application for employment background investigation

Transcription

TOWN OF SAUGERTIES POLICE DEPARTMENT
Adm. 14
Rev. 03/22/2011
APPLICATION FOR EMPLOYMENT
BACKGROUND INVESTIGATION
INSTRUCTION SHEET
Dear Applicant:
This is your application for employment with the Town of Saugerties Police Department.
Part of the hiring process includes your ability to read, understand, and follow directions. This
application is to be filled out completely using a computer, typewriter or print using black ink. You must attach
a completed Ulster County Civil Service application before returning it to this department. You are to include
following items with this packet:
1) Original:
2) Photo Copies:
Ulster County Civil Service Application
Driver's License
Social Security Card
Birth Certificate
High School Diploma
High School Transcripts
GED Certificate
College Degrees
College Transcripts
Selective Service Card/Registration (Males 18-26)
Military Discharge DD214 (Stating Honorable Discaharge)
Training Certificates related to position
Copy of Marriage License
Name Change Documents (marriage, adoption, etc.)
3) Fingerprints:
Follow the enclosed instructions for biometric fingerprinting
with L1 Enrollment Services. Do not include any checks or
money orders with this application. Forward a copy of the
receipt from L1 Enrollment Services in addition to the documents
listed above.
Page 1 of 22
Adm. 14
Rev. 03/22/2011
4)
Upon submission of this application, you should be prepared for an oral interview involving the Chief
of Police. (You will be contacted with the date and time)
5)
Department policy dictates the following automatic disqualifications for employment with this
department:
a.
Within the past twelve (12) months used, tried, experimented with or otherwise
possessed any illegal controlled substance including Marihuana.
b.
Within the past sixty (60) months used, tried, experimented with or otherwise
possessed any illegal controlled substance classified as a Schedule I or Schedule
II illegal substance ("Hard" Drugs).
Sold or delivered any illegal controlled substance at any time
Ever convicted of any felony.
c.
d.
6)
AT TIME OF APPOINTMENT (After being offered a position):
a. You must possess a:
Graduate certificate from senior high school, or
New York State High School Equivalency Diploma, or
Military GED Certificate, or
High School Equivalency Diploma from another state converted to a NYS
High School Equivalency Diploma, and
(Police Officer Position)
Must have completed 60 credit hours at an accredited college or university at
the time of appointment.
- OR Completion of sixty (60) credit hours at a regionally accredited or New York State
registered College or University; OR
Completion of thirty (30) credit hours at a regionally acredited or New York State
registered Colled or University; AND
A)
B)
One (1) year of active military service with an honorable
discharge; OR
The equivalent of one (1) year full-time work experience in a criminal
justice field, for example a police officer, correction officer, police
dispatcher, investigator or licensed security guard; OR
Page 2 of 22
Adm. 14
Rev. 03/22/2011
APPLICATION FOR EMPLOYEMENT
C)
Four (4) years of satisfactory, full-time work experience or its prorated part-time equivalent in any field of employement; OR
An equivalent amount of training and experience as definded by the limites of A, B
and C above.
Special Requirements:
A)
United States Citizenship is required at time of appointment.
B)
Possession of a valid New York State Driver's license is required at
time of appointment.
Exceptions:
30 college credits may be waived, if the candidate has
either: Received and Honorable Discharge from the United
States military after two years of active military service; OR
Successuflly completed a Certificed Police Officer Training
Course approved by the New York State Municipal Police
Training Council. A certified Peace Officer Training course
does not qualify.
(Police Officer Positions)
b)
Must be a New York State resident, and
c)
Must be able to work rotating shifts any any day of the week, including holidays, and
d)
Must comply with the Town of Saugerties Police policy wich requires all members to
present a neat and professional appearance at all times. Tattoos, brands, body
pearcing and other body art shall not be visible while a member is in uniform or other
business attire. The uniform includes a short sleeve shirt open at the front of the
neck. In addition to visibility, some tattoos or brands may have symbolic meanings
that are inconsistent with the values of the Town of Saugerties Police, and
e)
Participate in a pre-employement Polygraph Examination; and
f)
Participate in a pre-employment - drug pre-screening tests; and
g)
Participate in a pre-employment Psychological Exam to be cleared of any "emotional,
or mental condition which might adversely affect the exercise of the powers of a
police officer or police dispatcher" as determinded by a qualified, experienced
psychologist or psychiatrist.
