Fill - Free fillable 85th RTT Application Blank 2-25-19 - 82nd_RTT_Application

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Department of State Police

Instructions Sheet

85th R.T.T. Application for State Police Trooper

1. This is a fillable PDF document. Open the document and save it to your

hard drive. The first time you save the application select “File” then select

“Save As”; select the folder you want to save the application in, create a

“file name” and select “Save”. The application is now saved and you may

work on it as time permits. Exit the web browser and be sure to fill out the

version of the application saved to your hard drive. Please use Adobe

Acrobat 7.0 or later to fill out the application.

2. Once you have saved the document you will be positioned to complete it as

time permits. Each time you work on the application “s

ave” you

r changes;

do not close the application without saving your changes as your work will

be compromised. To “save” the application, select “file” then select

“save”.

3. If asked to select an answer from a list of options please place an upper

case “X” on the line adjacent to your answer

4. Complete the application accurately and truthfully.

5. Once you have completed the application save all changes, print the

completed application, sign the original and prepare the required number of

copies.

6. You will be advised of when and how to submit your completed

application.

Note: This application may only be completed by candidates that have

receiv

ed a notification letter for the 85th RTT.

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MASSACHUSETTS STATE POLICE

85th RTT

Human Resources Section

0 Worcester Road

Framingham, Massachusetts 01702

Application and Personal History Statement – Position applied for: TROOPER Date:_____________

1. FULL NAME: If you have no middle name, enter “NMI”. If you are a Jr., Sr., III, etc., enter the same after your middle initial.

LAST NAME: ______________________________ FIRST____________________ MI_______ JR, SR, ETC.___________

DATE OF BIRTH: ________________________ SOCIAL SECURITY #:

3. PLACE OF BIRTH: (use the two-letter code for the state) COUNTRY: ________________

CITY: __________________________________ STATE: __________ ZIP CODE: ____________________

3A. ARE YOU A CITIZEN OF THE UNITED STATES? YES__________ NO__________

If you are NOT a US Citizen, provide your Certificate of Naturalization Number: __________________________________

4. OTHER NAMES USED:

(Give other names used such as your maiden name, name(s) by a former marriage, alias, etc.)

NAME_____________________________________ DATE(S) WHEN USED____________________________________

5. IDENTIFYING INFORMATION: HEIGHT:_______’_______” WEIGHT:___________ HAIR COLOR:___________

EYE COLOR:___________ MALE:______________ FEMALE:_______________

SCARS, TATTOOS OR OTHER DISTINGUISHING MARKS:

________________________________________________________________________________________________________

6. TELEPHONE NUMBERS:

WORK: ____________________ HOME: __

___________________

(Optional):________________________ FAX (Optional):________________ CELL (Optional):_________________

7. RESIDENCE:

Provide your addresses for every place you have lived, beginning with the present and working backward, since your 15

birthday. If you attended school away from your permanent residence, list the address you lived at while attending school. For any address in

the past three (3) years, list a person who knew you at that address, preferably someone who still lives in that area. If you rented, please give the

name and address of the person responsible for collecting rent.

#1 _________to Present ______________________________________________________________________________

Month/Year Street Address, Apt. No. City State/Zip

________________________________________________________________________________________________________

Name of person who knows you Street Address, Apt No. City State/Zip Telephone #

#2 __________to _________ _______________________________________________________________________________

Month/Year Street Address, Apt. No. City State/Zip

________________________________________________________________________________________________________

Name of person who knows you Street Address, Apt No. City State/Zip Telephone #

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7. RESIDENC

E (continued):

#3 __________to _________ _______________________________________________________________________________

Month/Year Street Address, Apt. No. City State/Zip

________________________________________________________________________________________________________

Name of p

erson who knows you Street Address, Apt. No. City State/Zip Telephone #

#4 __________to _________ _______________________________________________________________________________

Month/Year Street Address, Apt. No. City State/Zip

______________________

__________________________________________________________________________________

Name of pe

rson who knows you Street Address, Apt. No. City State/Zip Tele

phone #

8. EDUCATION:

Provide information about schools you are attending or, have attended, beyond Junior High School, beginning with the most

recent (#1) and working backward. For schools you attended in the past three (3) years, list a person who knows you at the school, such as an

instructor or student. For correspondence schools and extension classes, list records location and address. In the “Code” Block, use one of the

following codes: 1 = HIGH SCHOOL 2 = COLLEGE/UNIVERSITY 3 = VOCATIONAL/TRADE SCHOOL

4 = CORRESPONDENCE/EXTENSION.

#1 ________to_________ _____ ____________________________ ____________________________________

Month/Year Code Name of School Degree/Diploma (include date)

_______________________________________________________________ ____________________________________

Street Address and City of School State/Zip

___________________________ ____________________________ _______________________ ______________

Name of person who knows you Street Address, Apt. No. City/State/Zip Telephone No.

#2 ________to_________ _____ ____________________________ ____________________________________

Month/Year Code Name of School Degree/Diploma (include date)

_______________________________________________________________ ____________________________________

Street Address and City of School State/Zip

___________________________ _____________________________ _______________________ ______________

Name of person who knows you Street Address, Apt. No. City/State/Zip Telephone No.

#3 ________to_________ _____ ____________________________ ____________________________________

Month/Year Code Name of School Degree/Diploma (include date)

_______________________________________________________________ ____________________________________

Street Address and City of School State/Zip

___________________________ _____________________________ _______________________ ______________

Name of person who knows you Street Address, Apt. No. City/State/Zip Telephone No.

