Officer Paul Myers paul.myers@cityofrockhill.com
City of Rock Hill P.O. Box 11706 Rock Hill, SC 29731-1706 (803) 329-5570 Application For Employment - OFFICE USE ONLY- Your interest in employment with the City of Rock Hill is appreciated, and you will be contacted by phone or mail should an interview be desired. This application will remain active for six (6) months. Please type or complete in black ink only. Today s Date NAME HOME PHONE WORK PHONE (Last) (First) (Middle) ADDRESS CITY STATE ZIP CODE SOCIAL SECURITY # DRIVER S LICENSE # STATE & EXPIR. DATE COMMERCIAL DRIVER S LICENSE # CLASS Are you a citizen of the United States? Yes No Are you an alien lawfully authorized to work in the United States? Yes No LIST POSITION & SALARY DESIRED (1) (2) (3) (4) (5) EDUCATION--What specific academic, vocational, technical, or professional education have you had that relates to this job? Circle last grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 / GED / College 13 14 15 16 / Graduate School 17 18 19 NAME & LOCATION OF SCHOOLS DATES ATTENDED GRADUATE DEGREE MAJOR YES NO YES NO YES NO YES NO Office Skills/Equipment: Equipment You Can Operate: (Examples: Switchboard, 10 Key) Trucks/Dump Trucks: Yes No Backhoes: Yes No Motor Graders: Yes No Other: Computer Skills: List Software Used (Examples: WordPerfect, Professional Registrations/Licenses/Certifications: (Examples: Lotus 1-2-3, D-Base, Powerpoint) CPA, EMT, PE, Water or Wastewater Certificate) Other Training (Include Military): Have you worked for the City of Rock Hill before? Yes No If yes, what department and when?
EMPLOYMENT HISTORY: List below your experience record. Please include part-time and temporary employment, as well as job-related military service. Start with your present or most recent job. Account for any gaps in your employment history. List any self-employment. Under specific duties, describe the kind of work you did, machines or equipment operated, and the number and title of employees you supervised, if any. Attach additional sheets if necessary. Last or Current Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties Starting Salary Last Salary Supervisor s Name Reason for Leaving May we contact this employer? Yes No Job Held Before Last or Current Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties Starting Salary Last Salary Supervisor s Name Reason for Leaving May we contact this employer? Yes No Next Most Recent Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties Starting Salary Last Salary Supervisor s Name Reason for Leaving May we contact this employer? Yes No Next Most Recent Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties Starting Salary Last Salary Supervisor s Name Reason for Leaving May we contact this employer? Yes No Next Most Recent Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties May we contact this employer? Yes No Starting Salary Last Salary Supervisor s Name Reason for Leaving
Next Most Recent Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties Starting Salary Last Salary Supervisor s Name Reason for Leaving May we contact this employer? Yes No Next Most Recent Job: Company Name From: Month Year Company Address To: Month Year City and State Were You Full-Time Or Part-Time Your Title Specific Duties May we contact this employer? Yes No Starting Salary Last Salary Supervisor s Name Reason for Leaving References: List name, occupation, and phone number of three references (not related to you). List any relatives presently working for the City of Rock Hill (give name, department, and relationship to you). Check Boxes as Applicable: I hereby certify that all statements made herein and/or attached hereto are true to the best of my knowledge, and I understand that, if employed, any falsehood or misrepresentation is cause for separation from service with the City of Rock Hill. I authorize the release of such information as my work, school, police, medical, personal, and mental records, and other information as needed to determine my qualifications and fitness for the position I am seeking with the City of Rock Hill. I hereby release former employers and reference sources from all liability for divulging such information. I agree to submit to a pre-employment drug testing and a follow-up drug testing during my six (6) month probation period. I understand that testing positive for use of an illegal drug, abuse of a legal drug, use of an unprescribed legal drug, refusal to take the test, or failure to keep the scheduled appointment for the test will generally result in denial of employment with the City of Rock Hill. APPLICANT S SIGNATURE DATE This application is not, and is not intended to be, a contract of employment. (Continued on Next Page)
APPLICANT DATA RECORD Qualified applicants are considered for all positions and are treated without discrimination as to race, color, religion, sex, national origin, age, marital status, medical condition, or disability. The information requested below is needed for state and federal reporting and internal personnel research. This information will be kept in a confidential file within the Human Resources Department. DATE OF BIRTH SEX: Male Female (Month) (Day) (Year) ETHNIC BACKGROUND (Check One) American Indian/Alaskan Native Asian American/Pacific Islander Black Hispanic Caucasian/White Other How were you referred to the City of Rock Hill? Check which one(s) apply. City Jobline Professional Journal College Placement Other Walk-In Friend or Relative Internet City Employee Newspaper Ad Agency In cooperation with the Family Independence Act of 1995, we are actively recruiting Family Independence, Welfare, and food stamp recipients. If you are eligible, you may also qualify for special job training. Are you currently receiving AFDC or food stamps? Yes No An Equal Opportunity Employer M-F-D-V Please contact Phyllis Fauntleroy at (803) 329-5571 to give advance notice if you need a reasonable accommodation.