It is most important that this package be COMPLETE and ACCURATE. After your application packet has been
submitted properly, then your packet will be assigned for processing.
Any missing information will delay the completion of your background, which may result in delaying the date of your
possible employment.
All applicants for employment will be required to execute any and all releases required by the Town of
Saugerties Police Department including the attached GENERAL RELEASE, as well as any release required by any
outside contactors working on behalf of the Town of Saugerties Police Department. Failure to sign any release is
an automatic disqualification for employment.
Page 3 of 22
Adm. 14
Rev. 03/22/2011
DO NOT call for background information status. Any specific questions regarding any issues in this application
should be directed to Sgt. Filak at (845) 246-9800 between 8:00 A.M. and 4:00 P.M., Monday through Friday except
holdiays BEFORE it is submitted.
The Town of Saugerties is an Equal Employment Opportunity Employer. We consider applications for all
positions without regard to race, color, national origin, sex, age, handicap, martial status, religion or any other legally
protected status.
By signing below, I indicate I have read, understand, and wish to comply with the informaiton
contained on this and the previous pages of instructions.
S/_____________________________________
Sworn to before me this ____ day of
__________________________, 20___
________________________________
NOTARY PUBLIC
Page 4 of 22
Adm. 14
Rev. 03/22/2011
AUTHORIZATION FOR RELEASE OF
PERSONAL INFORMATION
I, __________________________________________, do hereby authorize a review and full disclosure of
(FULL NAME - SPELLED OUT)
all records concerning myself, to any duly authorized agent of the Town of Saugerties Police Department, whether the
said records are of a public, private or confidential nature.
The intent of this authorization is to give my consent for a full and complete disclosure of the records of
education institutions, finacial or credit institutions, including records of loans, the records of commercial retail credit
agencies (including credit reports and/or ratings), and other finacial statements and records wherever filed, medical and
psychiatric treatment and/or consultations, including hospitals, clinics, and private practitioners, the U.S. Armed Forces,
Maritime Services, Selective Service Administration and the U.S. Veterans Administration, employement and preemployment records, including background reports, efficiency ratings, complaints or grievances filed by or against me
and the records and recollections of attorneys at law or of other council, whether representing me or another person in
any case, either criminal or civil, in which I presently have or have had an interest.
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 Town of Saugerties Police Department, I also certify that any person(s) who may furnish such
information concerning me shall not be held accountable for giving this informaiton, and I hereby release said person(s)
from any and all liability which may be incurred as a result of furnishing such information. I also agree to pay any and all
charges or fees concerning this request and can be billed for such charges at the below address.
A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not
contain and original writing of my signature.
_________________________________________
Signature (Including Maiden Name)
Sworn to before me this ____ day of
__________________________, 20___
________________________________
NOTARY PUBLIC
THIS DOCUMENT MUST BE NOTARIZED
BEFORE RETURNING.
_________________________________________
Address (Number and Street)
_________________________________________
Town/City
State
Zip
Phone Number: (
)
Date of Birth:
Social Security Number:
Height:____________Weight:
Eyes:
Hair:
-
Page 5 of 22
Adm. 14
Rev. 03/22/2011
POSTITION APPLYING FOR:
DATE OF APPLICATION:
INSTRUCTIONS
This application must be typewritten or printed legibly in ink. ALL questions must be answered; if
a question is not applicable, so state and indicate N/A (not applicable). If space provided
is not sufficient for complete answers, or you wish to furnish additional information, use the
attached NOTES sheet making sure you number your answer with the correct question number
(QUESTION 2 - ANSWER 2).
1. PERSONAL INFORMATION
A.
Full Name:
(Last
First
Middle
Maiden)
Nicknames:
YES
NO
Has your name changed:
If YES: Date of change:
Changed To:
(Provide legal documentation of name change)
B.
Height:
Date of Birth:
Place of Birth:
Weight:
Reason:
Eyes:
Hair:
Sex:
Race:
Age:
City and State - Country
Languages you speak fluently:
YES
Are you a United States Citizen?
If NO, explain:
C.