#4 ________to_________ _____ ____

________________________ ____________________________________

Month/Year Code Name of School Degree/Diploma (include date)

_______________________________________________________________ ____________________________________

Street Address and City of School State/Zip

___________________________ _____________________________ _______________________ ______________

Name of person who knows you Street Address, Apt. No. City/State/Zip Telephone No.

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8a. ACADEMIC RECORD: Have you ever been suspended or expelled from any high school or post-secondary school? (Post-secondary

schools include two and four year colleges, universities and business and vocational schools or any other educational institutions beyond the

high school level.) If “YES”, please explain (include school, date(s) or incident(s) and circumstances).

YES__________ NO__________

9. EMPLO

YMENT: Provide your employment history, beginning with the present (#1) and working backward ten (10) years. PLEASE

INCLUDE ALL FULL-TIME AND PART-TIME WORK, ALL PAID WORK, ANY SELF-EMPLOYMENT, ALL PERIODS OF

UNEMPLOYMENT, ACTIVE MILITARY DUTY AND VOLUNTEER WORK.

1 ________to________ ________________________________________________________ ___________________

Month/Year Employer Your Supervisor

our Title/Position

________________________________________ ___________________ ____

________ _____________________

Employer’s Street Address City State/Zip Telephone Number

________________________________________ ___________________ ____

________ _____________________

Street Address of Job Location City State/Zip Telephone Number

(If different than Employer’s Address)

________________________________________ __________________________________ _____________________

Reason for leaving

(Exclude Medical Reasons) Co-Worker(s) Telephone Number(s)

#2 ________to________ ________________________________________________________ _____________________

Month/Year Employer Your Supervisor

our Title/Position

________________________________________ ___________________ ____

________ _____________________

Employer’s Street Address City State/Zip Telephone Number

________________________________________ ___________________ ____

________ _____________________

Street Address of Job Location City State/Zip Telephone Number

(If different than Employer’s Address)

________________________________________ __________________________________ _____________________

Reason for leaving

(Exclude Medical Reasons) Co-Worker(s) Telephone Number(s)

#3 ________to________ ________________________________________________________ _____________________

Month/Year Employer Your Supervisor

our Title/Position

________________________________________ ___________________ ____

________ _____________________

Employer’s Street Address City State/Zip Telephone Number

________________________________________ ___________________ ____

________ _____________________

Street Address of Job Location City State/Zip Telephone Number

(If different than Employer’s Address)

________________________________________ __________________________________ _____________________

Reason for leaving

(Exclude Medical Reasons) Co-Worker(s) Telephone Number(s)

#4 ________to________ ________________________________________________________ _____________________

Month/Year Employer Your Supervisor

our Title/Position

________________________________________ ___________________ ____

________ _____________________

Employer’s Street Address City State/Zip Telephone Number

________________________________________ ___________________ ____

________ _____________________

Street Address of Job Location City State/Zip Telephone Number

(If different than Employer’s Address)

________________________________________ __________________________________ _____________________

Reason for leaving

(Exclude Medical Reasons) Co-Worker(s) Telephone Number(s)

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9. EMPLOYMENT (

continued):

#5 ________to________ ____________________ ________________________________ ____________________

Month/Year Employer Your Supervisor Your Title/Position

________________________________________ ___________________ ____________ _____________________

Employer’s Street Address City State/Zip Telephone Number

________________________________________ ___________________ ____________ _____________________

Street Address of Job Location City State/Zip Telephone Number

(If different than Employer’s Address)

________________________________________ __________________________________ _____________________

Reason for leaving

(Exclude Medical Reasons) Co-Worker(s) Telephone Number(s)

9a. EXTENDED ABS

ENCES FROM E MPLOYMENT:

Have you had any extended work absences for reasons other than earned

vacation (exclude medical reasons)? If “YES”, please explain (include when, name of employer, circumstances).

YES__________ NO__________

10. COMMUNITY INVOL

VEMENT:

List any activities which may reflect favorably on your application. Activities that demonstrate

leadership, responsibility, honesty, and integrity are desirable. (response is optional).

#1 ________to________ _______________________________________ ____________________________________

Month/Year Activity Location of Activity (City/County/State)

#2 ________to________ _______________________________________ ____________________________________

Month/Year Activity Location of Activity (City/County/State)

#3 ________to________ _______________________________________ ____________________________________

Month/Year Activity Location of Activity (City/County/State)

11. FOREIGN COUNTR

IES VISITED:

List foreign countries you have visited, beginning with the most recent (#1) and working backward

ten (10) years. In the “CODE” Block, use one of the following: 1 = BUSINESS; 2 = PLEASURE; 3 = EDUCATION; 4 = OTHER

#1 _________to_________ ______ _______________ #3 _________to__________ ______ ______________

Month/Year Code Country Month/Year Code Country

#2 _________to_________ ______ _______________ #4 _________to__________ ______ ______________

Month/Year Code Country Month/Year Code Country

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12. M

ILITARY HISTORY:

A. Are you registered for Selective Service? YES__________ NO___________

If “YES”, Selective Service Number _____________________________________________________________

Local Board Number ________________________ City_________________ State__________

B. H

ave you served in the United States Military? YES__________ NO___________

ave you served in the United States Merchant Marine? YES__________ NO___________

IF YOUR ANSWER TO BOTH QUESTIONS 12A AND 12B IS “NO”, GO TO QUESTION 13

IF YOUR ANSWER TO EITHER QUESTION 12A OR 12B IS “YES”, COMPLETE QUESTION 12

C. Starting with the most current (#1) and working backward, enter information for all periods of Active/Reserve Service into the table below.

