Town of Marana Police Department

Transcription

1 Town of Marana - Police Department VOLUNTEER APPLICATION Location & Mailing Info: Integrity Duty Town of Marana Police Department Ethical Attn: Volunteer Program Coordinator Attitude W. Civic Center Drive Building B Leadership Marana, Arizona Service Phone: (520) All requested information must be furnished. The information you provide will determine whether you are eligible for the position. All information contained on this volunteer application is subject to verification. Any omission, misstatement or falsification may be cause for rejection of this volunteer application. Date of Birth and Social Security Number are required for Criminal History Check. GENERAL INFORMATION (Please type or print legibly with ink) Name: (Last) (First) (Middle Initial) Address: (Street) (City/State) (Zip) Age: Date of Birth: Place of Birth: Social Security Number: Phone: (Home) (Work-Optional) (Cell/Message) Address: ( Please indicate best contact number) Which of the following apply to you? Unemployed Employed Retired Student full time/part time Part Time/ per week House Hold Manager AVAILABILITY How many hours per week would you like to volunteer? What type of volunteer work do you desire? What days and hours are you available to volunteer? Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Date Received / / 1

2 EDUCATIONAL BACKGROUND Name of School and Location Course of Study Years Completed Diploma Degree High School Undergraduate College Graduate Professional Other (specify) U.S. MILITARY EXPERIENCE From To Branch Final Rank Occupational Specialization Describe any job-related training received in the United States military. LICENSES-CERTIFICATIONS-SPECIAL SKILLS Do you have a valid Driver s license? Yes No List any CDL endorsements: Professional Certifications, Licenses or Memberships: License Number & State: CDL Classification: Yes No Language Proficiency (Any Language other than English) Language: Speak: Read: Write: Yes No Yes No Yes No List any specialized training you have that may be beneficial in your volunteer position (include number of hours and course content): List any computer software training you have received: List any equipment that you are to operate that relates to this position: 2

3 EMPLOYMENT HISTORY Begin with your present or most recent position. List all jobs held over the last ten years. Your qualifications will be evaluated on the basis of the information provided on this application. You may attach a separate sheet if additional space is needed, or to include applicable experience prior to ten years ago. EMPLOYER NAME/ADDRESS List all Positions Held Dates May we contact your employer? EMPLOYER NAME/ADDRESS List all Positions Held Dates May we contact your employer? EMPLOYER NAME/ADDRESS List all Positions Held Dates May we contact your employer? 3

4 EMPLOYER NAME/ADDRESS List all Positions Held Dates May we contact your employer? VOLUNTEER EXPERIENCE VOLUNTEER AGENCY/ADDRESS List all Positions Held Special Skills Dates May we contact your agency? VOLUNTEER AGENCY/ADDRESS List all Positions Held Special Skills Dates May we contact your agency? 4

5 REFERENCES List three (3) references (not relatives, former employers, or neighbors) who are responsible adults, and who have known you well for at least the last five years. Name Street Address How Long known? Occupation City State Zip Home Phone Business Phone Name Street Address How Long known? Occupation City State Zip Home Phone Business Phone Name Street Address How Long known? Occupation City State Zip Home Phone Business Phone ARREST HISTORY The following questions pertain to your experiences in this country and all other countries as both a juvenile and an adult. Do include minor traffic violations. Explain all yes answers in detail on the back page. A. Have you ever had any contact with any Law Enforcement Official? Yes No B. Have you ever been warned about anything by a Law Enforcement Official? Yes No C. Have you ever been detained by a Law Enforcement Official? Yes No D. Have you ever been accused of a crime? Yes No E. Have you ever been charged with a crime? Yes No F. Have you ever been arrested? Yes No G. Have you ever been convicted of a crime? Yes No H. Have you ever been booked into jail? Yes No I. Have you ever received a criminal citation? Yes No J. Have any relatives of you or your spouse ever been convicted or held in any detention facility, jail, or prison? Yes No K. Have the police ever been called to your home for any reason? Yes No If you have answered yes to any of the above questions, list the incident below and make certain you have explained it on the back page. All incidents must be explained in detail. Section #(A-K) Date Reason/Charge Law Enforcement Agency- City/State Disposition/Sentence 5