Current Address:
(Street
Apt. #
NO
City
State
Zip
List all persons living with you at this time:
Name:
Name:
Name:
Date of Birth:
Date of Birth:
Date of Birth:
Relationship:
Relationship:
Relationship:
Page 6 of 22
Adm. 14
Rev. 03/22/2011
Dates you resided at this location: FROM
TO
Rent Amount: $
Mortgage Amount: $
Rent/Mortgage Free
D.
Contact information where you can be reached:
Home Telephone:
Work Telephone:
e-mail:
Cellular Telephone:
Other:
E.
Drivers License:
F.
Full Name of Present Spouse:
Spouces Date of Birth:
G.
State
Marital Status:
License Number
Type
Expiration Date
Maiden Name:
Single/Never Married
Married
Separated
Divorced
Number of Children:
Chilren's Full Name
Age
Date of Birth
Chilren's Full Name
Age
Date of Birth
Chilren's Full Name
Age
Date of Birth
Have you, in the past five years, cohabitated with another person?
If yes, with whom (give full name including maiden):
Provide current address and telephone number:
H.
YES
NO
Parents:
Full Name of Father / Step Father
Full Name of Mother / Step Mother
Living/Deceased
Living/Deceased
Street Address
Street Address
City
State
Zip
City
State
Zip
Page 7 of 22
Adm. 14
Rev. 03/22/2011
I.
Home and Business Telephone
Home and Business Telephone
Date of Birth
Date of Birth
Place of Birth
Place of Birth
List all brothers and sisters (including half-brothers, half-sisters, etc.), and indicate exact
relationship:
Full Name
Address
Date of Birth
Phone Number
Full Name
Address
Date of Birth
Phone Number
Full Name
Address
Date of Birth
Phone Number
J.
Any relatives currently employed by the Town of Saugerties?
If yes, give name(s) and position(s):
K.
Have you ever worked for another Law Enforcement Agency in the past?
YES
If YES:
L.
NO
What agency:
When:
Position:
Are you using Veterans Credits towards this application for employment?
YES
NO
M.
Are you a member of the New York State Police and Firemen's Retirement System?
YES
NO If Yes: For how many years:
N.
Have you ever been married before?
YES
NO
If Yes: Spouses full name, maiden name and date of birth:
Current Address:
Current Telephone number:
Are you currently:
Separated
Annulled
Divorced
Date of such action:
(provide legal documentation)
Any children in this marriage:
How many:
YES
NO
Are you responsible for child support:
YES
NO
YES
NO
If Yes, how much:
Payments current:
If no, why:
Page 8 of 22
Adm. 14
Rev. 03/22/2011
2. EDUCATION
A.
B.
C.
D.
Name of High School Attended:
Address:
Dates Attended:
Graduated:
YES
NO
Name of College Attended:
Address:
Dates Attended:
YES
Graduated:
to
NO
to
Degree:
Major:
Name of other school attended:
Address:
Dates Attended:
YES
NO
Graduated:
to
Degree:
Major
High School Equivalent Certificate Obtained:
If Yes, Date:
Name of Facility:
Location of Facility:
YES
NO
PROVIDE COPY OF CERTIFICATE
Page 9 of 22
Adm. 14
Rev. 03/22/2011
3. PERSONAL REFERENCES
List the names, addresses and telephone numbes of three (3) persons you have known for
at least the past five (5) years. These persons must not be relatives, present or former employers, or
former supervisors. Local references are preferred. Do not list husbands, wives, as separate references,
and include their title (Mr., Mrs., Miss, Dr., etc.).
A.
NAME:
NUMBER OF YEARS AQUANTED:
MAILING ADDRESS (Street/PO Box, City, State, Zip)
HOME TELEPHONE:
BUSINESS ADDRESS:
WORK TELEPHONE:
OCCUPATION:
B.
NAME:
HOME TELEPHONE:
BUSINESS ADDRESS:
WORK TELEPHONE:
OCCUPATION:
C.
NAME:
HOME TELEPHONE:
BUSINESS ADDRESS
WORK TELEPHONE:
OCCUPATION:
Page 10 of 22
Adm. 14
Rev. 03/22/2011
4. SOCIAL COMPANIONS
List the names, addresses and telephone numbes of three (3) persons you regualarly associate
with. These persons must not be relatives, present or former employers, or former supervisors. Local
companions are preferred. Do not list husbands, wives, as separate references, and include their title
(Mr., Mrs., Miss, Dr., etc.).
