POLICE OFFICER EMPLOYMENT APPLICATION PLATTEVILLE POLICE DEPARTMENT 165 N. Fourth Street Platteville, Wisconsin 53818 (608) 348-2313 IMPORTANT INSTRUCTIONS: This application must be completely filled out and clearly printed in black ink. Your answer to any particular question may not necessarily eliminate you from consideration. Failure to complete this form may result in disqualification of this application. If a question does not apply to you, write N/A in the space provided. The Platteville Police Department requests this information to complete the employment background verification. The information obtained is used exclusively for the purpose of employment consideration. Any falsification on this form will result in disqualification of your application or if discovered after employment may be grounds for discharge. Conviction of a crime, other than a felony, in and of itself is not an automatic bar to employment, but only in so far as it relates to fitness to perform a particular job. Age at time of the offense and rehabilitation will be taken into account when considering an applicant. The City of Platteville complies with the Americans with Disabilities Act and fully supports the concepts of Equal Employment Opportunity and Affirmative Action. Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should contact a representative of the Police Department. Today s Date: Position Desired: Legal Name: Last First Middle Social Security Number: Age if under 18 Resident Street Address AND Mailing Address if different: County of Residence: Are you a United States citizen? Yes No Home Phone: Work Phone: List all names other than your present legal name (including nicknames and aliases) by which you have been known at any time: How were you referred: Advertisement School Employee Other FOR OFFICE USE ONLY - Investigation Number: 1
RESIDENCY HISTORY List chronologically starting with the most recent address, all of your past residences during the past fifteen years. Include addresses while attending school if away from home and all military addresses. (Use additional sheets if necessary.) Date (Month/Year) From To Street Address (Apt. No.), City, State AND Zip Code If Rented, give name, address and phone of person responsible for the collection of rent Is there a location in which you spend a regular part of your free time? (Example parent s residence, friends residence or home town. Any location where you would be well known other than listed above?) Please tell us that area. Do you have any special skills, abilities, experiences, hobbies, etc. which may enhance your qualifications for the position? 2
EMPLOYMENT HISTORY LIST ALL EMPLOYERS BEGINNING WITH THE MOST RECENT AND WORK BACK. INCLUDE ALL PART-TIME EMPLOYERS. ACCOUNT FOR ALL TIME PERIODS. MAKE ADDITIONAL COPIES OF THIS PAGE IF NECESSARY. Employer Name and Address (If unemployed indicate dates) Date (Mo/Yr) Position Held (PH) Salary From Duties (D) To Reason for Leaving (RL) Begin End Supervisor Name and Telephone May we Contact (Y/N) PH: D: RL: PH: D: RL: PH: D: RL: PH: D: RL: PH: D: RL: Are you presently a permanent classified state civil service employee? No Yes If yes, complete the following: Class Title: Pay Range: Agency: Seniority Date: Were you ever subjected to disciplinary action in connection with any employment? No Yes If yes, give details: 3
PERSONAL INFORMATION Please list the required information for your father, mother, step parent, guardian, sister(s), and brother(s). Relationship Name Address Occupation Telephone REFERENCES Give three social acquaintances, not in law enforcement: Name AND Address (Area Code) Home Phone (Area Code) Work Phone Best Time to Contact List five law enforcement officers with whom you are acquainted, if any: Name Department Address (If Known) Telephone 4
List all professional or civic organizations that you are a member or have been a member of: From: Month/Yr. To: Month/Yr. Name Types Have you been the subject of a background investigation by a law enforcement agency which was If yes, complete the following: considering you for employment? No Yes Date Agency List all Law Enforcement intern programs you have been a part of (high school and college). Date School Department Involved Advisor and Telephone Number DRIVING HISTORY No Yes Do you have a valid Drivers License? Driver s License Number/State: No Yes Do you hold a valid Drivers License from other states than listed above? If yes, list the states: No Yes Have you ever had a Drivers License suspended, revoked or restricted: If yes, please explain: 5
USE OF ALCOHOL OR DRUGS No Yes Have you ever consumed alcohol while working? If yes, explain when, how often, and circumstances: No Yes Do you use non-prescriptive illegal drugs, such as opiates, LSD, cocaine, etc? When was the last time you used them? JUDICIAL ACTION Note: Conviction of a crime, other than a felony, in and of itself is not an automatic bar to employment, but only in so far as it relates to fitness to perform a particular job. Age at time of the offense and rehabilitation will be taken into account when considering an applicant. No Yes Have you ever been charged or convicted of ANY law violation including traffic law, other than parking tickets? If yes, complete the following: Date (Mo/Day/yr Location Charge/Violation Final Disposition Comments (Agency/Court) No Yes Are you now, or have you ever been, involved as a plaintiff, defendant, petitioner or respondent in any civil court action? If yes, explain. (Include when, where, name and location of court, circumstances, and disposition). No Yes Have you ever been fingerprinted? If yes, complete the following: Date Location Reason for Fingerprinting No Yes Have you ever received a pardon for a crime? If yes, complete the following: Date State County Offense Age Then Police Agency Involved 6
