9-1-1 TELECOMMUNICATION EMPLOYMENT APPLICATION

Transcription

1 JOHN DAY POLICE DEPARTMENT 911 CENTER Chief Richard Gray 24 Hour Dispatch 450 E Main St Phone (541) John Day, OR Fax (541) TELECOMMUNICATION EMPLOYMENT APPLICATION TO BE RETURNED TO THE JOHN DAY POLICE DEPARTMENT BY MAIL OR IN PERSON

2 APPLICATION FOR EMPLOYMENT (please type or print) Date: Name: l l Last First Middle Date of Birth: Sex: Address: City: State: Zip Code: Telephone: Cell: Work: List any other names which you have used or by which you may have been known. Explain fully why it was used, where and when. Include nicknames, aliases and maiden name CITIZENSHIP Are you a U.S Citizen? Yes No Naturalized? Yes No If naturalized, give date, place and court of naturalization Place of Birth: Height: Weight: Eye Color Hair Color Distinguishing marks or other features:

3 Drivers License Are you licensed to operate a motor vehicle? Yes No Has your driver s license ever been suspended or revoked? Yes No If yes, explain fully: List any other states and dates which you have been licensed to operate a motor vehicle. TRAFFIC RECORD List all traffic citations you have received: Date Place Agency Charge Final Disposition MOTOR VEHICLE ACCIDENTS Have you ever bee involved in a motor vehicle accident? Yes No Date Police investigation Location Police Agency Yes No injury Non Injury Yes No injury Non Injury Yes No injury Non Injury Were you at fault in any of these accidents? Yes No If yes, please explain: If there is anything you wish to discuss about your driving record, please use the space below

4 MILITARY STATUS Have you served in the U.S. Armed Forces? Yes No (include active duty, US Reserve and National Guard) Branch of Service Component From Date To Date Type of Discharge & Service Number If yes, attach a copy of discharge or separation papers (DD214). While in the military service were you ever arrested for any offense, or a defendant in any trail, or did you receive any disciplinary action? Yes No If yes, give dates, place, law enforcing authority or type: or court martial, charge and action taken in each incident, on a supplemental sheet. If you are currently on active duty, or a member of the Reserves / National Guard, list your: Unit mailing address City State or Country Zip Unit Telephone Number Currant Duties Graded Rank Military Obligation remaining Salary (monthly) ARREST RECORD Have you ever been arrested? Yes No (if yes, please provide a complete explanation, include date, place, charge, final disposition, police agency and full details) Additional Comments:

5 EDUCATION (Attach all high school and college transcripts and diplomas) High School(s) attended: High School GPA: Year Graduated: Passed G.E.D. Test: Yes No If yes attach certificate Circle highest grade you completed: Name of school Address City State Zip Advanced Education: Account for all Civilian and Military school: (list most currant first) from date to date name of school address city state zip graduated major degree credits RESIDENCES List below all residences since the age of 17 or for the last ten years, whichever is longer. List present residence first. Include military duty stations.

6 RESIDENCE (CONT)

7 RELATIVES List below the full names of all parents, step parents, step brothers / sisters, in-laws, spouse and children. If deceased, indicate with an asterisk (*) and provide the date of death. Father DOB Home phone Address, city, state, zip Fathers employer and occupation business phone address ========================= Mothers DOB Home phone Address, city, state, zip Mothers employer and occupation business phone address ========================== Step Father / Mother DOB Home phone Address, city, state, zip Step Fathers/ Mother employer and occupation business phone address ===========================

8 Father in Law Date of Birth Home Phone Address, City, State, Zip Mother in Law Date of Birth Home Phone Address, City, State, Zip Brother / Sister In Law Date of Birth Home Phone Address, City, State, Zip Brother / Sister In Law Date of Birth Home Phone Address, City, State, Zip Brother / Sister In Law Date of Birth Home Phone Address, City, State, Zip Brother / Sister In Law Date of Birth Home Phone Address, City, State, Zip Brother / Sister In Law Date of Birth Home Phone Address, City, State, Zip Marital Status Married Divorced Separated Widowed Single Current Spouse Date of Birth Home Phone Address, City, State, Zip Date Married Where performed Spouse s Employer & Occupation Business Phone Business Address / City, State, Zip Spouse s Maiden Name Social Security Number Driver s License Number Issuing State Child Date of Birth Home Phone Home Address, City, State, Zip Child Date of Birth Home Phone Home Address, City, State, Zip

9 Child Date of Birth Home Phone Home Address, City, State, Zip Child Date of Birth Home Phone Home Address, City, State, Zip Ex Spouse Current Address Date Divorced Where Issued Ex Spouse Current Address Date Divorced Where Issued Are you required to pay child support? Yes No If yes, list the monthly payment $ Has any member of your family, including in-laws or anyone else you are closely associated with, or people with whom you have lived, been arrested for anything other than traffic violations in the last five years? Yes No Date Name / Relationship Birth Date Place / Police Agency Charge Final Disposition

10 References List five (5) persons not related by blood or marriage. Do not list employers, co-workers or supervisors. List residents of Oregon if you are residing in Oregon or recently moved from Oregon. List individuals who have known you for at least three (3) years. Complete Name of Reference Years Known Place of Employment Street Address City State Zip Home Phone Employment Address City State Zip Home Phone Complete Name of Reference Years Known Place of Employment Street Address City State Zip Home Phone Employment Address City State Zip Home Phone Complete Name of Reference Years Known Place of Employment Street Address City State Zip Home Phone Employment Address City State Zip Home Phone Complete Name of Reference Years Known Place of Employment Street Address City State Zip Home Phone Employment Address City State Zip Home Phone Complete Name of Reference Years Known Place of Employment Street Address City State Zip Home Phone Employment Address City State Zip Home Phone