6 GAMBLING A. DO YOU NOW, OR HAVE YOU EVER HAD ANY GAMBLING DEBTS? YES NO B. HAVE YOU EVER USED AN EMPLOYER S MONEY TO GAMBLE WITH? YES NO LIQUOR AND NARCOTICS A. DO YOU DRINK ALCOHOLIC BEVERAGES? YES NO B. HAVE YOU EVER HAD DIFFICULTY WITH YOUR FAMILY DUE TO DRINKING YES NO, IF YES EXPLAIN BELOW. C. HAVE YOU EVER TRIED OR USED ANY NARCOTIC OR DANGEROUS DRUG WITHOUT A DOCTOR S PRESCRIPTION? YES NO, IF YES EXPLAIN BELOW. D. IF YOU HAVE EVER TRIED, USED OR INGESTED ANY NARCOTIC OR DANGEROUS DRUG LISTED BELOW, CHECK THE YES BOX. IF YOU HAVE NOT, CHECK THE NO BOX. INCLUDE THE NUMBER OF TIMES USED AND DATES. DRUG NAME YES NO TOTAL # TIMES USED MARIJUANA (OTHER THAN PRESCRIBED BY A PHSICIAN AS DEFINNED IN ARS ) TOTAL # TIMES USED SINCE 21 ST BDAY DATES (MO/YR) DRUG NAME YES NO TOTAL # TIMES USED TOTAL # TIMES USED SINCE 21 ST BDAY ( ) ( ) COCAINE ( ) ( ) DATES (MO/YR) INHALENTS ( ) ( ) HEROIN ( ) ( ) THAI STICKS ( ) ( ) OPIUM ( ) ( ) BARBBITUATES ( ) ( ) AMPHETAMINES (SPEED,ETC.) ( ) ( ) HASHIS ( ) ( ) INJECTABLE STEROIDS HALLUCINOGENIC SUBSTANCES (LSD, PCP, MESCALINE, MUSHROOM, ETC.) ( ) ( ) ( ) ( ) IF YOU HAVE TRIED OR USE ANY OF THE DRUGS LUSTED ABOVE OR IF YOUR HAVE TRIED OR USED ANY OTHER DRUGS WITHOUT A DOCTOR S PRESCRIPTION, EXPLAIN IN DETAIN BELOW. IF MORE SPACE IS NEEDED, USE THE BACK PAGE. YOU MUST INCLUDE DATES AND NUMBER OF TIMES USED.. 6

7 DRIVING HISTORY A. Have you ever had a Driver s License cancelled, refused, revoked or suspended? Yes No If Yes, explain in detail on the back page the reason for this action. List Dates B. Have you ever had your driving privileges suspended? Yes No If yes, explain in detail on back page. C. Have you ever attended a driver improvement school? Yes No When? Where? D. Have you ever been charged with driving under the influence of alcohol or drugs? Yes No E. Have you ever been involved with aggravated, aggressive or reckless driving? Yes No Hit & Run with injuries? Yes No If Yes, explain on back page. List each and every traffic citation and summons you have received within the last ten years, list in chronological order beginning with the most recent. If you need more space, use the back page. Month/Year Charge City or State Disposition/Result READ THIS APPLICATION AND VERIFY YOUR ANSWERS BEFORE SIGNING BELOW I certify that this application contains no misrepresentations or falsifications, omissions, or concealment of material fact, and that all information given by me is true and complete to the best of my knowledge and belief. I am aware that statements made by me on this application are subject to later investigation. I understand that any false or misleading information given in my application or interview may result in forfeiture of eligibility to participate in the Volunteer in Police Service program. I authorize the Town of Marana Police Department to thoroughly investigate all aspects of my personal background, qualifications, employers and references. I authorize any individual, company, organization, or institution to release all information concerning statements made by me on this application. I do hereby release all parties and individuals connected there with from all liabilities for any damages incurred in furnishing such information.. Signature of Applicant Date: 7

8 VOLUNTARY DISCLOSURE FORM It is the policy of the Town of Marana to provide equal employment opportunity to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, veteran s status or status within any other protected group. Various agencies of the United States government require employers to collect information about applicants. Information requested on this sheet is for purposes of compliance with these record-keeping requirements and to determine recruiting and employment patterns. Such information will in no way affect the decision regarding your application for employment. This information will be kept confidential and maintained separately from your application form. Completion of this sheet is voluntary and is not a requirement for employment. PLEASE TYPE OR PRINT IN INK Last Name First Name Middle Name Social Security Number Date Position Applied For REFERRAL SOURCE POSITION APPLIED FOR (list only one) Walk In Full-Time Summer/Seasonal Newspaper Ad (please name) Part-Time Temporary Current Employee Relative RACE Town of Marana Web Site White/Caucasian Other Internet Site (please describe) Black/African American Town of Marana Job Line Hispanic Temporary Agency Asian or Pacific Islander State Employment Office Native American or Alaska Native Private Employment Agency Other (please specify) Contacted After Submitting Town of Marana Interest Form Previous Employee SEX High School Referral Male Other (please describe) Female Regulations issued by the U.S. Department of Labor with respect to handicapped, disabled veterans and Vietnam Era Veterans require that federal contractors provide a self-identification opportunity to applicants for employment. Such self-identification and any information provided by the applicant are submitted on a confidential basis and for use only in accordance with information you wish to submit. If an applicant or employee so identifies him/herself, the Town of Marana shall seek the advice of the applicant or employee regarding proper placement and appropriate accommodation. ARE YOU HANDICAPPED? No Yes (Have a physical or mental impairment which substantially limits a major activity or have a history of such impairment.) ARE YOU A DISABLED VETERAN? No Yes (Entitled to disability compensation under law administered by Veteran s Administration for disability rated 30% or more OR discharged/released from active duty for disability incurred or aggravated in the line of duty.) ARE YOU A VIETNAM ERA VETERAN? No Yes (Served on active duty for a period of more than 180 days, any part of which occurred between 8/5/64 and 5/7/75 and was discharged/released with other than dishonorable discharge or for a service connected disability.) ARE YOU A SPECIAL DISABLED VETERAN? No Yes (Discharged/released from active duty because of service connected disability OR entitled to disability compensation [or who, but for receipt of military retired pay, would be entitled to disability compensation] for a disability rated at 30% or more or rated at 10% or 20% and under 38 USC 1506 has been determined to have a serious employment handicap.) 8