In the “CODE” block use one of the following: 1 = AIR FORCE; 2 = ARMY; 3 = NAVY; 4 = MARINE CORPS; 5 = COAST

GUARD; 6 = MERCHANT MARINE; 7 = NATIONAL GUARD (For RESERVES, place an “R” after the appropriate CODE.

For example: Army Reserve would be “2R”)

INDICATE STATUS (MARK “X” IN APPROPRIATE BLOCKS – USE STATE CODE FOR NATIONAL GUARD)

MONTH/YEAR CODE RANK

STANDBY

ACTIVE

DUTY

ACTIVE

RESERVE

NATIONAL

GUARD

INACTIVE

RESERVE

RETIRED

#1________to________

#2________to________

#3________to________

#4________to________

MILITARY RECORD:

PAST COMMANDING OFFICERS OR MILITARY ACQUAINTANCES are potential sources of relevant

information pertaining to your background. Please list those individuals who know you well enough to provide accurate information about

you.

Name Contact Address/City/State/Zip Contact Telephone Years Known

1. ___________________ ______________________________________________ ___________________ ___________

2. ___________________ ______________________________________________ ___________________ ___________

3. ___________________ ______________________________________________ ___________________ ___________

MILITARY DISCHARGE AND DISCIPLINARY RECORD

A. If you have been discharged from military service, what type of discharge did you receive?

Type of Discharge ______________________________ Date of Discharge ______________________________

B. Was any type of Disciplinary action taken against you while in the Service? YES__________ NO__________

If “YES”, complete the following:

Month/Year Charge of Specification/Action Taken Place (City and County/Country if outside US)

1. ____

_____________________________________________________ _________________________________________

2. _________________________________________________________ _________________________________________

3. _________________________________________________________ _________________________________________

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13. IMMEDIATE F

AMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT:

Per E xecutive O rder 444, p lease

disclose any immediate family members, including those related to your immediate family by marriage who are employed by the

Commonwealth of M assachusetts. You are required t o complete t he i nformation below: “ Immediate family” is de fined as spouse, child,

parent, and sibling. Include those employed in all branches of state government: judicial, legislative, executive, higher education and state

authorities; and those employed as regular or contract employees or elected officials. This “sunshine disclosure” is intended to ensure that the

citizens of our Commonwealth have full confidence in their government and its hiring process. The disclosure will not be used to exclude any

qualified applicant seeking a position within the Executive Branch from receiving full consideration based on the merits of his/her credentials

and the requirements of the job. Attach additional pages if needed.

COMPLETE NAME, INCLUDING MIDDLE NAME (NO INITIALS), COMPLETE ADDRESS

#1 ______________________________ __________________ _______________ _____________________

Name of Relative Relationship to you Birth Date Birthplace

______________________________ _____________________________________ _____________________

Street Address City/State/Zip Telephone No.

_________________________________________ __________________________ _____________________

Title of Job and State Agency Supervisor/Co-Worker Telephone No.

#2 ______________________________ __________________ _______________ _____________________

Name of Relative Relationship to you Birth Date Birthplace

______________________________ _____________________________________ _____________________

Street Address City/State/Zip Telephone No.

_________________________________________ __________________________ _____________________

Title of Job and State Agency Supervisor/Co-Worker Telephone No.

#3 ______________________________ __________________ _______________ _____________________

Name of Relative Relationship to you Birth Date Birthplace

______________________________ _____________________________________ _____________________

Street Address City/State/Zip Telephone No.

_________________________________________ __________________________ _____________________

Title of Job and State Agency Supervisor/Co-Worker Telephone No.

#4 ______________________________ __________________ _______________ _____________________

Name of Relative Relationship to you Birth Date Birthplace

______________________________ _____________________________________ _____________________

Street Address City/State/Zip Telephone No.

_________________________________________ __________________________ _____________________

Title of Job and State Agency Supervisor/Co-Worker Telephone No.

13a. RELATIVES:

All applicants must provide complete information concerning their Mother, Father, Brothers and Sisters. E ven though a

relative is deceased, give al l the information requested and indicate last residence and year of death. If you have b een r aised by someone

other than your parents, the requested information should be furnished concerning them, as well as your natural parents. If you are engaged to

be married or contemplating marriage in the near future, completed information must be included for your future spouse.

(Information

concerning your

current or former spouses will be provided at Question “14”).

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Home Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Home Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Home Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

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13a. RELATIVES (continued):

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Home Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Home Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

Name of Relative Relationship to you Birth Date Birthplace

Street Address City/State/Zip Home Telephone No.

Employer Work Telephone No. Date of Death (If Applicable)

14. MARITAL STATUS:

Mark one of the following to show your current marital status:

1. ______ Never Married (go to Question 15) 2. ______ Married 3. ______ Separated

4. ______ Legally Separated 5. ______ Divorced 6. ______ Widowed

CURRENT SPOUSE: Please complete the following about your current spouse:

___________________________________ _____________ ____________________________ ________________

Full Name Date of Birth Place of Birth

(include Country if outside US) Social Security No.

______________________________________________________________________________________________________

Other Names Used (Specify Maiden name, names by other marriages, etc., and show all dates used for each name)

_______________________________ ___________ ________________________________________ _______

Country of Citizenship Date Married Place Married State

_______________________________ ________________________________________________________________

If Separated, Date of Separation If Legally Separated, where is the record located (City/State/Country)

______________________________________________________________________________________________________

Address of Current Spouse (Street, City, State and Country if outside of US)

FORMER SPOUSE: Complete the following about your former spouse(s).