11 EMPLOYMENT Please list below every period of employment and employer since age 17 or for the last ten years, whichever is longer. Begin with present employment, include part time and volunteer jobs. If you have any periods of military service or unemployment, list those periods in sequence in the spaces provided. Attach additional sheets of paper if needed. From Date Name of Employer Name of Supervisor To Date Address Name(s) of Co-worker(s) Full Time City, State, Zip Phone Monthly Salary Part Time Job Title and Duties List any disciplinary action taken against you Reason for Leaving Do you want your present employer contacted? Yes No (Contact must be made prior to final acceptance for employment) If no, state reason: From Date Name of Employer Name of Supervisor To Date Address Name(s) of Co-worker(s) Full Time City, State, Zip Phone Monthly Salary Part Time Job Title and Duties List any disciplinary action taken against you Reason for Leaving Do you want your present employer contacted? Yes No (Contact must be made prior to final acceptance for employment) If no, state reason: ==

12 From Date Name of Employer Name of Supervisor To Date Address Name(s) of Co-worker(s) Full Time City, State, Zip Phone Monthly Salary Part Time Job Title and Duties List any disciplinary action taken against you Reason for Leaving Do you want your present employer contacted? Yes No (Contact must be made prior to final acceptance for employment) If no, state reason: == From Date Name of Employer Name of Supervisor To Date Address Name(s) of Co-worker(s) Full Time City, State, Zip Phone Monthly Salary Part Time Job Title and Duties List any disciplinary action taken against you Reason for Leaving Do you want your present employer contacted? Yes No (Contact must be made prior to final acceptance for employment) If no, state reason: ==

13 From Date Name of Employer Name of Supervisor To Date Address Name(s) of Co-worker(s) Full Time City, State, Zip Phone Monthly Salary Part Time Job Title and Duties List any disciplinary action taken against you Reason for Leaving Do you want your present employer contacted? Yes No (Contact must be made prior to final acceptance for employment) If no, state reason: == From Date Name of Employer Name of Supervisor To Date Address Name(s) of Co-worker(s) Full Time City, State, Zip Phone Monthly Salary Part Time Job Title and Duties List any disciplinary action taken against you Reason for Leaving Do you want your present employer contacted? Yes No (Contact must be made prior to final acceptance for employment) If no, state reason: ==

14 PERSONAL HISTORY If any of these questions are answered yes, provide an explanation in the comments section. List the dates, circumstances and frequency. (Attach an additional sheet to the back of the form in needed) Have you ever? 1. Used an illegal drug? (i.e. marijuana, cocaine, etc) Yes No 2. Used a controlled substance other than those prescribed by a doctor? Yes No 3. Been discharged from any position for failing a probationary period? Yes No 4. Resigned to avoid discharge or while under suspension or while dismissal proceedings were pending? Yes No 5. Resigned under pressure or unfavorable circumstances? Yes No 6. Sued anyone or been sued by anyone? Yes No 7. Applied for employment with any criminal justice agency? Yes No 8. Had any licenses or permits issued to you? Yes No 9. Been refused a license or permit? Yes No 10. Been bonded? Yes No 11. Been refused a bond by a bonding company? Yes No 12. Applied for a permit to carry a concealed weapon? Yes No If yes, was permit granted? Yes No Name of Police Agency Reason for Permit 13. Are there any current or pending civil actions against you? Yes No 14.To your knowledge, have you ever been the subject of any criminal or civil rights investigation? Yes No 15. Have you ever been denied employment by any other criminal justice system agency? Yes No Comments:

15 SUMMARY Summarize experience, training, knowledge, skills and abilities which, in your opinion, establish your fitness for service as a Dispatcher and Records Clerk. Include experience in criminal justice agencies, awards and community service.

16 APPLICANT S CERTIFICATION AND RELEASE A. I hereby certify that all statements made in this application or appended to it are true and correct to the best of my knowledge. I am aware that withholding pertinent information or information found to be materially (grossly) inaccurate will be cause for refusing further consideration of my application or will constitute grounds for my termination if I am employed. I understand that the acceptance by the John Day Center of this application for employment is a part of the selection process only. No guarantee of employment is promised or implied. I understand that failure on my part to notify the John Day Center of a change of address within thirty (30) days may subject my file to being closed. B. Authority to Release Credit, Character and Personal History Information: Having made my application with the John Day Center, I hereby authorize a complete investigation of my record, including personal history, academic record, job performance and criminal arrest and conviction by the John Day Center, John Day City Police or another police agency authorized to conduct their Applicant Investigation. To ascertain any and all information which may concern my credit and character, whether the same is of record or not, I release your organization and all persons whomsoever from any charges arising from their furnishing of said information. I hereby acknowledge that I am aware that the results of this investigation are confidential, for John Day Center use only and will not be disclosed to myself or any other person without proper authorization. C. School Information Authorization: This is to authorize the release to the John Day Center, John Day Police or another police agency authorized to conduct their Applicant Investigation, information regarding my school records and transcripts. Name (Print or Type) Signature Subscribed and sworn to before me, this day of, 20. Notary Public for Oregon My Commission expires The City of John Day, John Day Center and John Day Police Department are Equal Opportunity Employers.