YOU EVER HAD A WAGE GARNISHMENT? YES NO 5. HAVE YOU EVER BEEN INVOLVED IN ANY TYPE OF LAWSUIT (CRIMINAL, CIVIL, DIVORCE)? YES NO 28

29 FINANCIAL INFORMATION CONTINUED 6. BELOW LIST INFORMATION CONCERNING ALL OF YOUR CURRENT LIABILITIES (INCLUDE MORTGAGE, LOANS, CREDIT CARDS, ETC). BANK / FIRM NAME BALANCE 29

30 PERSONAL REFERENCES PROVIDE THREE (3) PERSONAL REFERENCES. REFERENCES MUST HAVE KNOWN YOU FOR AT LEAST THREE (3) YEARS OR MORE AND CANNOT BE A FAMILY MEMBER, BOYFRIEND OR GIRLFRIEND, CURRENT OR PAST EMPLOYERS/SUPERVISORS. MAKE SURE YOUR REFERENCES KNOW YOU AND CAN SPEAK TO YOUR CHARACTER. REFERENCES CANNOT BE RELATED TO EACH OTHER OR LIVE AT THE SAME RESIDENCE. YOU MAY ONLY USE ONE (1) LAW ENFORCEMENT OFFICER AS A REFERENCE. PLEASE PROVIDE CURRENT AND CORRECT CONTACT INFORMATION BELOW. PROVIDING INCORRECT CONTACT INFORMATION WILL DELAY THE APPLICATION PROCESS. NAME: PHONE #: ADDRESS: ADDRESS: CITY: STATE: ZIP: YEARS KNOWN: RELATIONSHIP: NAME: PHONE #: ADDRESS: ADDRESS: CITY: STATE: ZIP: YEARS KNOWN: RELATIONSHIP: NAME: PHONE #: ADDRESS: ADDRESS: CITY: STATE: ZIP: YEARS KNOWN: RELATIONSHIP: 30

31 NCIC / GCIC REQUEST INFORMATION DATE: POSITION APPLIED FOR: FULL NAME: (FIRST) (MIDDLE) (LAST) LIST ANY OTHER NAME YOU HAVE EVER USED OR GONE BY FOLLOWED BY AN EXPLANATION (ALIAS, MAIDEN NAME, NICKNAME, PREVIOUS MARRIAGE, ETC). SSN: RACE: SEX: DATE OF BIRTH: PLACE OF BIRTH: HEIGHT: WEIGHT: EYE COLOR: HAIR COLOR: DRIVER S LICENSE #: STATE: LIST BELOW ALL THE CITIES AND STATES YOU HAVE LIVED IN (INCLUDE ALL LOCATIONS WHERE YOU ATTENDED SCHOOL & MILITARY STATIONS). CITY STATE CITY STATE ************************DEPARTMENT USE ONLY************************ NO LOCAL RECORD LOCAL RECORD ATTACHED NCIC/GCIC ATTACHED DRIVER S HISTORY ATTACHED COMMENTS: PLACE STAMP BELOW 31

32 ADDITIONAL INFORMATION *****THE FOLLOWING PAGES ARE PROVIDED FOR ADDITIONAL INFORMATION. PLEASE REFER TO PAGE NUMBER AND QUESTION NUMBER WHEN ADDING INFORMATION***** 32

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