___________________________________ _____________ ____________________________ ________________

Full Name Date of Birth Place of Birth

(include Country if outside US) Social Security No.

___________________________________ ___________ ________________________________________ _______

Country of Citizenship Date Married Place Married State

Check one of the below, then give date: Month/Day/Year: If Divorced, where is the record located (City/State/Country)?

Divorced Widowed ______________ _______________________________________________

Address of Former Spouse:

_____________________________________________________ ____________________________ ___________________

Street City / State Country (if outside US)

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15. PERSONS RESIDING WITH YOU: Does

anyone reside

with you, other than your spouse or relatives indicated in

Questions “13 and 14”? If “YES”, provide the information below: YES ______ NO

______

Name of Person Relationship

1. ______________________________________________________________ ____________________________

2. ______________________________________________________________ ____________________________

3. ______________________________________________________________ ____________________________

4. ______________________________________________________________ ____________________________

16. EMPLOYMENT TERMINATION: Has any

of the foll

owing happened to you in the last ten (10) years? If “YES”, begin

with the most recent occu

rrence and go backward, providing the date fired, quit, or left under conditions other than favorable:

1 = Fired from a job 4 = Lef

t a job by mutual agreement following

allegations of unsatisfactory performance

2 = Quit a job after being told you would be fired

5 = Left a job for other reasons under

3 = Left a job by mutual agreement under unfavorable unfavorable circumstances

circumstances

YES __________ NO __________

Month/Year Code Specif

y Reason Employer’s Name & Address

__________ _____ ______________________________ _________________________________________

(City, State, Zip Code)

__________ _____ ______________________________ _________________________________________

(City, State, Zip Code)

__________ _____ ______________________________ _________________________________________

(City, State, Zip Code)

17.

CRIMINAL RECORD: An applicant for employment with a record expunged pursuant to section 100F, section 100G,

section 100H or section 100K of chapter 276 may answer ‘no record’ with respect to an inquiry herein relative to prior arrests,

criminal court appearances or convictions. An applicant for employment with a record expunged pursuant to section 100F,

section 100G, section 100H or section 100K of chapter 276 may answer ‘no record’ to an inquiry herein relative to prior arrests,

criminal court appearances, juvenile court appearances, adjudications or convictions. (see MGLc276).

A. Have you ever been charged with a crime?

YES __________ NO __________

B. Have you ever been arrested, detained or booked

by a law enforcement agency?

YES __________ NO __________

C. Has a criminal complaint ever been issued against you?

YES __________ NO __________

If you answered “YE

S” to any of the

abov

e questions, explain your answer(s) in the space provided below:

_____________ __________________________________ ________________________________________________

Month/Year Offense Action Taken/Disposition

______________________________________________________________________________________________________

Law Enforcement Agency or Court

_____________ __________________________________ ________________________________________________

Month/Year Offense Action Taken/Disposition

______________________________________________________________________________________________________

Law Enforcement Agency or Court

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17a. MISSING PERSONS: Have you ever been reported to a law enforcement agency as a missing person or runaway? If “YES”,

please give details: YES __________ NO __________

Date Law Enforcement Agency Circumstances

__________ ____________________________________ ________________________________________________

18.

ILLEGAL DRUGS: Do you cu

rrently use, or have you EVER used, possessed, supplied or manufactured any illegal drugs?

When used

without a prescription, illegal drugs include cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.),

stimulants (cocaine, amphetamines, etc.) depressants (barbiturates, methaqualorte, tranquilizers, etc), hallucinogenics (LSD,

PCP,

etc) and performance enhancement drugs. NOTE: The information you provide in response to this question WILL NOT

be provided for use in any criminal proceedings against you.

YES __________ NO __________

If “YES”, provide below any information relating to the types of substance(s), the nature of the activity, and

any other details relating to your involvement with illegal drugs:

Month/Year Type of Substance Explanation

1. __________ ___________________________________ _______________________________

2. __________ ___________________________________ ______________________________________________

3. __________ ___________________________________ ______________________________________________

Have you ever used, supplied, possessed or manufactured marijuana? YES __________ NO __________

If “YES”, provide the following information:

Month/year of the first time you used supplied, possessed or manufactured marijuana

Month/year of the most recent time you used supplied, possessed or manufactured marijuana

Describe the frequency of usage:

19. GAMBLING RELATED HISTORY:

Do you gamble? Never __________ Seldom __________ Occasionally __________ Regularly __________

Have you ever placed an illegal wager or bet by telephone or made YES __________ NO __________

a hand to hand transaction with a book maker (bookie or numbers man)?

Participation in legitimate lotteries or other legalized gambling does not

require a “YES” answer.

Have you ever been “paid off” while or after playing any illegal slot YES __________ NO __________

machine or video game?

Have you ever worked for a bookie? YES __________ NO __________

Do you have any outstanding gambling debts? YES __________ NO __________

Have you ever borrowed money to gamble? YES __________ NO __________

Have you ever used an employer’s money to gamble? YES __________ NO __________

Have you ever stolen money to gamble with? YES __________ NO __________

If you answered “YES” to any of the above questions, explain below:

______________________________________________________________________________________________________

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If you answered “YES” to any of the above questions under section 19, explain below:

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20.