A.
NAME:
HOME TELEPHONE:
BUSINESS ADDRESS:
WORK TELEPHONE:
OCCUPATION:
B.
NAME:
HOME TELEPHONE:
BUSINESS ADDRESS:
WORK TELEPHONE:
OCCUPATION:
C.
NAME:
HOME TELEPHONE:
BUSINESS ADDRESS:
WORK TELEPHONE:
OCCUPATION:
Page 11 of 22
Adm. 14
Rev. 03/22/2011
5. ARRESTS
Since your birth:
A.
B.
C.
D.
YES
Have you ever been arrested for a Violation?
YES
Have you ever been arrested for a Misdemeanor?
YES
Have you ever been arrested for a Felony?
Have you ever been arrested for an alcohol related traffic offense?
NO
NO
NO
YES
NO
If you answered "Yes" to any of the above four questions, give the following details:
(Provide as much details as possible on the attached "NOTES" portion of this packet)
A.
Date of Arrest:
Court:
Arresting Agency:
Charges:
Disposition:
B.
Date of Arrest:
Court:
Arresting Agency:
Charges:
Disposition:
C.
Do you feel you cannot recall details of one or more prior arrests to make the appropriate
YES
NO
entries?
- If Yes, on the notes portion of this packet, provide
us with at least a time periord and location.
NOTE: None of the above circumstances represents an automatic bar to employement. Each case is considered and evaluated
on individual merits in relation to the duties and responsibilities of the position for which you are applying.
6. TRAFFIC VIOLATIONS
A.
Since you have been driving motor vehicles, list all traffic violations you have received with the
exception of parking violations: (If needed list additional on attached note sheet)
Date
Court
Arresting Agency
Location
Charge
Disposition
Date
Court
Arresting Agency
Location
Charge
Disposition
Date
Court
Arresting Agency
Location
Charge
Disposition
Page 12 of 22
Adm. 14
Rev. 03/22/2011
B.
Do you feel you cannot recall details of one or more prior violations to make the appropriate
YES
NO - If you answer "Yes," on the notes portion of this
entires?
packet, provide us with at least a time period and location
NOTE:
C.
None of the above circumstances represents an automatic bar to employement. Each case is considered and
evaluated on individual merits in relation to the duties and responsibilities of the position for which you are
applying.
Has your driver's license ever been suspended and/or revoked since you have been
YES
NO
driving?
If "Yes," give details:
D.
Are you previously or presently the subject or a party to, any investigation or pending
YES
NO
litigation, civil or criminal?
If "Yes," give details:
7. MOTOR VEHICLE INFORMATION
License Plate Number
State
Year
Make
Model
State
Year
Make
Model
State
Year
Make
Model
Page 13 of 22
Adm. 14
Rev. 03/22/2011
B.
Describe any and all motor vehicle accidents you have been a party of:
Date
Location
Police Agency Involved
Summons Issued
Injury or Property Damage
Description of Accident:
List additional accidents on the notes portion of this packet.
C.
Have you ever submitted a Workman's Compensation Claim?
If "Yes," describe below including dates and injuries sustained:
YES
NO
Describe any injuries you sustained where you were seen by a doctor:
D.
Give name, address and telephone number of your personal physician.
Date
E.
Location
Police Agency Involved
Summons Issued
Injury or Property Damage
Have you ever been treated for or do you have any history of Mental or Emotional Illness?
YES
NO
If "Yes," describe below including dates:
Page 14 of 22
Adm. 14
Rev. 03/22/2011
8.
MILITARY
A.
Have you ever served (for any period of time) in the Armed Forces of the United States?
YES
NO
If Yes:
Branch of Service:
Serial Number:
Date of Active Duty: From
to
Type of Discharge:
Separation Center:
B.
Are you currently a member of an Active Reserve Unit of the National Guard?
YES
NO
If Yes, which unit?
Location:
Branch:
C.
Are you designated as disabled because of any military service?
YES
NO
D.
Was any type of disciplinary action taken against you in the service?
If Yes, Date:
Place:
Nature of Offense:
Action Taken:
YES
NO
E.
Veterans Preference:
Check the appropriate block if you are claiming veterans preference
DOCUMENTATION SUBSTANTIATING YOUR CLAIM MUST BE FURNISHED WITH THIS
APPLICATION.