PERSONAL HISTORY STATEMENT Part I INS TRUCTIONS: Using a typewriter or legibly printing in black ink, fill out this form completely and accurately. If you need extra space, add additional pages and identify the information by item number. If an item does not apply to you, indicate by entering N/A in the blank. NOTE: All statements are subject to verification and any incorrect statements or omissions may bar or remove you from consideration. Truthful statements to any item requested will not necessarily exclude you from consideration. THIS FORM MUS T BE NOTARIZED UPON COMPLETION. PERS ONAL: 1. Name (Last) (First) (Middle) (Maiden Name) 2. Social Security Number / / 3. Present Address Permanent Address Number & Street City State Zip Number & Street City State Zip Home Phone # Work Phone # Cell Phone # 4. Date of Birth 5. Place of Birth 6. Citizenship: U.S. Born U.S. Naturalized Other 7. Have you previously submitted an application for employment with this agency? Yes Approximate Date: No Page 1
EDUCATION: 8. List all high schools attended. Attach transcript from last high school attended (if within five years of application date). NAME & LOCATION OF HIGH SCHOOLS DATES YEARS COMPLETED GRADUATED YES or NO 9. Higher education. List information for all colleges or universities attended. Attach transcript from last institution of higher education attended. NAME & LOCATION OF COLLEGE/UNIVERSITY DATES ATTENDED MAJOR & MINOR DEGREE YEAR RECEIVED 10. Other schools or training (trade, vocational, business, military). For each give the name and location of school, dates attended, subjects studied, certificates, and any other pertinent data. S PECIAL QUALIFICATIONS AND S KILLS: 11. Indicate type of special license, such as pilot, radio op erator, etc., showing licensing authority, where the license was first issued, and the date your current license expires (except vehicle operator's license). 12. Special skills you possess; machines and equip ment you can use. Example: data entry, computer, scientific or professional devices, short wave radio, etc. Typing (wpm) Page 2
13. M emberships in professional associations/organizations. 14. List any foreign language that you speak, write, or read fluently. Indicate also if you can use American sign language. LANGUAGE SPEAK WRITE READ FAMILY HIS TORY: 15. Are you related by blood or marriage to any person(s) now employed by the Rock Hill Police Department? If yes, give name(s) and details: 16. Is any member(s) of your immediate family now in prison or on probation or parole? If yes, give name(s) and details: Page 3
RES IDENCES: 17. List all of your addresses beginning with your present address: FROM DATE TO DATE ADDRESS OF RESIDENCE CITY/STATE LANDLORD Attach additional sheets for additional residences. 18. Have you ever been sued with a civil judgement being rendered against you? If yes, give details: Page 4
WORK HIS TORY: 19. Have you ever applied with another law enforcement agency? If yes, complete the following: Agency Name Position Date of Application 20. Have you ever been denied employment by a criminal justice agency? If yes, list agency name and give details: 21. Are you willing and able to wear a uniform? 22. Are you willing and able to work nights and holidays? 23. Are you willing and able to work rotating shifts? 24. Occasionally you may be asked to be away from home overnight and for other periods of time attending meetings, acquiring training, and otherwise performing official duties. Would you be able to fulfill these obligations? 25. If you have ever been dis charged or requested to resign from any position because of criminal or personal misconduct, or rules violations, give details. Page 5
VOLUNTEER S ERVICE: 26. In the past ten (10) years, have you served as a volunteer in any capacity? If yes, complete the following: Agency/Organization Address Telephone # S upervisor/ Coworker Dates of Service MILITARY S ERVICE: 27. Were you ever in the U.S. Military Service or any other military organization? QUESTIONS 28 THROUGH 38 APPLY ONLY TO VETERANS: 28. What is your service number? 29. What was the highest rank you held? 30. What was the date and location of your first entrance into active duty? Date: Location: 31. What were your unit assignments in the service? Branch Unit Location From: Mo/Yr To: Mo/Yr Page 6