INVESTIGATIONS RECORD:

List ALL of the law enforcement, co

rrections, fire or EMS departments you have applied to and the YEAR you applied.

Include all federal, state, county and municipal departments. Check those steps of the hiring process that were

completed.

Department/Year Written Physical Oral Board Background Hired

Exam Exam Review Investigation

_________________________________

B. Have you ever atte

nded a public safety training academy including, but not limited to, formal training relative to work in

law enforcement, corrections, firefighting, sheriff’s departments, federal law enforcement, or like military training?

YES ________ NO__________

If you answered Yes t o t he question a bove b ut d id not complete t he training program f or a ny rea son, please use the

additional space provided at the end of this application to provide a detailed explanation of the circumstances.

Do you have experience as a sworn police/law enforcement officer? YES ________ NO _________

Do you have experience in private security? YES ________ NO _________

Do you have experience as an intern, volunteer, cadet or explorer YES ________ NO _________

with any police/law enforcement/public safety agency?

Do you have experience as a member, paid or volunteer, of any YES ________ NO _________

fire department or rescue squad?

Are you currently attending a police academy? YES ________ NO _________

If you have answered “YES” to any of the above questions, explain below and include agency, position, and length

of service.

C. Do you personally know any Massachusetts State Troopers? YES __________ NO__________

If “YES”, list their names and duty station if known, and length of time you have known them.

D. Do you have any family members/relatives who are current or past members of a law enforcement agency?

If “YES” please list name, relationship and their department/agency YES____________ NO__________

_________________________________________________________________________________________________

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20. I

NVESTIGATIONS RECORD (continued):

E. I

f you are a current or former police officer, answer the following questions, if not, go to Question “21”.

ave you ever been the subject of an internal investigation YES __________ NO__________

or citizens complaint?

ave you ever been suspended from duty, with or without YES __________ NO__________

your police powers, for any reason except medical?

ave you ever been subjected to departmental disciplinary action? YES __________ NO__________

ave you ever been involved in any traffic accident while YES __________ NO__________

operating a departmental or government vehicle?

ave you ever received less than satisfactory performance YES __________ NO__________

reports or evaluations?

ave you ever been questioned/interviewed/interrogated YES __________ NO__________

by your department’s internal affairs unit?

ave you ever discharged your service weapon either YES __________ NO__________

on-duty or off-duty, other than for training purposes or

for authorized animal destruction?

ave you ever been deemed untruthful in any judicial or YES __________ NO__________

administrative proceeding?

ave you ever been charged with or, investigated for, use YES __________ NO__________

of excessive force or police brutality?

ave you ever been investigated by your current or past YES __________ NO__________

agency for an allegation of domestic violence or spousal abuse?

f you answered “YES” to any of the above questions, fully explain all circumstances below:

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21. F

INANCIAL RECORD:

A. In the last seven (7) years, have you, or a company of which you own 10% or more, filed for bankruptcy, been

declared bankrupt, been subject to a t ax lien, or had legal judgement rendered against it for a d ebt? I f you answer

“YES”, provide the date of initial action and other information requested below:

YES __________ NO __________

Month/Year Type of Action Business Name Name of Court of Jurisdiction (City/State/Zip)

1. __________ ___________________ _____________________ _________________________________________

2. __________ ___________________ _____________________ _________________________________________

3. __________ ___________________ _____________________ _________________________________________

B. A

re you now over 180 da ys delinquent on a ny loan or financial obligation? I

nclude loan or obligations funded or

guaranteed by the Federal Government. If yo

u answer “YES”, provide the information requested below:

YES __________ NO __________

onth/Year Type of or obligation (Account #) Name/Address of Creditor or Obligee (State/Zip)

1. __________ ________________________________________ _________________________________________

2. __________ ________________________________________ _________________________________________

3. __________ ________________________________________ _________________________________________

C. List all loans whose principal outstanding balance exceeds $1,000.00 and, on which you are individually or jointly

lia

ble either directly or as a guarantor:

Lender Loan # Original Balance Outstanding Balance Purpose of Loan

1. __________________ __________________ ______________ _________________ ___________________

2. __________________ __________________ ______________ _________________ ___________________

3. __________________ __________________ ______________ _________________ ___________________

D. S

UPPORT ORDERS

1. Are there any orders/agreements entered in court against you regarding YES_____ NO_____

child support/alimony? If “NO”, go to Question “22”

2. If “YES” to Question 1, are the orders/agreements being complied with? YES_____ NO_____

3. If “YES” to Question 1, have there been any previous compliance issues YES_____ NO_____

with these orders/agreements?

If you answered “YES” to 1, 2, or 3 above, explain your answer(s) in the space below (include court,

judgement, and penalties):

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22. INCOME TAXES:

A. Have your Massachusetts Tax Returns been filed on time for the last seven (7) years? YES_____ NO_____

B. Have your Federal Tax Returns been filed on time for the last seven (7) years? YES_____ NO_____

C. Are you delinquent on any Local, State or Federal Tax liabilities? YES_____ NO_____

If you answered “YES” to C, or “NO” to A or B above, explain your answer(s) in the space provided below:

23. B

USINESS INVOLVEMENT:

A. Do you presently own, or within the last seven (7) years have you owned more than 10% of the following:

1. A Company YES_____ NO_____

2. A Partnership (include general or limited partnership) YES_____ NO_____

3. Joint Venture YES_____ NO_____

4. Joint Enterprise YES_____ NO_____

If you answered “YES”, provide the required information below:

Name of Business Location (Address/City/Zip) Percentage Owned

1. _____________________________________ _________________________________ ________________

2. _____________________________________ _________________________________ ________________

f the company does business with the Commonwealth, list the agencies and the nature of business conducted.