1.
A veteran with a service-connected disability who is eligible for or receiving
compensation, disability retirement, or pension under public laws administered by the
U.S. Veterans Administration and the Department of Defense; or
2.
The spouse of a veteran who cannot qualify for employment because of a total permanent
disability, or the spouse of a veteran missing in action, captured, or forcibly detained by a
foreign country; or
3.
A veteran of any war who has served on active duty for 181 consecutive days or more, or
who has served 180 consecutive days or more since January 31, 1955 and who has
honorably discharged from the Armed Forces of the United States of America if any part of
such active duty was performed during a wartime era, excluding active duty for training; or
4.
The un-remarried widow or widower of a veteran who died or a service-connected
disability
Page 15 of 22
Adm. 14
Rev. 03/22/2011
F.
Have you claimed and been employed using veterans preference since October 1, 1987?
YES
NO
If Yes, please give name of employer:
9.
FINANCIAL
A.
List bank / financial institutions used:
Type of Account
Institution
Location
Type of Account
Institution
Location
Type of Account
Institution
Location
Type of Account
Institution
Location
B.
Do you have any source of income other than your salary or the salary of your spouse?
YES
NO
If Yes, proved type and amounts:
C.
Are you or your spouse indebted to anyone?
YES
NO
If Yes: Please list all debts over $100.00. Be sure to include student loans and charge
accounts. Also, list all accounts where payments are past due regardless of the
amount:
*** We WILL be obtaining a credit check history ***
D.
Have you or your spouse ever been foreclosed on or filed Bankruptcy?
YES
NO
If Yes, explain:
Page 16 of 22
Adm. 14
Rev. 03/22/2011
10. EMPLOYMENT HISTORY
List chronologically ALL (since age 16) employment beginning with present employment including
summer and part-time employment while attending school. All times must be accounted for. If unemployed for a
period of time, indicate setting forth the dates.
A.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
B.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
C.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
Page 17 of 22
Adm. 14
Rev. 03/22/2011
D.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
E.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
F.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
Page 18 of 22
Adm. 14
Rev. 03/22/2011
G.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
H.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
I.
EMPLOYERS NAME:
POSITION HELD:
TELEPHONE:
SALARY:
$
Full-time
Part-time
DATES EMPLOYED:
From:
to
(Use the notes sheet or additional paper for more entries)
Do you feel you cannot recall details of one or more prior employment to make the appropriate entries?
YES
NO
If you answered "Yes" on the notes portion of this packet, provide us with at least a time period and location.
Page 19 of 22
Adm. 14
Rev. 03/22/2011
11. RESIDENCY
A.
List in chronological order all of your residences for the past ten (10) years including addresses
while attending school, if away from home.
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
To
From
Street Address
City
State
12. LAW ENFORCEMENT INTERACTION
A.
Please list all the times you can recall having interaction with a police department over the past
ten years.
Agency
Approximate Date
Agency
Approximate Date
Agency
Approximate Date
Agency
Approximate Date
Agency
Approximate Date
Agency
Approximate Date
Page 20 of 22
Adm. 14
Rev. 03/22/2011
13. FIREARMS INFORMATION
A.
Do you currently hold a New York State pistol permit?
If Yes - what County?
(Provide photo copy of all sides of permit)
YES
Do you possess any handguns on the authority of a police agency?
If Yes - List all including make, model, caliber and serial number:
B.
YES
Do you own any handguns?
If Yes - List all not shown on your pistol permit:
NO
YES
NO
NO
APPLICANT'S CERTIFICATION
I understand that any employment offered me will be contingent upon the results of a completed character and
fitness investigation, and I am aware that willfully withholding information or making a false statement on this application
will be the basis for no further consideration or dismissal by the Town of Saugerties Police Department.
I agree to these conditions and I hereby certify and affirm that all statements made by me in this application are
true, correct and complete to the best of my knowledge.
S/ _________________________________________
Applicant
Sworn to before me this ______ day of
____________________________, 20____.
___________________________________
Notary Public
Page 21 of 22
Adm. 14
Rev. 03/22/2011
APPLICANT'S NOTES
APPLICANT'S NAME:
Page 22 of 22

application for employment background investigation

Transcription

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