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ETROPO
OLITAN P
POLICE
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RTMENT
T
BACKG
GROUND
D INVES
STIGATIION QUE
ESTION
NNAIRE
Applicant: _______
_________
_________
_______________________________________
INSTRU
UCTIONS:: Please co
omplete thee questionnnaire. If appplicable, pprovide ansswers to
all questions.
1. Fulll Name (L
Last, First, Middle) __________
__
_____________________________
Names you
u have beenn known byy to includde
2. Lisst ALL aliaas names(N
niccknames)__
_________
_________
_______________________________________
h:________
_________
_______________________________________
3. Daate of Birth
_______________________________________
4. Social Securiity Number: _______
L
heeld for all states
s
whetther currenntly valid oor non-validd must
5. Alll Driver’s License
be listed:
ber_______
______________________ State::_______
Driiver’s Liceense Numb
Driiver’s Liceense Numb
ber_______
______________________ State::_______
Driiver’s Liceense Numb
ber_______
______________________ State::_______
Driiver’s Liceense Numb
ber_______
______________________ State::_______
nited Statess Citizen: _____
_
Yess _____ Noo
6. Are you a Un
phone Num
mbers and E
Email Adddresses:
7. Lisst ALL Currrent Telep
Ho
ome: _____
_________
_________
_______________________________________
Cellular: ___
__________
_________
_______________________________________
mail: _____
_________
_________
_______________________________________
Em
Em
mail: _____
_________
_________
_______________________________________
8. List ALL persons which you have had a significant relationship with (if different
from your spouse) in the last five years. This includes but is not limited to past or
current fiancés, relationships, that lasted over three months, relationships that
produced a child, or relationships where you cohabitated.
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
List Names, Ages and Addresses of Children over the age of 17:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
9. Spouse’s Full Name and Place of Employment (if applicable):
Name: ______________________________________________________________________________
Place of Employment: _________________________________________________________________
Work Schedule: ______________________________________________________________________
Work Telephone: ____________________________Cell: _____________________________________
Email: ______________________________________________________________________________
10. Spouse’s maiden name and all other names that your spouse has been known
by (if applicable):
__________________________________________________________________
11. Date of Marriage: __________________________________________________
12. Place of Marriage: __________________________________________________
13. List Names, Ages and Addresses from this Marriage over the age of 17:
Name: __________________________________________________________Age:__________
Address: ______________________________________________________________________
City: _______________________________ State: _________ Zip: _______________________
Telephone: _______________________________Cell: _________________________________
Email: ________________________________________________________________________
Name: __________________________________________________________Age:__________
Address: ______________________________________________________________________
City: _______________________________ State: _________ Zip: _______________________
Telephone: _______________________________Cell: _________________________________
Email: ________________________________________________________________________
Name: __________________________________________________________Age:__________
Address: ______________________________________________________________________
City: _______________________________ State: _________ Zip: _______________________
Telephone: _______________________________Cell: _________________________________
Email: ________________________________________________________________________
Name: __________________________________________________________Age:__________
Address: ______________________________________________________________________
City: _______________________________ State: _________ Zip: _______________________
Telephone: _______________________________Cell: _________________________________
Email: ________________________________________________________________________
14. List all Former Marriages (attach a separate sheet if additional space is needed):
Ex-Spouse’s Name: __________________________________________________________________
Address: ____________________________________________________________________________
Telephone: ________________________________Cell: ______________________________________
Email: ______________________________________________________________________________
Date of Marriage: _____________________________ Date of Divorce: _________________________
List Names, Ages and Addresses of All Children from this Marriage over age 17:
Name: __________________________________________________________Age:________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
Ex-Spouse’s Name: __________________________________________________________________
Address: ____________________________________________________________________________
Telephone: ________________________________Cell: ______________________________________
Email: ______________________________________________________________________________
Date of Marriage: _____________________________ Date of Divorce: _________________________
List Names, Ages and Addresses of All Children from this Marriage over age 17:
Name: __________________________________________________________Age:________________
Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________________
Telephone: _______________________________Cell: _______________________________________
Email: ______________________________________________________________________________
