Joint Application – Collinsville

Step 1 of 15

A. Collinsville Applicant Identification
Information provided in this section is used for identification purposes only.
Name*
First Middle Last
List any other names or aliases you have used or been known by (include maiden name, if applicable).
Address*
Street Address City State ZIP Code
Primary Phone*
Secondary Phone
Email*
Social Security Number*
xxx-xx-xxxx
Are you a U.S. Citizen?*
- Yes
- No
If yes*
- Native Born
- Naturalized
If "naturalized," give particulars
Are you authorized to work in the United States on an unrestricted basis?*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No

B. Educational History
High School Name, City, & State*
Graduate?*
- Yes
- No
High School Name, City, & State
Graduate?
- Yes
- No
High School Name, City, & State
Graduate?
- Yes
- No
College/University Name, City, & State
Major/Minor
Degree Received, if any
College/University Name, City, & State
Major/Minor
Degree Received, if any
College/University Name, City, & State
Major/Minor
Degree Received, if any
List other schools attended (trade, vocational, business, etc...).
Give name and dates attended, course of study, certificate, and any other pertinent information.
Were you ever suspended or expelled from any school?*
- Yes
- No
If yes, explain
List other formal education beyond high school you may have, including special training courses:
List any special licenses or certificates you hold or have held:

D. Special Qualifications & Skills
List any special licenses you hold (such as Paramedic, Pilot, Radio Operator, Scuba, etc...).
Show licensing authority, original dates of issue, and date of expiration.
List any specialized machinery or equipment that you can operate.
Are you fluent in a foreign language?*
Which Language?
Reading Ability
Speaking Ability
Understanding Ability
Writing Ability
Which Language?
Reading Ability
Speaking Ability
Understanding Ability
Writing Ability
Please use the space below to state why you want to work as a police officer and why you wish to work in Collinsville, Fairview Heights, and/or O'Fallon. You should also state the special talents that you feel you would bring to the position.*

E. References
List five persons who you know well enough to provide current information about you. Do not list relatives or former employers.
1.
Name*
First Last
Years Known*
Please enter a number from 0 to 99.
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Business Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
2.
Name*
First Last
Years Known*
Please enter a number from 0 to 99.
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Business Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
3.
Name*
First Last
Years Known*
Please enter a number from 0 to 99.
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Business Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
4.
Name*
First Last
Years Known*
Please enter a number from 0 to 99.
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Business Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
5.
Name*
First Last
Years Known*
Please enter a number from 0 to 99.
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Business Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code

F. MEMBERSHIP IN ORGANIZATIONS
(Past and/or Present)
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliations
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliations
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliations
Date From
MM slash DD slash YYYY
Date To
MM slash DD slash YYYY

K. FINANCIAL OBLIGATIONS
Give 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, child support payments and other debts and payments. Include account numbers were applicable. Use extra sheet if necessary.
List
Type Name and Address of Creditor Reason for debt or item purchased Account Number Total Balance Monthly Payment

M. RESIDENCE
List ALL addresses where you have lived during the past ten years, beginning with the present address. List date by month and year. Attach extra page if necessary.
From To Address
With whom do you live at your current address?
Full Name Relationships

AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS
*
I do hereby authorize a review of all records concerning myself to any duly authorized agent of the Fairview Heights Police Department, whether the said records are of a public, private or confidential nature, including, but not limited to, applicant background information. I authorize you to furnish the Fairview Heights, Illinois Police Department with any and all information that you have concerning my: work record, salary, attendance, reputation, medical records, criminal history, credit history, loan history, driving history, and military service records. Information of a confidential or privileged nature may be included. Your reply will be used to assist the Fairview Heights Police Department in determining my qualifications and fitness for the position I am seeking with the department. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the Fairview Heights Police Department. I understand that all materials pertaining to this background investigation become the property of the Fairview Heights Police Department and will not be returned to me. I hereby release you and your organization from any and all liability or damages which may result from furnishing the information requested. I further release the Fairview Heights Police Department, and its agents, from any and all liability which may be incurred or as a result from the collection of such information. I further understand that in the event my application is disapproved; the sources of confidential information cannot be revealed to me.
Applicant's Electronic Signature*
First Last
Subscribed and sworn before me this day of*
(Today's Date)
MM slash DD slash YYYY
Signature*

Name	Date of Birth	Place of Birth	Where does child live and with whom?

Charge	Agency	Date	Disposition

Offense Charge	Police Agency, City and State	Date	Disposition of Case

Month and Year	Charge	City and State	Disposition

Step 1 of 15

A. Collinsville Applicant Identification

B. Educational History

C. Employment History

1.

2.

3.

4.

5.

D. Special Qualifications & Skills

E. References

1.

2.

3.

4.

5.

F. MEMBERSHIP IN ORGANIZATIONS

G. TATTOOS

H. PERSONAL DECLARATIONS

I. BACKGROUND INFORMATION

J. FINANCIAL HISTORY

K. FINANCIAL OBLIGATIONS

L. MILITARY RECORD

M. RESIDENCE

N. CRIMINAL HISTORY

O. TRAFFIC RECORD

AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS

Name	Relationship	Address	Occupation

Type	Name and Address of Creditor	Reason for debt or item purchased	Account Number	Total Balance	Monthly Payment

From	To

From	To	Address

Step 1 of 15

A. Collinsville Applicant Identification

B. Educational History

C. Employment History

1.

2.

3.

4.

5.

D. Special Qualifications & Skills

E. References

1.

2.

3.

4.

5.

F. MEMBERSHIP IN ORGANIZATIONS

G. TATTOOS

H. PERSONAL DECLARATIONS

I. BACKGROUND INFORMATION

J. FINANCIAL HISTORY

K. FINANCIAL OBLIGATIONS

L. MILITARY RECORD

M. RESIDENCE

N. CRIMINAL HISTORY

O. TRAFFIC RECORD

AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS

CONTACT US TODAY!