Agency Nature of business conducted

1. _____________________________________________________ _______________________________________

2. _____________________________________________________ _______________________________________

3. _____________________________________________________ _______________________________________

4. _____________________________________________________ _______________________________________

B. D

o you or a ny member o f your immediate family (spouse or child) hold a 10% or g reater equity i nterest, in a

usiness entity (include general or limited partnership, joint venture or enterprise)? YES_____ NO_____

f you answered “YES”, provide the information required in the space provided below:

Name of Business Location (Address/City/Zip) Percentage Owned

1. _________________________________ ________________________________________ ________________

2. _________________________________ ________________________________________ ________________

o owns the Business Interest? Describe the Nature of the Business

1. ____________________________________________ ________________________________________________

2. ____________________________________________ ________________________________________________

24. CIVIL/PROBATE LITIGATION:

A. To the best of your knowledge, are there any civil/probate actions pending against you? YES_____ NO_____

B. Have there been any civil/probate actions concluded against you within the past seve

(7)

years favorably or adversely? YES_____ NO_____

If you answered “YES” to A or B above, explain your answer(s) in the space below. (If known, include: court(s), case

name(s), docket number(s), nature of lawsuit and outcome).

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USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

25. P

REVIOUS INTERACTIONS WITH STATE AGENCIES:

A. Have you ever filed a financial disclosure form with the State YES_____ NO_____

Ethics Commission or a similar body in another state?

If “YES”, submit with this application a copy of your most recent submission.

B. Have any proceedings been instituted against you by the State Ethics YES_____ NO_____

Commission or a similar body in another state?

C. To your knowledge, have any complaints or disciplinary actions been YES_____ NO_____

filed against you with regard to any licenses or registrations you possess?

D. To your knowledge, have any complaints or disciplinary actions been filed against YES_____ NO_____

you with regard to your membership in any professional or trade association(s)?

E. Do you presently have any business, hearings, complaints, or claims YES_____ NO_____

or any other matters pending before any regulatory agency or board?

F. Within the past seven (7) years, have you had any business, hearing, YES_____ NO_____

complaint or claim with any regulatory agency or board?

If you answered “YES” t o B, C , D, E, o r F above, explain your answer(s) i n the s pace below. ( Include nature of

allegations, date and outcome of proceedings):

26. LI

CENSES:

A. Are you a licensed motor vehicle operator? YES_____ NO_____

If “YES”, please provide the information requested below:

river’s License Number State Expiration Date Restrictions (if any) Status (active, revoked, etc.)

_____________________ ______ ______________ ____________________ ____________________________

B. P

lease list other states where you have been a licensed motor vehicle operator:

License Number State License Number State

___________________ _____ ____________________ _____

C. Have you ever been refused a driver’s license for non-medical reasons? If “YES”, please explain (include when, where

and why): YES_____ NO_____

Month/Year State Circumstances

_____________ ____

D. Has your license, in any state, ever been suspended or revoked f or non-medical reasons? If “YES”, provide details

below (include why, when, length of time taken away): YES_____ NO_____

E. Have you received any traffic citations (excluding parking tickets) within the last seven (7) years?

If “YES”, list all traffic citations and other information requested below: YES_____ NO_____

ature of violation Location (City, State) Approximate Da

te Action Taken

1. __________________________ ______________________ ________________ _________________________

2. __________________________ ______________________ ________________ _________________________

3. __________________________ ______________________ ________________ _________________________

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USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

26. LI

CENSES (continued):

F. Have you ever been involved, as a driver of a motor vehicle,

in an accident within the last seven (7) years? YES_____ NO_____

If “YES”, please give details for each accident in the spaces below:

Mon

th/Day/Year Location (City/State) Injuries (yes or no) Investigating Police Agency, if any

1. _______________ _____________________________ ________________ ________________________________

2. _______________ _____________________________ ________________ ________________________________

3. _______________ _____________________________ ________________ ________________________________

G. Li

st all motor vehicles currently owned, registered to or operated by the applicant.

#1 Make________________________ Model_______________________ Reg. #_____________ State______

Automobile Insurance Company(s)________________________________ Agent_________________________

Policy #______________________ Address__________________________________ Phone #____________

#2 Mak

e________________________ Model_______________________ Reg. #_____________ State______

Automobile Insurance Company(s)________________________________ Agent_________________________

Policy #______________________ Address__________________________________ Phone #____________

#3 Mak

e________________________ Model_______________________ Reg. #_____________ State______

Automobile Insurance Company(s)________________________________ Agent_________________________

Policy #______________________ Address__________________________________ Phone #____________

26a. Do you possess any other license(s), permit(s), or registration(s) such as

Firearms, Professional, Trade, etc.? YES_____ NO_____

If “YES”, provide the information required below:

Type of License License Number Date Issued Date of Expiration

1. ________________________ _________________________ _____________________ __________________

2. ________________________ _________________________ _____________________ __________________

3. ________________________ _________________________ _____________________ __________________

Issuing State Issuing Agency (include address)

1. ________________________ ________________________________________________________________________

2. ________________________ ________________________________________________________________________

3. ________________________ ________________________________________________________________________

ve y ou ev er been d enied or h ad a p ermit t o ca rry a firearm of F ID ca rd suspended o r rev oked f or non-medical

reasons? If “YES”, explain: YES_____ NO_____

____________________________________________________________________________________________________

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USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

27. P

ROFESSIONAL / TRADE ASSOCIATIONS:

Do you hold membership in any professional or trade organization(s) YES_____ NO_____

If “YES”, provide the information required below:

Organization Address Type Present member position held

1. ____________________________ _______________________ ____________ ____________________________

2. ____________________________ _______________________ ____________ ____________________________

3. ____________________________ _______________________ ____________ ____________________________

28. R

EAL PROPERTY: List any real property in which you, your spouse, or your minor children have an equity or financial

interest

Property Address Owner Relationship (self, spouse, etc.)

