NAME (Last) (First) (Middle) (Title of position for which you are applying) (Lowest acceptable salary) (Per)?

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1 615/ (Tel.) EMPLOYMENT APPLICATION 615/ (Fax) POLICE DEPARTMENT CITY OF BERRY HILL, TENNESSEE 698 THOMPSON LANE, NASHVILLE, TENNESSEE TO THE APPLICANT: The City of Berry Hill is pleased that you are interested in submitting an application for employment. Please complete all questions and sections of the application by typing or printing and return completed application to the city s administrative offices. For new employees, current federal law (the Immigration Reform and Control Act of 1986) requires verification of documents which establish employment authorization and identity. This can be done easily at the time of interview by presentation of the Social Security card and driver s license; other documents may be substituted if necessary. The social security number is used solely for verifying employment data. NAME (Last) (First) (Middle) (Title of position for which you are applying) (Lowest acceptable salary) (Per)? Present Address (Street) (City) (State) (Zip Code) Telephone Number & Area Code address Do you have a TN Drivers License? Yes No. If yes, give Driver s license number Do you have a TN Commercial Drivers License Yes No If yes, what type of endorsement? If you are under 18 years of age, can you provide required proof of your eligibility to work? YES NO Have you ever filed an application with us before? YES NO If yes, give date Have you ever been employed with the City of Berry Hill before? YES NO If yes, give date/department Are you currently employed? YES NO If yes, may we contact your present employer? YES NO Are you prevented from lawfully becoming employed in this country because of VISA or Immigration status? YES NO (Proof of citizenship or immigration status will be required upon employment.) On what date would you be available for work? Are you available to work: Full Time Part Time Shift Work Temporary Have you been convicted of a felony within the last 7 years? YES NO (Conviction will not necessarily disqualify an applicant from employment.) If yes, please explain: Do you have any relatives employed with the City of Berry Hill? YES NO If yes, give name, relationship and department in which they are employed.

2 EDUCATION ELEMENTARY SCHOOL NAME & ADDRESS OF SCHOOL COURSE OF STUDY YEARS COMPLETED & CREDIT HOURS DIPLOMA DEGREE & DATE AWARDED HIGH SCHOOL UNDERGRADUATE SCHOOL GRADUATE PROFESSIONAL OTHER (Specify) Attach copy of High School Diploma or GED Certificate and College Transcript (if applicable). Are you a CERTIFIED Tennessee Law Enforcement Officer? YES NO If yes, give Certification Number and date of certification Are you a certified police officer in another state? YES NO If yes, give state, Certification Number and date of certification Are you a Certified Police Dispatcher? YES NO Describe any specialized training, apprenticeship, skills or other certifications. SPECIALIZED SKILLS - CHECK SKILLS/EQUIPMENT OPERATED Other (list): PC Excel/Lotus Word/WordPerfect Typewriter Microsoft Power Point List any profession you are licensed to practice, giving data on which license was issued and the state from which it was received. 2

3 EMPLOYMENT EXPERIENCE Start with your present or last job. Include, at a minimum, all employment for last ten years and all law enforcement employment. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. 1. Employer Work Performed Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving 2. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving 3. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving 4. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving Dates Employed From To Hourly Rate/Salary Starting Final Dates Employed From To Hourly Rate/Salary Starting Final Dates Employed From To Hourly Rate/Salary Starting Final Dates Employed From To Hourly Rate/Salary Starting Final Work Performed Work Performed Work Performed 3

4 5. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving 6. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving 7. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving 8. Employer Address Telephone Number(s) Job Title Supervisor Supervisor s Reason for Leaving Dates Employed From To Hourly Rate/Salary Starting Final Dates Employed From To Hourly Rate/Salary Starting Final Dates Employed From To Hourly Rate/Salary Starting Final Dates Employed From To Hourly Rate/Salary Starting Final Work Performed Work Performed Work Performed Work Performed If you need additional space, please continue on a separate sheet of paper. 4