15. Has an Ex-Parte or Other Type of Restraining Order Ever been placed against you?
_________ Yes ___________ No
If “Yes” please explain:_________________________________________________
16. Do you have any tattoos?
_________ Yes ___________ No
If “Yes”, describe and list locations:_______________________________________
17. List all clubs, group associations or organizations that you belong or have had an
affiliation with. Exclude those that would indicate race, religion, color, sex or
national origin.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
18. List the Full Names of all ADULTS that have resided in the same household with
you in the past ten (10) years:
Name:___________________________________________________________
Relationship:______________________________________________________
Address:_________________________________________________________
City:______________________State:____________________Zip:____________
From Date:_________________________To Date:_________________________
Persons Current Address:_____________________________________________
City:______________________State:_______________Zip_________________
List the Full Names of all ADULTS that have resided in the same household with
you in the past ten (10) years:
Name:___________________________________________________________
Relationship:______________________________________________________
Address:_________________________________________________________
City:______________________State:____________________Zip:____________
From Date:_________________________To Date:_________________________
Persons Current Address:_____________________________________________
City:______________________State:_______________Zip_________________
List the Full Names of all ADULTS that have resided in the same household with
you in the past ten (10) years:
Name:___________________________________________________________
Relationship:______________________________________________________
Address:_________________________________________________________
City:______________________State:____________________Zip:____________
From Date:_________________________To Date:_________________________
Persons Current Address:_____________________________________________
City:______________________State:_______________Zip_________________
List the Full Names of all ADULTS that have resided in the same household with you
in the past ten (10) years:
Name:___________________________________________________________
Relationship:______________________________________________________
Address:_________________________________________________________
City:______________________State:____________________Zip:____________
From Date:_________________________To Date:_________________________
Persons Current Address:_____________________________________________
City:______________________State:_______________Zip_________________
EDUCATION
19. Do you possess a
G.E.D.,
High School Diploma, or
College Degree?
(check all that apply): Received G.E.D. or High School Diploma
from:_____________________________________________________________
Received College Degree from:________________________________________
20. List all Colleges or Universities that you have attended (attach a separate sheet if
additional space is needed):
Name:__________________________________________________________
Address:________________________________________________________
City:______________________State:_________________Zip:_____________
Phone:_____________________Email:________________________________
Name:__________________________________________________________
Address:________________________________________________________
City:______________________State:_________________Zip:_____________
Phone:_____________________Email:________________________________
Name:__________________________________________________________
Address:________________________________________________________
City:______________________State:_________________Zip:_____________
Phone:_____________________Email:________________________________
21. Give a brief explanation of any academic or disciplinary problems in which you
were involved in while attending college (including academic suspension):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
22. List and explain ALL contacts that you had with college
security:___________________________________________________________
__________________________________________________________________
SKILLS AND TRAINING
23. List any special skills or training that you have received or are
licensed:___________________________________________________________
__________________________________________________________________
24. List all foreign or sign languages in which you are fluent:
__________________________________________________________________
EMPLOYMENT HISTORY
Important Notice: You must list every job you have held in the last ten (10) years
regardless of whether you feel they are relevant to the position for which you are
applying. Failure to do so will result in automatic disqualifications. Failure to
complete all required information, Names, Addresses, Dates, Phone Numbers, Etc.
may limit our ability to assess you suitability for hire, eliminate you from further
consideration.
25. List all dates of UNEMPLOYMENT in the last ten (10) years. Include the
length of unemployment and efforts to seek employment.
Unemployed From Date:________________ To Date:_________________
Efforts seeking employment:______________________________________
Unemployed From Date:________________ To Date:_________________
Efforts seeking employment:______________________________________
Unemployed From Date:________________ To Date:_________________
Efforts seeking employment:______________________________________
26. List ALL jobs you have held, including part time, temporary, and volunteer work
in the last ten (10) years with the most recent position held and work back (attach a
separate sheet if additional space is needed).