1. _____________________________________ ___________________________ ____________________________

2. _____________________________________ ___________________________ ____________________________

3. _____________________________________ ___________________________ ____________________________

29. R

EFERENCES: Provide

TEN references from at least four of the different categories listed below. People who are

included in previous sections should not be used as references.

Relatives:

Name:___________________________________________________ R

elationship:________________________________

Address:_____________________________________________________________________________________________

Telephone: ______________________________________________ How long have you known this person?___________

ame:___________________________________________________ Relationship:________________________________

Address:_____________________________________________________________________________________________

Telephone: ______________________________________________ How long have you known this person?___________

Teachers:

Name:___________________________________________________ R

elationship:________________________________

Address:_____________________________________________________________________________________________

Telephone: ______________________________________________ How long have you known this person?___________

ame:___________________________________________________ Relationship:________________________________

Address:_____________________________________________________________________________________________

Telephone: ______________________________________________ How long have you known this person?___________

Co-Workers

Name:___________________________________________________ Relationship:________________________________

Address:_____________________________________________________________________________________________

Telephone: ______________________________________________ How long have you known this person?___________

ame:___________________________________________________ Relationship:________________________________

Address:_____________________________________________________________________________________________

Telephone: ______________________________________________ How long have you known this person?___________

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USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

29. R

EFERENCES (continued):

Friends / Associates

ame:___________________________________________________ Relationship:________________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

ame:___________________________________________________ Relationship:_____

___________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

Roommates (past and present)

ame:___________________________________________________ Relationship:________________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?___________

Name:________

___________________________________________ Relationship:_____

___________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

Clergy Members

ame:___________________________________________________ Relationship:________________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

ame:___________________________________________________ Relationship:_____

___________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

Community Leaders

ame:___________________________________________________ Relationship:________________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

ame:___________________________________________________ Relationship:_____

___________________________

ddress:_____________________________________________________________________________________________

lephone: ______________________________________________ How long have you known this person?_____

______

- 20 -

USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

29. R

EFERENCES (continued):

Police / Government

ame:___________________________________________________ Relationship:________________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?_____

______

ame:___________________________________________________ Relationship:_____

___________________________

ddress:_____________________________________________________________________________________________

elephone: ______________________________________________ How long have you known this person?___________

THE DEPARTMENT OF STATE POLICE IS AN EQUAL OPPORTUNITY EMPLOYER

- 21 -

USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

CONTINUATION SPACE

Use the space below to continue answers to all questions and any information you would like to add. If more space is needed

than what is provided below, use a blank sheet(s) of paper. Start each sheet with your Name and Social Security Number.

Identify the number of the question.

- 22 -

USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

Signature Page

After completing this form and any attachments, you should review all your

answers to ensure the form is complete and accurate. Submit the original and keep

a copy for your files.”

Certification that my answers are true:

I have read each question asked of me and understand each question. My

statements on this form and any attachments to this form are true and correct to the

best of my knowledge and belief and are made in good faith.

__________

___________________________ __________________

Signature (sign in ink) Date

It is unlawful in Massachusetts to require or administer a polygraph as a condition of employment or continued

employment. An employer who violates this law shall be subject to criminal penalties and civil liability (MGL c149

§19b).

- 23 -

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Com

monwealth of Massachusetts

Department of State Police

AGREEMENT

Carefully read each statement below, and after having the form notarized, return it with your

application.

1. I authorize investigation of all statements contained in this Application and Personal History Statement

Form as may be necessary in arriving at an employment decision.

2. I understand that this Application and Personal History Statement is but one element of the selection

process for Trooper Trainee, and that an acceptable background investigation does not guarantee my

selection as a Trooper Trainee.

3. I understand that false or misleading information given herein or during interview(s) will result in my

being disqualified from further consideration and/or terminated from employment with the Department

of State Police.

4. I understand and agree that information about me, provided by individuals, and the identity of those

individuals are considered confidential and will not be disclosed to me.

Applicant’s Full Name (type or print legibly): ___________________________________________________

Applicant’s Signature: ___________________________________________________

Applicant’s Home Address: ___________________________________________________

___________________________________________________

Date: ___________________________________________________

MUST BE SIGNED IN THE PRESENCE OF A NOTARY

On this, the ________ day of _____________________, 20___, before me, the undersigned Notary Public,

personally appeared __________________________, proved to me through satisfactory evidence of

identification, which was/were ________________________________ to be the person whose name is signed

on this document and who swore or affirmed to me that the contents of the Document are truthful and accurate

to the best of his/her knowledge and belief.

