KenCom Public Safety Dispatch 1100 Cornell Lane, Yorkville, Illinois Phone (630)

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1 KenCom Public Safety Dispatch 1100 Cornell Lane, Yorkville, Illinois Phone (630) Instructions: Fill out this application completely and accurately. All statements in your application are subject to verification. An incorrect statement(s) will remove you from the hiring process. You must personally prepare this application. If additional writing space is required, use the continuation sheet at the end of this application and identify the additional information by question number. Use the term DNA (does not apply) if the question does not apply. Date: Position applied for: Full Time Part Time Either How did you learn about the position? 1. Name: (Last) (First) (Middle) 2. List any other surnames or aliases you have used or been known by (include maiden name, if applicable). 3. Home address (address number, apt., street, city, state, zip code and county). 4. Home telephone number: 5. Cellular telephone number: 6. address: 7. Social Security Number: 8. Date of Birth: 9. Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No 10. Have you ever been employed with us before? Yes No 11. Are you willing to take a drug test? Yes No

2 Education 12. Provide the information requested regarding your educational background. Name of School Attended (including and State) (a) High Schools No. of Years Completed Date(s) Attended Field of Study Degree Earned Average Grade (b) Junior College(s) (c) College(s) or University(s) (d) Vocational School (s) 13. List any other formal education beyond high school you may have, including special training courses: 14. List any professional licenses, certificates or certifications you hold or have held.

3 Military Service 15. Are you a veteran of the U.S. Military? Yes No If yes, what Branch? What type of discharge did you receive? Honorable Dishonorable Honorable Conditions Criminal History 16. Driver s License Number: State: Class: Expiration Date: Has your license ever been suspended or revoked? Yes No If yes, please explain: 17. Have you ever been convicted of a crime? Yes No If Yes, explain: (Conviction will not necessarily disqualify applicant from employment) Date Age at time of offense Police Agency Crime Charged Disposition 18. Have you ever been fingerprinted by a police agency other than for an arrest? Yes No If Yes, explain. Date Agency Purpose

4 Residences 19. List your addresses for the last ten years beginning with the most current. From Date To Date and State Employment History 20. May we contact your present and previous employers? Yes No 21. Were you ever subjected to disciplinary action in connection with any employment? If Yes, explain. Yes No 22. Were you ever discharged or forced to resign because of misconduct or unsatisfactory service? If Yes, explain and include name(s) & addresses of employers. Yes No

5 23. List all jobs you have held, including periods of unemployment. List your present or most recent job first. Include Military Service in the proper time sequence and temporary or part-time jobs.

6 References 24. Provide the names of four adults who are not related to you, are not former employers and have known you for at least five years. All persons to whom you refer will be asked to appraise your character, ability, experience, personality and other qualities. Name Personal Phone # Occupation Business Phone # # of Years Known Name Personal Phone # Occupation Business Phone # # of Years Known Name Personal Phone # Occupation Business Phone # # of Years Known Name Personal Phone # Occupation Business Phone # # of Years Known

7 25. I hereby certify that there are no willful misrepresentations, omissions, or falsifications in this application and that all of my answers are true and correct to the best of my knowledge. I am aware that willfully withholding information or making false statements on this application or during the employment process may be considered sufficient cause for rejection or be the basis for dismissal from KenCom Public Safety Dispatch, no matter when discovered. I agree to these conditions and I hereby certify that all statements made by me on this application are true and complete, to the best of my knowledge. Signature in Full Date Print Name

8 Continuation of Answers Indicate in the left hand column the number of the question you are answering then complete your answer in the space provided. Question # Answer

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