Business Name:__________________________________________________
Address:________________________________________________________
City:____________________State:____________________Zip:___________
Start Date:________________ End Date:______________________________
End Salary:________________ Supervisor:____________________________
Supervisor’s Phone Number:__________________ Cell Phone:____________
Email:__________________________________________________________
Brief Job Description:______________________________________________
Reason for leaving:________________________________________________
Business Name:__________________________________________________
Address:________________________________________________________
City:____________________State:____________________Zip:___________
Start Date:________________ End Date:______________________________
End Salary:________________ Supervisor:____________________________
Supervisor’s Phone Number:__________________ Cell Phone:____________
Email:__________________________________________________________
Brief Job Description:______________________________________________
Reason for leaving:________________________________________________
Business Name:__________________________________________________
Address:________________________________________________________
City:____________________State:____________________Zip:___________
Start Date:________________ End Date:______________________________
End Salary:________________ Supervisor:____________________________
Supervisor’s Phone Number:__________________ Cell Phone:____________
Email:__________________________________________________________
Brief Job Description:______________________________________________
Reason for leaving:________________________________________________
Business Name:__________________________________________________
Address:________________________________________________________
City:____________________State:____________________Zip:___________
Start Date:________________ End Date:______________________________
End Salary:________________ Supervisor:____________________________
Supervisor’s Phone Number:__________________ Cell Phone:____________
Email:__________________________________________________________
Brief Job Description:______________________________________________
Reason for leaving:________________________________________________
Business Name:__________________________________________________
Address:________________________________________________________
City:____________________State:____________________Zip:___________
Start Date:________________ End Date:______________________________
End Salary:________________ Supervisor:____________________________
Supervisor’s Phone Number:__________________ Cell Phone:____________
Email:__________________________________________________________
Brief Job Description:______________________________________________
Reason for leaving:________________________________________________
27. Have you ever been fired from, terminated from, or asked to resign from a job?
Yes
No
If yes please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MILITARY RECORD
Read and answer this section carefully, even if you have never served in the
military.
28. Sign the following statement if you have never served in any branch of the Armed
Forces, including the National Guard or Military Reserves. If you have served I
the military, skip the next question.
I swear or affirm that I have never served in ANY Branch of the Armed Forces at any time.
Signature:______________________________Date:______________________________
29. Are you currently participating in any military reserve or National Guard
program?
Yes
No
If “Yes” Branch of Service:_______________________________________
MOS:____________________________ Date of Enlistment:_____________
Initial Rank:_______________________ Current Rank:_________________
Commander:_______________________ Phone:_______________________
Address:_______________________________________________________
Email:_________________________________________________________
List
all duty stations and assignments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
30. List all prior military experience, attach a copy of your DD-214 (Long Form):
MOS:____________________________ Date of Enlistment:_____________
Initial Rank:_______________________ Current Rank:_________________
Commander:_______________________ Phone:_______________________
Address:_______________________________________________________
Email:_________________________________________________________
List all duty stations and assignments:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________ List any medals or awards
received:________________________________________________________________
_______________________________________________________________________
30. (Continued)
List and explain all disciplinary problems while in the military, article 15’s, UCMJ
convictions, demotions, etc.:
__________________________________________________________________
__________________________________________________________________
31. List ALL traffic summons, tickets, or citations you have ever received for the past
(10) years, regardless of disposition, i.e. Expunged etc. (Attach a separate sheet if
additional space is needed):