5 References - Do not include relatives or former supervisors. 1. (Name) Day Phone # (Address) 2. (Name) Day Phone # (Address) 3. (Name) Day Phone # (Address) State any additional information you feel may be helpful to us in considering your application. ******************************************************************************************************** Note to Applicant: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED OR UNDERSTAND ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner the essential functions involved in the job or occupation for which you have applied with or without reasonable accommodation? YES NO ******************************************************************************************************** PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING This Application is but one part of the employment process. Other parts may include an interview, an employment examination or test, and a demonstration of an ability to perform the essential functions of the job. As you complete this application, please bear in mind the following: We reserve the right to check all information for accuracy and completeness. All applications for employment are a matter of public record. A pre-employment or post-employment physical exam, psychological exam, polygraph test and/or drug screening may be required. A background investigation may be required. ******************************************************************************************************** APPLICANT S STATEMENT I hereby affirm that the information provided on this application and any accompanying resume is true and complete to the best of my knowledge. I understand that falsified information provided on this form shall be sufficient cause for cancellation of this application or, if I am employed, for dismissal. The City of Berry Hill is hereby authorized to make an investigation of my personal background and employment history. I understand that I will have to complete an authorization and release of information form. I also understand that, if employed, I am required to abide by all rules and regulations of the City of Berry Hill, and that I shall be on a temporary status for a specified introductory period, during which period I may be terminated at any time without cause or recourse. Signature of Applicant Date 5

6 Berry Hill Police Department 698 Thompson Lane Nashville, Tennessee PERSONAL HISTORY STATEMENT POLICE OFFICER Applicant Name: Last First Middle Applicant date of birth S.S. # Applicant Contact Number(s): Including Area Codes Home Work Cell Pager APPLICANT INSTRUCTIONS 1. Type or neatly print, in ink, responses to all questions. If there are questions or sections that does not apply to you write N/A (not applicable) in the space provided for your response. If you cannot remember or obtain certain information, indicate so in your response. 2. Answer each question as accurately and completely as possible. 3. When listing phone numbers, include area codes. 4. When listing addresses, include street address, city, state and zip code. 5. The authorization for the release of information/ background investigation form must be signed, dated and notarized. DISQUALIFICATION Deliberate misstatements, omissions and/or incomplete applications can and often will result in your application being rejected, regardless of the nature or reason for the misstatements, omissions and/or incomplete applications Initial this page to indicate you have read and understand this page: 1

7 RESIDENCE List all residences for the past twenty years starting with your present address. Provide complete addresses, including street name, street number, city, state and unit or apartment number. Do not use P.O. boxes. If you rented or leased, list the name and address of whom you rented or leased from. If more space is needed use page 17 for additional information. 1. From: Month/Year To: Month/Year If renting; list the following information for the property manager, rent collector or owner. Name: Phone number ( ) 2. From: Month/Year To: Month/Year If renting; list the following information for the property manager, rent collector or owner. Name: Phone number ( ) 3. From: Month/Year To: Month/Year If renting; list the following information for the property manager, rent collector or owner. Name: Phone number ( ) 2

8 4. From: Month/Year To: Month/Year If renting; list the following information for the property manager, rent collector or owner. Name: Phone number ( ) 5. From: Month/Year To: Month/Year If renting; list the following information for the property manager, rent collector or owner. Name: Phone number ( ) 6. From: Month/Year To: Month/Year If renting; list the following information for the property manager, rent collector or owner. Name: Phone number ( ) 3

11 APPLICANTS MILITARY SERVICE /STATIS Have you ever served in the armed Forces of the United States? Yes No If yes attach copy of DD-214 long form. If Yes, List the Branch Dates of Service: From: To: Service Number: Classification: Type of Discharge: If other than honorable, List type of Discharge and Explain: Have you ever been, or currently a member of a reserve unit? Yes No Have you ever been, or currently a member of the National guard? Yes No If Yes, What branch Ready Standby/RR Are you currently active in the Military? Yes No If yes, what is your anticipated release date? Did you ever have ANY type of disciplinary action taken against you while in the military? (This includes article 15, Captain s mast, court martial, etc.) Yes. If yes, explain No 6

12 PRIOR APPLICATION HISTORY WITH OTHER LAW ENFORCEMENT AGENCIES. List all law enforcement agencies that you previously submitted an application for employment with and/or tested for employment with that you were not hired. If more space is needed use page 17 for additional information. Agency _Phone # Address Date of Application Reason you were not hired Agency _Phone # Address Date of Application Reason you were not hired Agency _Phone # Address Date of Application Reason you were not hired 7

13 EMPLOYMENT TERMINATION/ RESIGNATION HISTORY Have you ever been dismissed, terminated, fired, released from probation or resigned in lieu of termination? Yes No if yes complete below. If more space is needed use page 17 for additional information. Employer Phone # Address Applicant s Position: Supervisor Name Dates of Employment Explain in full detail the circumstances of termination or resignation. Employer Phone # Address Applicant s Position: Supervisor Name Dates of Employment Explain in full detail the circumstances of termination or resignation. 8