No Yes Have you ever had any contact with a police agency as a victim or witness? If yes, please list the following: Date Location Circumstances Police Agency Involved FINANCIAL HISTORY Provide the names and addresses of the individuals, companies or others to whom you are indebted and the extent of your debt. Include rent, mortgages, vehicle payments, charge accounts, credit cards, loans, and any other debts and payments. Include account numbers where applicable. Type of Account Name and Address of Creditor Account # Total Balance Monthly Payment No Yes Do you have a savings, checking or money market account? If yes, complete the Following: Name of Institution and Address Type of Account No Yes Have you ever had any garnishment, wage attachment, or civil judgement pending against you? If yes, give details: No Yes Have you ever been declared delinquent in child support payments ordered by the court? If yes, give details: 7
Highest level of education: EDUCATION HISTORY College credit hours Associate Bachelor of Arts Bachelor of Science Master Degree Date (Mo/Yr) High School Name AND Address From To Diploma Granted (Mo/Yr) Credits Earned Date (Mo/Yr) College/Universities Name AND Address From To Major Field of Study Degree Granted (Mo/Yr) Credits Earned Date (Mo/Yr) Graduate School - Name AND Address From To Major Field of Study Degree Granted (Mo/Yr) Credits Earned Miscellaneous Name and Address Dates (Mo/Yr) From To Major Field of Study Degree/Diplom a Granted (Mo/Yr) Credits Earned Attach copies of all diplomas and transcripts. List all awards received from high school and college: No Yes Has disciplinary action ever been taken against you in college? If yes, please explain: 8
MILITARY SERVICE No Yes Have you served in the United States Armed Forces? If yes, complete the following: Name Used During Service (Last, First and Middle) Social Security Number Date of Birth Place of Birth Active Service, Past and Present: Branch of Service Dates of Active Service Date Entered Date Released Check One Officer Enlisted Service Number During this Period Reserve Services, Past or Present - If none check here Dates of Membership Branch From To Check One Officer Enlisted Service Number During Period National Guard Membership (Check One) Army Air Force None Branch of Service From Dates of Membership To Check One Officer Enlisted Service Number During this Period How many discharges/separations from the service were given to you? Discharges: Separations: No Yes Has your discharge or separation notice ever been corrected or changed? Explain: List all medals and decorations awarded you as a member of the Armed Forces. No Yes Have you ever applied for Department of Defense Security Clearance? Date: No Yes Were you ever court-martialed, tried, or charged, or were you subject of punishment, or any other disciplinary action? If yes, how many times? Give details of charges, agency concerned, dates, and dispositions. NOTE: Already included in Judicial Action Section. 9
JOB PERFORMANCE No Yes Do you know of any reason why you would not be able to perform (with reasonable accommodation) any job related task or function as specified in the job description? If yes, please explain: Prior to final appointment, all persons who receive a tentative offer of employment will be required to submit to physical/eyesight/hearing/medical/psychological and drug screen examination by a physician and psychologist of the City s choice at the City s expense. No Yes Will you consent to such examinations? CERTIFICATION I certify to the best of my knowledge this application is true and complete. Misrepresentation of any material fact contained in the application shall be sufficient cause for excluding the applicant from the examination or for removing the applicant s name from the eligibility pool, or for the applicant s discharge, at any time, from the Department. (Applicant Signature and Date) List the required information for all children born to you. Please include adopted and/or step-children: Name Date of Birth With Whom and Where Does Child Reside Please list all persons who live in the same household with you (if not listed above or under references). Name Relationship Occupation Place of Employment 10
City of Platteville Residency Policy The following is the employee residency policy of the City of Platteville. 1. Department Heads, as defined in the City s Employee Handbook (City Clerk, City Manager, Community Planning & Development Director, Director of Administrative Services, Director of External Activities, Director of Public Works, EMS Administrator, Finance Director, Fire Chief, Library Director, Museum Director, Police Chief, Recreation Coordinator, Streets Superintendent Utility Office Manager and Utility Superintendent), shall live within the City limits. 2. All other City employees who regularly work more than twenty hours per week shall be required to live within a 15-mile radius of Platteville City Hall. Employees may live anywhere within the City limits of Lancaster or Hazel Green. All employees must live within the State of Wisconsin. The map below shows the limits of the 15-mile radius. 3. Exceptions to this policy may be made on a case-by-case basis by the Common Council.