32. What was the date and location of your last discharge from active duty? Date: Location: 33. Was your discharge: Honorable General Dishonorable Bad Conduct 34. Were you ever court-martialed, tried on charges, the subject of a summary court, deck court, captain's mast or company punishment, or any other disciplinary action while a member of the armed forces? If yes, explain: 35. List any disciplinary action taken against you in the National Guard or other reserve unit. 36. List all medals and decorations awarded to you during your military service. 37. If you are presently a member of the National Guard or any other military reserve, give the unit and location, and describe your obligation. 38. Attach DD-Form 214 (for ex-military personnel). Page 7
CRIMINAL OFFENS E RECORD AND DIS CIPLINARY ACTIONS: NOTE: Include all offenses other than minor traffic offenses. The following are not minor traffic offenses and must be listed below: DWI/DUI (alcohol or drugs), failure to stop in the event of an accident, driving with a revoked or suspended license. Answer all of the following questions completely and accurately. Any falsification or misstatement of fact may be sufficient to disqualify you. If any doubt exists in your mind as to whether or not you were arrested or charged with a criminal offense at some point in your life or whether an offense remains on your record, you should answer "yes." You should answer "no" only if you have never been arrested or charged, or your record was expunged by a judge's court order. 39. Have you ever been arrested by a law enforcement officer or otherwise charged w it h a criminal offense? If YES, give details below. (Attach extra pages if necessary.) OFFENSE CHARGED LAW ENFORCEMENT AGENCY DATE DISPOSITION OF CASE 40. Have you ever been charged with or convicted of a felony? If yes, give details. 41. Have you ever been charged with, or convicted of, the crime of domestic violence? If yes, give details. Page 8
42. Have you ever been involved in a physical confrontation/altercation with a close family member (i.e., current or former spouse, your child, brother, sister, parent or grandparent?) Yes No If yes, give details. 43. Have you ever been the subject of a restraining order? If yes, give details. 44. Have you ever been placed on probation? If yes, give details. 45. Have you ever been required to pay a fine in excess of $50.00 (this does not include court costs)? If yes, give details. 46. In the past ten (10) years, have you ever stolen from a person or business? If yes, give details. 47. In the past ten (10) years, have you ever embezzled from a person or business? If yes, give details. Page 9
48. Have you ever paid or received anything that could have the appearance of a bribe or inappropriate gratuity? (A bribe may be defined as accepting anything [e.g., money, drugs, merchandise, sex] in return for overlooking an actual or anticipated illegal act.) If yes, give details. 49. Have you committed any crimes that you were not charged with? If yes, give details. 50. Can you operate a motor vehicle? 51. Do you possess a valid driver's license from the State of South Carolina? Driver's License Number Year issued If CDL, which class? 52. Do you now possess a driver's license issued by any state(s) other than South Carolina? If yes, give state(s) and number(s). 53. Have you ever possessed a valid driver's license issued by any state or the military? If yes, give state(s) and number(s). 54. Was your license ever suspended or revoked? If yes, give state(s), date(s) and reason(s). Page 10
55. Was your license ever restored? If yes, date? 56. Have your driving privileges ever been restricted? If yes, give details. 57. Police Officer and Correctional Officer candidates only, supply a certified driving history report for each state in which you have held a driver's license during the past five (5) years. *F.Y.I. - You must possess a legally issued South Carolina drivers license to be enrolled and begin at the South Carolina Criminal Justice Academy. Page 11
REFERENCES: 58. Give the names of responsible persons other than relatives or past employers who will provide information about your character, ability, experience, personality, and other qualities. NAME ADDRESS HOW KNOWN DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT NAME ADDRESS HOW KNOWN DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT NAME ADDRESS HOW KNOWN DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT NAME ADDRESS HOW KNOWN DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT NAME ADDRESS HOW KNOWN DAY PHONE # NIGHT PHONE # BEST TIME TO CONTACT Page 12