14 EMPLOYMENT WORK HISTORY 1. Have you ever been disciplined at work? This includes written warnings, formal letters of counseling, counseling statements, reprimands, suspensions, reductions in pay, reassignments or demotions. Yes No 2. Have you ever been involved in a physical altercation with a supervisor, co-worker or customer? Yes No 3. Have you ever quit without giving proper notice? Yes No 4. Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment etc) by a co-worker, superior, subordinate or customer? Yes No 5. Have you ever received an unsatisfactory performance review or evaluation? Yes No 6. Have you ever been the subject of a written complaint at work? Yes No If you answered yes to any of questions 1-6 above, explain; including when, where and the circumstances; Indicate corresponding number. If more space is needed use page 17 for additional information. 9

15 CRIMINAL/CIVIL RECORD Either as an adult or a juvenile, have you EVER been detained for investigation, held on suspicion, questioned, fingerprinted, arrested, indicted, criminally charged, or convicted of any misdemeanor or felony offense in the state or in any other legal jurisdiction (including offenses punishable under the uniform code of military justice)? Yes No If yes, explain each incident. List all incidents even if the records were sealed, expunged, dismissed or pardoned. If more space is needed use page 17 for additional information. Offense _Date charged Jurisdiction in which incident happened (city, county and state) How charge was placed; Arrest Indictment Citation Summons Explain what happened: _ Disposition: Offense _Date charged Jurisdiction in which offense happened (city, county and state) How charge was placed; Arrest Indictment Citation Summons Explain what happened: _ Disposition: 10

16 7. Have you ever been placed on probation as an adult? Yes No 8. Were you ever required to appear before a juvenile court for an act which would have been a crime if committed as an adult? Yes No 9. Have you ever been a party in a civil lawsuit (small claims actions, dissolutions, child custody, child support, paternity support, etc)? Yes No 10. Have you or your spouse/partner ever been referred to child protective services? Yes No 11. Have you ever been the subject of an emergency protective order/ restraining order or stay away order? Yes No 12. Have you ever settled any civil suit in which you, your insurance company, or anyone else on your behalf was required to make payment to the other party? Yes No 13. Have you ever fraudulently received welfare, unemployment compensation, workers compensation or other state or federal assistance? Yes No 14. Have you ever filed a false insurance or workers compensation claim? Yes No If you answered yes to any of questions 7-14, explain court case or document, dates and circumstances and disposition. Indicate corresponding number. If more space is needed use page 17 for additional information. 11

17 DRUG/ALCOHOL 15. In the past three years, have you missed days or been late for work due to drug or alcohol consumption? Yes No 16. Has your job performance ever been affected by your use of alcohol or drugs? Yes No 17. In the past three years, have you been warned by an employer about your drinking or drug habits and their impact on your job performance? Yes No 18. Check all drugs you have used in the past year: Amphetamines Barbiturates Cocaine/Crack Marijuana Hallucinogens Hashish PCP Steroids 19. Prior to one year ago have you ever used drugs recreationally? Yes No If yes; list type of drugs and the last time used. 20. Have you ever sold, manufactured or cultivated any type of drug? Yes No If you answered yes to any of questions 15-20, explain (include when, where, why and disposition of each incident) If more space is needed use page 17 for additional information. 12

18 FINANCIAL RECORD 21. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)? Yes No 22. Have any of your bills ever been turned over to a collection agency? Yes No 23. Have you ever had purchased goods repossessed? Yes No 24. Have you ever had your wages garnished? Yes No 25. Have you ever avoided paying any lawful debt by moving away? Yes No 26. Have you ever defaulted on (failed to pay) a loan? Yes No 27. Have you ever failed to make or been late on a court ordered payment (child support, alimony, restitution, etc.)? Yes No 28. Have you ever been involved as a party in any civil court action or suit? Yes No 29 Do you owe money to any courts for settlements, judgments or fines? Yes No If you answered yes to any of questions 21-29, explain (include when, where, why and disposition of each incident) If more space is needed use page 17 for additional information. 13