Charge:________________________________________________________
Date:__________________________________________________________
Agency:________________________________________________________
Location:_______________________________________________________
Court where Filed:________________________________________________
Disposition:______________________________________________________
Charge:________________________________________________________
Date:__________________________________________________________
Agency:________________________________________________________
Location:_______________________________________________________
Court where Filed:________________________________________________
Disposition:______________________________________________________
Charge:________________________________________________________
Date:__________________________________________________________
Agency:________________________________________________________
Location:_______________________________________________________
Court where Filed:________________________________________________
Disposition:______________________________________________________
32. List ALL traffic accidents in which you were the driver of the vehicle involved.
Date of Accident:______________ Monetary Amount of Damage:$:__________
Address Where Accident Occurred:____________________________________
City:______________________ State:___________________ Zip:___________
Party at Fault:______________________________________________________
Circumstances surrounding the accident:_________________________________
32. (Continued)
Date of Accident:______________ Monetary Amount of Damage:$:__________
Address Where Accident Occurred:____________________________________
City:______________________ State:___________________ Zip:___________
Party at Fault:______________________________________________________
Circumstances surrounding the accident:_________________________________
33. List EVERY State in which you have been licensed to operate a motor vehicle.
State:_________________________Year(s):__________________________
State:_________________________ Year(s):__________________________
State:_________________________ Year(s):__________________________
34. Has your license ever been suspended or revoked?
Yes
No
If yes, please give details (include when and where):_____________
_______________________________________________________
_______________________________________________________
35. Have you ever been refused automobile insurance coverage or has it ever been
cancelled?
Yes
No
If yes, please give details (include when and where):_______________
_________________________________________________________
__________________________________________________________
36. List the Insurance Company and Agent currently holding an insurance policy on the
vehicles you currently own.
Company Name:__________________________________________________
Agent:_____________________________ Phone:_______________________
City:______________________________ State:___________ Zip:__________
36. (Continued)
Company Name:__________________________________________________
Agent:_____________________________ Phone:_______________________
City:______________________________ State:___________ Zip:__________
LAW ENFORCEMENT CONTACT
37. List ALL official contact you have had with any law enforcement agency or court
system. This includes municipal, county, state, and federal agencies or court systems, as
well as military courts, military police and military investigative units, including any
judicial or non-judicial action in the military. List all incidents where you were
questioned, warned, issued a summons, detained, arrested, or convicted. This includes all
infractions, ordinance violations, misdemeanors and felonies. Do not include traffic
violations previously covered. (Attach a separate sheet if additional space is needed).
Name of Agency or Court: ____________________________________________
Date of Contact: ____________________________________________________
Name of Officer: ____________________________________________________
Reason of Contact: ___________________________________________________
Charge (if any):______________________________________________________
Sentence (if any):_____________________________________________________
Disposition of Incident: ________________________________________________
Name of Agency or Court: ____________________________________________
Date of Contact: ____________________________________________________
Name of Officer: ____________________________________________________
Reason of Contact: ___________________________________________________
Charge (if any):______________________________________________________
Sentence (if any):_____________________________________________________
Disposition of Incident: ________________________________________________
38. Have you ever been fingerprinted?
Yes
No
If “Yes” please give details (include reason, when, and where):
_______________________________________________________________
_______________________________________________________________
39. Have you ever been the victim of a crime?
Yes
No
If “Yes” please explain:
_______________________________________________________________
_______________________________________________________________
40. Have you ever been reported to a law enforcement agency as a missing person or
runaway?
Yes
No
If “Yes” please explain:
________________________________________________________________
________________________________________________________________
41. Have you ever applied for a permit to carry a concealed weapon?
Yes
No
If “Yes” Name of Law Enforcement Agency:_____________________________
Date of Application: _________________________________________________
Was the request granted?
Yes
No
Explain the purpose of carrying the concealed weapon: ____________________
_________________________________________________________________
_________________________________________________________________
42. Do you currently have any unpaid fines, court costs, or court ordered restitution?
Yes
No
If yes, give all details, including the law enforcement agency, location and court dates:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
43. List any friends, associates/relatives, past and present, which have been convicted of
a felony or participate in a criminal act. Give a brief explanation of your relationship to
the person and the criminal activity in which they are or were involved:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
44. Give a brief explanation of any neighborhood disputes in which you have been
involved in, include names of persons involved, dates and locations:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
45. Do you now, or have ever illegally used, possessed, supplied, or sold any narcotic or
controlled substance such as, but not limited to, marijuana, hashish, cocaine, LSD,
methamphetamine, heroin, steroids, pharmaceuticals, prescription drugs or drugs of
similar nature? Drug use is not necessarily an automatic disqualification. Intentionally
omitting information or falsifying information is an automatic disqualifier.