Notary Public

- 24 -

USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

NAME:______________________________________ ______ _______________________________________________________

First Name Middle Initial Last Name

PREVIOUS NAME OR ALIAS (Include Maiden name): _____________________________________________________________

RESIDENTI

AL ADDRESS: ___________ ________________________________________________________________________

(Not a Post Office Box) Number

Street

__________________________________________ _____________________________________________ _________________

City/Town

State Zip Code

MAILING ADDRESS (If different)_______________________________________________________________________________

SOCIAL SECURITY NO.: DRIVERS LICENSE NUMBER:___________________________

DATE OF BIRTH

PLACE OF BIRTH:_______________________________________________________

I, , do hereby authorize a review of and a full disclosure of all records, or any part thereof, concerning myself,

by and to ANY duly authorized agent of the Department of State Police, whether the said records are public, private or confidential in nature.

The intent of this authorization is to give my consent for a full and complete disclosure of the records of educational institutions; financial or credit

institutions, including records of deposits, withdrawals and balances of checking and saving accounts, and loans, and also the records of commercial or retail

credit agencies (including credit reports and/or ratings); public utility companies; employers including but not limited to employment and pre-employment

records, background reports, efficiency ratings, complaints and/or grievances filed by me or against me, and salary records; real and personal property tax

statements and records, and other financial statements and records wherever filed; records of complaint, arrest, trial, and/or convictions for alleged or actual

violations of the law, including criminal, civil and/or traffic records; records of complaint of a civil/probate nature made by or against me, wheresoever

located, and to include the records and recollections of attorneys at law, or of other counsel, whether representing me or another person in any case in which I

presently have an interest.

I reiterate, and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the

specific purpose of pursuing a background investigation which may provide pertinent data for the Department of State Police to consider in determining my

suitability for employment by the Department of State Police. It is my specific intent to provide access to personal information, however personal or

confidential it may be, and the sources of information specifically identified herein.

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 Department of State Police. I understand that all materials

pertaining to this background investigation become the property of the Department of State Police and will not be returned or provided to me.

I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims, damages,

losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request. I further understand that in the event my

application is disapproved, the sources of confidential information cannot and will not be revealed to me.

I understand a photocopy of this release form will be valid as an original hereof, even though said photocopy does not contain an original writing of my

signature.

MUST BE SIGNED IN THE PRESENCE OF A NOTARY

On this, the ________ day of _____________________, 20___, before me, the Signature:

undersigned Notary Public, personally appeared __________________________,

proved to me through satisfactory evidence of identification, which was/were Street Address

________________________________ to be the person whose name is signed

on this document and who swore or affirmed to me that the contents of the City:

document are truthful and accurate to the best of his/her knowledge and belief.

State:

Notary Public Zip Code:

The Commonwealth of

Massachusetts

Department of State

Police

Human Resources Section

470 Worcester Road, Framingham, MA 01702

(508) 820-

2292

- 25 -

USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING NOTICE

PLEASE READ BEFORE SIGNING

If an offer of employment is made to you, the Department of State Police (hereinafter “the Department”), as a Commonwealth

of Massachusetts employer (hereinafter “the Commonwealth”), may specify that it is contingent upon the results of a medical

examination. I freely and voluntarily agree to submit to a pre-employment physical and/or drug screen, as it relates to the

requirements of a specific job, as part of my pre-employment application to the Department and the Commonwealth. I

understand that either refusal to submit to such screening, or failure to qualify according to the minimum standards

established by the Department for this screening, may disqualify me from further consideration for employment. Further, I

understand that any positive drug test results will be communicated in a confidential manner.

I hereby acknowledge that I have read in full and understand the above statements.

_____________________________

Signature of Applicant Date

____________________________________________________

Printed Name

- 26 -

USE CONTINUATION SPACE OR ADDITIONAL PAGES IF NECESSARY

COMMONWEALTH OF MASSACHUSETTS

Department of State Police

AFFIRMATIVE ACTION DATA RECORD

CONFIDENTIAL

The Department of

State Police, as a Commonwealth of Massachusetts employer, is committed in spirit as well as in

action to abide by all laws dealing with equal employment opportunity. It is our policy to guarantee equal employment

opportunities for all qualified persons without regard to their age, race, creed, color, national origin, ancestry, marital

status, gender, military status, sexual orientation, or disability, which can be reasonably accommodated.

Further, the D

epartment will act in good faith to affirmatively recruit and consider for promotion individuals in protected

categories. Age, race, creed, color, national origin, ancestry, marital status, gender, military status, sexual orientation, or

disability are not factors in employment, promotion, transfer, compensation, lay-off, disciplining and termination.

In order to effec

tively monitor the success of our recruitment and employment efforts, it is requested that you provide the

following information.

The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Affirmative Action Data Records are kept in a

confidential file and are not a part of your application for employment or your personnel file. Your cooperation is voluntary. Inclusion or exclusion of any affirmative

action data will not jeopardize or adversely affect any employment decision.

(PLEASE PRINT)

me (First) (Middle) (Last)

Address (Street) (City) (State) (Zip/Postal Code)

Telephone Number (s)

National ID (Social Security Number)

CHECK ONE Male Female

Check one of the following: (Race)

White B

lack Hispanic Asian/Pacific Islander Native American (American Indian or Alaskan Native)

(If Native American, please attach documentation of tribal affiliation)

Check if the following is applicable:

Vietnam Era Veteran*

(Ninety (90) days of active duty service, any part of which occurred between August 5, 1964 and May 7, 1975)

*In order to qualify for Affirmative Action status as a Vietnam Era Veteran, you must apply for Eligibility Certification

which is issued by the State Office of Affirmative Action. Forms are available from the State Office of Affirmativ

ction, (617) 727-

7441.

__________________________________ ________________________

pplicant Signature Date

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