19 DRIVERS LICENSE/ DRIVING RECORD Drivers License Number: State Date Expires Have you ever had your driver s license(s) or privileges cancelled, revoked, or refused for any reason? Yes No If yes, explain (include dates, cause, jurisdiction, state and disposition) _ TRAFFIC VIOLATIONS List all traffic citations violations, excluding parking citations you have received within the past ten (10) years. If more space is needed use page 17 for additional information. Nature of Violation. Date Jurisdiction where charges were placed (County and State) Disposition Nature of Violation. Date Jurisdiction where charges were placed (County and State) Disposition Nature of Violation. Date Jurisdiction where charges were placed (County and State) Disposition Nature of Violation. Date Jurisdiction where charges were placed (County and State) Disposition 14

20 TRAFFIC ACCIDENTS List all traffic accidents you have been involved in. If more space is needed use page 16 for additional information. Date of Accident Was personal injury involved? Yes No Jurisdiction where accident occurred (County and State) Were you found to be at fault? Yes No Were you issued citations? Yes No If yes list all charges Disposition Date of Accident Was personal injury involved? Yes No Jurisdiction where accident occurred (County and State) Were you found to be at fault? Yes No Were you issued citations? Yes No If yes list all charges Disposition Date of Accident Was personal injury involved? Yes No Jurisdiction where accident occurred (County and State) Were you found to be at fault? Yes No Were you issued citations? Yes No If yes list all charges Disposition Date of Accident Was personal injury involved? Yes No Jurisdiction where accident occurred (County and State) Were you found to be at fault? Yes No Were you issued citations? Yes No If yes list all charges Disposition 15

21 OTHER TOPICS 30. Have you at any time, used an alias or another name? Yes No 31. Are you now, or have you ever been a member or associate of a criminal enterprise, street gang or any other group that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality, gender, sexual preference or disability? Yes No 32. Do you have or have you ever had a tattoo signifying membership in or affiliation with a criminal enterprise, street gang or any other group that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality, gender, sexual preference or disability? Yes No 33. Have you ever been involved in an anger provoked physical fight, confrontation or other violent act? Yes No 34. Have you ever hit or physically overpowered a spouse or romantic partner? Yes No If you answered yes to any of questions 30-34, explain giving details including dates and circumstances; indicate corresponding number. If more space is needed use page 17 for additional information. CERTIFICATION I hereby certify that I have personally completed and initialed each page of this form and any supplemental page(s) attached and that all statements made are true and complete to the best of my knowledge and belief. I understand that any misstatement of material fact may subject me to disqualification; or, if I have been employed, may disqualify me from continued employment. Signature in full Date 16

22 Use this space to provide information that does not fit elsewhere on this form. Identify the page number and corresponding item being referenced. 17

23 CITY OF BERRY HILL POLICE DEPARTMENT 698 Thompson Lane Nashville, TN AUTHORITY FOR RELEASE OF INFORMATION AND BACKGROUND INVESTIGATION Last Name First Name Middle Name Sex Race Date of Birth (Month/Day/ Year) Place of Birth (City/County/State/Country) I,, do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning myself, by and to ANY duly authorized agent of the City of Berry Hill Police Department, whether the said records are of public, private or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; financial or credit institutions, including records of deposits, withdrawals and balances of checking and savings accounts, and loans, and also the records of commercial or retail credit agencies (including credit reports and/or ratings); public utility companies; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me, and salary records; real and personal property tax statements and records, and other financial statements and records wherever filed; records of complaint, arrest, trial and/or convictions for alleged or actual violations of law, including criminal, civil and/or traffic records; the results of any polygraph examinations; records of complaint of a civil nature made by or against me, wheresoever located, and to include the records and recollections of attorneys at law, or of other counsel, whether representing me or another person in any case in which I presently have or have had an interest. I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the City of Berry Hill Police Department to consider in determining my suitability for employment by that department. It is my specific intent to provide access to personal information, however personal or confidential it may appear to be, and the sources of information specifically identified herein. I understand that any information obtained by a personal history background investigation that is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the City Of Berry Hill Police Department. I understand that all materials pertaining to this background investigation become the property of the City of Berry Hill Police Department and will not be returned to me. Initial this page 18

24 I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney s fees, arising out of or by reason of complying with this request. I further understand that in the event my application is disapproved, the sources of confidential information cannot be revealed to me. A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature. MUST BE SIGNED IN THE PRESENCE OF A NOTARY: Signature of applicant Street address of applicant City, State and Zip Code of Applicant NOTARY PUBLIC FOR COUNTY STATE Subscribed and sworn before me this day of,. My Commission expires. Notary Signature: 19