APPLICANT DATA RECORD Applicants are considered for all positions, and all employees are treated during employment without regard to race, color, creed, religion, sex, national origin, age, marital or veteran status, medical condition or handicap. As employers/government contractors, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application or Employment. (PLEASE PRINT) Position applying for Referral source: Newspaper Advertisement (Name of paper) Friend Relative Walk-in Internet Advertisement (Name of website) Other Name Last First Middle Phone ( ) - Area code Phone# Address Number Street City State Zip Code Date: / / AFFIRMATIVE ACTION SURVEY Government agencies require periodic reports on sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information about a handicap is voluntary. Check one: Male Female Check one of the following race/ethnic group: White Black Hispanic American Indian/Alaskan Native Asian/Pacific Islander Check if any of the following are applicable: Vietnam Era Veteran Disabled Veteran Handicapped Individual
Please print your answers BACKGROUND INFORMATION DISCLOSURE Name First and Middle Name Last Position Any other names by which you have been known (including maiden name) Address Social Security Number(s) Current Employer Name & Address Section A ACTS, CRIMES AND OFFENSES THAT MAY ACT AS A PERMANENT BAR YES NO 1. Do you have any criminal charges pending against you or were you ever convicted of any crime or offense anywhere, including in federal, state, local and tribal courts, for any act or offense listed below: If Yes, list each crime and attach an explanation, including where and where it happened, and the name of the Judge. If available, attach a certified copy of each conviction, a copy of each criminal complaint, and any other relevant court or police documents. PENDING ARRESTS OR CONVICTIONS ARE NOT AN ABSOLUTE BAR TO EMPLOYEMENT AND WILL ONLY BE CONSIDERED IF THERE IS A SUBSTANTIAL RELATIONSHIP TO THE CIRCUMSTANCES OF THE POSITION APPLIED FOR. 2 Were you ever found to be (adjudicated) delinquent by a court of law on or after your 12 th birthday for a crime or offense listed below If yes, list each crime and attach an explanation of the offense or crime, including when and where it happened, and the name of the Judge. If you answered YES to question 1 or 2, check or specify each crime, act or offense from the following boxes HOMICIDES SEXUAL ASSAULT/SEX CRIMES ABUSE/ASSAULTIVE CRIMES Intentional Homicide (Murder 1st Sexual Assault of a Child Abuse of Vulnerable Adult Degree) Sexual Assault (1 st,2 nd,3 rd degree) Abuse of Patients or Residents Other (specify Sexual Exploitation Physical abuse of a child-intentional Possession of Child Pornography Physical abuse of a child failure to act Incest Causing Mental hare to Child Child Enticement Child Neglect (resulting in death) Other (Specify) Assault by Prisoner Kidnapping/Abduction Stalking (Felony) Other Specity PROPERTY CRIMES Arson Operating a Motor Vehicle without Owner s Consent (with force/weapon) Other (Specfy) OTHER Mayhem Hostage-Taking Racketeering (Organized Crime) Solicit/Use a Child to commit a felony
Section B ACTS, CRIMES OR OFFENSES THAT MAY ACT AS A BAR YES NO 1 Other than the offenses listed above, do you have criminal charges pending against you or were you ever convicted of any crime or offense anywhere, including in federal, state, local and tribal courts? If YES, list each crime: For each crime listed, attach an explanation of the offense or crime, including when and where it happened, and the name of the Judge. If available, attach a certified copy of each conviction, a copy of each criminal complaint, and any other relevant court or police documents. 2 Have you ever been found (adjudicated) delinquent by a court of law on or after your 12 th birthday, for any crime other than those listed in Section A? If YES, list each crime: For each crime listed, attach an explanation of the offense or crime, including where and where it happened, and the name of the Judge. 3 Has any agency ever found that you committed child abuse or neglect: If YES, attach an explanation, including when and where it happened 4 Has any agency ever found that you misappropriated (improperly took/used) the property of a person? If YES, attach an explanation, including when and where is happened. Section C OTHER REQUIRED INFORMATION YES NO 1 In the past 3 years, have you been discharged from a branch of the US Armed Forces, including any reserve component? If YES, attach and explanation of the reason for your discharge and a copy of your discharge papers (DD214). 2 Have you ever resided in any other state in the last 3 years? If YES, attach an explanation listing each state and the dates you lived There. NOTE: A NO answer to all questions does not guarantee employment I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly and intentionally providing false information is grounds to deny or terminate employment. Your Signature Date Signed
AUTHORIZATION FOR RELEASE OF INFORMATION (for official use only, not to be released to unauthorized persons) CITY OF PLATTEVILLE Employing Agency I hereby empower an employee of the City of Platteville or other authorized representative thereof bearing this release to, within one year of its date, obtain information and records pertaining to me from any or all of the following sources: 1. Municipal, State or Federal law enforcement agencies 2. Selective Service System 3. Any banking institution 4. Any place of business (for purposes of obtaining credit or employment data) 5. Credit rating bureaus or institutions maintaining individual credit rating files 6. Any previous employer 7. Present employer 8. Any school, college, university, or any other educational institution 9. Any law enforcement or jail officer Exceptions to this blanket authorization 1. Any medical information in the possession of any source named above until subsequent to a conditional offer of employment (per Americans with Disabilities Act). 2. 3. This release is executed to authorize the City of Platteville, as a prospective employer, to obtain the above information. It is understood that said information shall be used only in consideration of my employment and shall not be further disseminated for any purpose. Date: Signature: Full Name (print): Date of Birth: Sex: Male Female Address: Street and Number City State Zip Driver s License Number: Former States of Residence within Past 10 Years: