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Joint Application – Collinsville
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2021-04-21T15:39:48-05:00
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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:
C. Employment History
Have you ever taken a civil service exam?
*
Yes
No
Agency
Date
MM slash DD slash YYYY
Position on List
Status
Agency
Date
MM slash DD slash YYYY
Position on List
Status
Agency
Date
MM slash DD slash YYYY
Position on List
Status
Are you now on any eligibility list?
*
Yes
No
If yes, explain
Were you ever placed on a civil service list and not hired?
*
Yes
No
If yes, explain
Were you ever rejected for any service position?
*
Yes
No
If yes, explain
Have you ever been a law enforcement officer or held a similar position?
*
Yes
No
Position
Dates
Location
Position
Dates
Location
Were you ever discharged or forced to resign because of misconduct or unsatisfactory service or while under investigation?
*
Yes
No
If yes, explain
Are you now, or have you ever been, engaged in any business as an owner, partner, or corporate member?
*
Yes
No
If yes, explain
Beginning with your present or most recent job, list all employment since the age of 18, including part-time, temporary, or seasonal employment. Include all periods of unemployment.
1.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
Job Title
Supervisor
Name of a Coworker
Duties
Reason for Leaving
2.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
Job Title
Supervisor
Name of a Coworker
Duties
Reason for Leaving
3.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
Job Title
Supervisor
Name of a Coworker
Duties
Reason for Leaving
4.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
Job Title
Supervisor
Name of a Coworker
Duties
Reason for Leaving
5.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
Job Title
Supervisor
Name of a Coworker
Duties
Reason for Leaving
INDICATE BY NUMBER(S) ANY OF THE ABOVE EMPLOYERS WHOM YOU DO NOT WISH FOR US TO CONTACT.
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?
*
Select
Yes
No
Which Language?
Reading Ability
Select
Excellent
Good
Fair
Speaking Ability
Select
Excellent
Good
Fair
Understanding Ability
Select
Excellent
Good
Fair
Writing Ability
Select
Excellent
Good
Fair
Which Language?
Reading Ability
Select
Excellent
Good
Fair
Speaking Ability
Select
Excellent
Good
Fair
Understanding Ability
Select
Excellent
Good
Fair
Writing Ability
Select
Excellent
Good
Fair
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
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
G. TATTOOS
Do you have any tattoos?
Yes
No
If yes, list location(s) on your body.
H. PERSONAL DECLARATIONS
Have you ever made an application for employment with this or any other municipality?
Yes
No
If yes, give municipality, date(s), and status of application
Have you ever used or currently use marijuana, cocaine, or any other illegal substances?
Yes
No
Have you ever abused or currently abuse prescription drugs?
Yes
No
Have you ever abused or currently abuse alcohol?
Yes
No
Are there any incidents in your life or details not mentioned herein which may influence this department's evaluation of your suitability for employment as a police officer?
Yes
No
If yes, explain
I. BACKGROUND INFORMATION
Information provided in the following sections will only be used for background checks if you are offered a position and will not affect your status as an applicant in any manner.
List every member of your immediate family who is still living; include father, mother, sisters, & brothers.
Name
Relationship
Address
Occupation
Are you:
Single
Married
Separated
Widowed
Divorced
Civil Union
Are you living with your spouse/civil partner?
Yes
No
If no, explain
Give the following information regarding your marriage/marriages/civil unions:
Date
MM slash DD slash YYYY
Where
Spouse Maiden Name (if applicable)
Date
MM slash DD slash YYYY
Where
Spouse Maiden Name (if applicable)
Date
MM slash DD slash YYYY
Where
Spouse Maiden Name (if applicable)
If a marriage to which you were a party was ever dissolved, fill out the following:
Separated
To Whom Was Action Granted?
Divorced
To Whom Was Action Granted?
Annulled
To Whom Was Action Granted?
Are you paying alimony?