Yes
No
If “Yes” complete the following information for EACH illegal substance:
Drug Used: _____________________________________________________________
Number of Times: Used: ______Possessed: ______Supplied: _______Sold:________
Date First Time: Used: ______Possessed: ______Supplied: _______Sold:________
Date Last Time:
Used: ______Possessed: ______Supplied: _______Sold:________
Drug Used: _____________________________________________________________
Number of Times: Used: ______Possessed: ______Supplied: _______Sold:________
Date First Time: Used: ______Possessed: ______Supplied: _______Sold:________
Date Last Time:
Used: ______Possessed: ______Supplied: _______Sold:________
FINANCIAL
46. Have you ever filed for bankruptcy?
Yes
No
If “Yes”, please explain: _____________________________________________
_________________________________________________________________
__________________________________________________________________
47. Do you have any liens or encumbrances on your personal property?
Yes
No
If “Yes”, please explain: ______________________________________________
__________________________________________________________________
___________________________________________________________________
48. Have you ever had any debts turned over to a collections agency?
Yes
No
If “Yes”, please explain: ______________________________________________
__________________________________________________________________
49. Have your wages ever been garnished?
Yes
No
If “Yes”, please explain: ______________________________________________
__________________________________________________________________
50. Do you pay child support?
51. Is the child support ordered?
Yes
No
Yes
52. Are your child support payments current?
No
Yes
No
If “No”, please explain: ______________________________________________
__________________________________________________________________
53. Have you ever been delinquent with child support?
54. Do you owe overdue alimony?
Yes
Yes
No
No
If “Yes”, please explain: ______________________________________________
__________________________________________________________________
55. Have you ever been delinquent on tax due to any City, State, or Federal
Government?
Yes
No
If “Yes”, please explain: ______________________________________________
__________________________________________________________________
56. Have you ever had a civil or criminal lawsuit filed against you?
Yes
No
57. List all business ventures in which you have a financial interest in:
Name of Business:________________________________________________
Address of Business:______________________________________________
City:_________________State:_________________Zip:__________________
Name of Partners:_________________________________________________
Name of Creditors:________________________________________________
Name of Business:________________________________________________
Address of Business:______________________________________________
City:_________________State:_________________Zip:__________________
Name of Partners:_________________________________________________
Name of Creditors:________________________________________________
RESIDENCY
58. Have you ever been evicted or asked to leave a rental house, apartment, or other
dwelling?
Yes
No
If “Yes”, please explain: ______________________________________________
__________________________________________________________________
59. List the address of which you resided, on either a permanent or temporary basis for
the past (10) ten years. Start with your current address.
Address:_____________________________________________________________
City:____________________County:_________________State:______Zip:_______
Landlord’s Name:_______________________ Phone:_________________________
Address:______________________________________________________________
City:___________________State:________________________Zip:______________
Address:_____________________________________________________________
City:____________________County:_________________State:______Zip:_______
Landlord’s Name:_______________________ Phone:_________________________
Address:______________________________________________________________
City:___________________State:________________________Zip:______________
Address:_____________________________________________________________
City:____________________County:_________________State:______Zip:_______
Landlord’s Name:_______________________ Phone:_________________________
Address:______________________________________________________________
City:___________________State:________________________Zip:______________
Address:_____________________________________________________________
City:____________________County:_________________State:______Zip:_______
Landlord’s Name:_______________________ Phone:_________________________
Address:______________________________________________________________
City:___________________State:________________________Zip:______________
REFERENCES
60. List three individuals who have knowledge of your character: Excluding all relatives
and formers employers.
Name: ___________________________ Phone:_____________________
Address:_________________________ Email:______________________
City: ____________________________ State:_______________________
Name: ___________________________ Phone:_____________________
Address:_________________________ Email:______________________
City: ____________________________ State:_______________________
61. List any additional information you would like to provide that relates to your
background that you feel is important to this investigation.
__________________________________________________________________
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