To facilitate the background investigation of your application, please forward the following documents with your PERS ONAL HIS TORY S TATEMENT. Those marked * are required by S.C. State Law and Regulations for admittance to the South Carolina Criminal Justice Academy for training and certification. Birth Certificate * GED Certificate (if applicable) * High School Diploma * College Diploma College Transcripts (certified from school) Drivers License * (A South Carolina drivers license is required prior to admittance to the S outh Carolina Criminal Justice Academy.) Certified Ten (10)-Year Driver's History from Each State Where You Held a Driver's License * (Required for Police Officer and Correctional Officer candidates only.) Military Discharge Papers (DD-214) * Social Security Card * Any Certificates Received from Any Criminal Justice Academy or Law Enforcement Agency (and transcripts/course curricula if applicable) Any Certificates received relating to Telecommunications or Corrections training, etc. Rev. 05/05 Page 13
POLICE CANDIDATE ADDENDUM (To Be Competed by Police Officer Candidates Only) Complete form in your own handwriting Please describe how your skills and training would enhance the Police Department and its community policing program. Name: Date:
ROCK HILL POLICE DEPARTMENT 120 East Black Street Rock Hill, South Carolina 29730 Credit History Authorization I authorize the Rock Hill Police Department to obtain a report on my credit history in order to determine my suitability for employment. (Date) ( Signature) ( Name: Please Print) (Date) (W itness) For the purpose of obtaining the credit report, I provide the following information: ( Social Security Number) (Date of Birth) Current Address: Addendum to RHPD Personal History Statement Rev. 01/98
To Whom It May Concern: ROCK HILL POLICE DEPARTMENT BACKGROUND INVESTIGATION AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION I am an applicant for a position with the Rock Hill Police D ep art men t. In order to determine my suitability for employment, I understand that the Rock Hill Police Department of Rock H i l l, So u t h Carolina must make a thorough investigation of my personal records and personal background. It is in the public s interest that all relevant information concerning my personal and employment history be disclosed to the above agency. Therefore, I, DOB,, Operators License #, Social Security #, do hereby request and authorize any bank, credit union, lending or financial institution, credit bureau, consumer report agency, retail busines s e s tablishment, former and present employer, educational institution, doctor or other health care professional including mental health, alcohol treatment center, hospital or other repository of medical records, insurance company, governmental agency, criminal and civi l courts, certification/licensing commission, military organization, and any other individual agency to produce and provide copies of any a n d a l l information (including, but not limited to, performance evaluations, disciplinary actions, counseling, any information contai n e d in a law enforcement agency s internal affairs file or files, and any other information contained in my pers o n n el fi l es ) to the authorized agent of the Rock Hill Police Department of Rock Hill, South Carolina regarding me whether of a privileged or c o nfidential nature. Moreover, I h ereb y rel eas e the Rock Hill Police Department of Rock Hill, South Carolina from any civil or criminal liability whatsoever fo r seeking such requested information and for evaluating such information as it relates to my employment with the City of Rock Hil l. A n d, I hereby release the issuing agency and its agents and employees both individually and collectively, from any an d al l l i ab i l i t y for damages of whatever kind, which may at any time result because of compliance with the authorization and request. I further waive all right to inspect or review any information compiled i n referen ce to my application for employment as allowed by law. I do further authorize the Rock Hill Police Department, its agents and employees, to release copies of any and all information and other information contained in my personnel files to any agency or entity regulating the certification authority or conduct of law enforcement officers. I hereby acknowledge that this authorization is valid for one (1) year or until the employment application or investigative process has been completed, whichever is later. A copy of this document is considered valid, just as the original. I have read and fully understand the above statements. Applicant Signature Printed Name Address State of,, County Phone Number ( ) City,, State On this, day of, 20. whose name signed to the foregoing instrument, personally appeared before me, acknowledge the forgoing signature t o b e h i s, and having been duly sworn by me, made oath that the statements made on the said instrument are true. My commission expires:, Notary Public Addendum to RHPD Personal History Statement Rev. 04-04