Yes
No
If yes, explain
If divorced, list the name(s) of your previous spouse(s) and where he/she reside(s)
List below every child born to you or adopted by you, and stepchildren:
Name
Date of Birth
Place of Birth
Where does child live and with whom?
Are you now supporting all children born to you, adopted by you, and stepchildren?
Yes
No
If no, please explain fully
Have you ever been named as the natural father in a paternity proceeding?
Yes
No
If yes, please explain fully
Are you obligated to the State to pay child support, and if so, are you delinquent on any obligations to the State for unpaid child supports?
Yes
No
If yes, please explain
J. FINANCIAL HISTORY
Source of Income
What is your present salary or wages?
Do you have income from any source other than your principal occupation?
Yes
No
If yes, how much?
How often?
The source?
Do you own any real estate?
Yes
No
Value?
Location:
Do you own any bonds, government or other?
Yes
No
Value?
Do you own any corporate stock?
Yes
No
Value?
Do you have a bank account?
Yes
No
Savings Average Balance:
Name and address of Bank
Checking Average Balance:
Name and Address of Bank
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
L. MILITARY RECORD
Have you served in the U.S. Armed Forces?
Yes
No
Date of Service: From
Date of Service: To
Branch of Service
Unit Designation
Military Service Record
Highest Rank Held
Type of Discharge and Rank at Discharge
Date and location of entrance to active duty
Date and location of discharge
Period(s) of active service:
From
To
List all draft classifications you have had (i.e.,1-A, etc...)
If you are not a veteran, list the following:
Local Board Number
Address
Are you now, or were you ever, a member of any branch of the U.S. Reserve Forces?
Yes
No
If yes,
Active
Inactive
Branch
Unit
Rank
Address
From
To
Are you now, or were you ever, a member of the National Guard?
Yes
No
If yes, what state?
Regiment
Unit
Rank
Type of Discharge
From
To
Were you ever disciplined while in the Military Service? (include court martial, captain's masts, company punishments in active service, reserve unit, or National Guard)
Yes
No
Charge
Agency
Date
Disposition
Are you registered with the Selective Service?
Yes
No
If no, please explain:
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
N. CRIMINAL HISTORY
Have you ever been placed on probation?
Yes
No
If yes, please explain
Have you ever been required to pay a fine in excess of $25
Yes
No
If yes, please explain
Have you ever been reported as missing person or runaway?
Yes
No
If yes, please explain
Have you ever been the victim of a crime?
Yes
No
If yes, please explain
Have you ever been fingerprinted by a police agency other than for an arrest?
Yes
No
Are there any warrants, traffic or otherwise, now pending against you?
Yes
No
If yes, please explain
Have you ever been arrested, detained by police, or summoned into court for anything other than a traffic violation?
Yes
No
If yes, complete the following:
Offense Charge
Police Agency, City and State
Date
Disposition of Case
Have you ever been convicted of a felony or misdemeanor?
Yes
No
O. TRAFFIC RECORD
Can you operate an automobile?
*
Yes
No
Do you possess a valid operator's license from any state in the U.S.?
*
Yes
No
If yes, date of expiration
Driver's License Number
State
Have you ever been refused an operator's or chauffeur's license in any other state?
*
Yes
No
If yes, please explain
Have you ever had an operator's or chauffeur's license in any other state?
*
Yes
No
Has your driver's license ever been suspended or revoked?
*
Yes
No
If yes, give dates, location, and reasons below:
Has your license ever been placed on probation?
*
Yes
No
If yes, please explain
List, to the best of your memory, all traffic citations you have received (excluding parking tickets).
Month and Year
Charge
City and State
Disposition
In a brief narrative, describe any traffic accidents in which you have been involved, giving approximate dates and locations:
*
*
I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the statements and answers to questions I have provided in this application. I am fully aware that any such willful misrepresentation, omissions, or falsifications may be grounds for immediate rejection or termination of employment.
Full Name
*
First
Middle
Last
Today's Date
*
MM slash DD slash YYYY
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
*
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