Fillable AUTHORIZATION RELEASE OF INFORMATION This release, when presented (CITY OF LINDALE)

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AUTHORIZATION RELEASE OF INFORMATION This release, when presented (CITY OF LINDALE)

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1
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
LINDALE POLICE DEPARTMENT
105 BALLARD DRIVE LINDALE, TX 75771 PH. 903-882-3313 FAX 903-882-1054
AUTHORIZATION RELEASE OF INFORMATION
Last Name
First Name
Middle Name
Sex
Race
DOB
Address
County
State
Zip Code
This release, when presented by a duly authorized representative of the Lindale Police Department, constitutes my consent
and authority to examine and obtain copies and abstracts of records and to receive statements and information regarding my
background. This includes whether the records are public, private or confidential. THIS AUTHORIZATION DOES NOT
INCLUDE ANY MEDICALLY RELATED HISTORY OR WORKER’S COMPENSATION CLAIMS.
Specifically, I authorize the release of the following data or records to the Lindale Police Department: Employment and Pre-
employment records; including background reports, efficiency ratings, complaints or grievances filed by or against me,
records of recollections of attorneys at law or other counsel, whether representing me or another person in any case, either
civil or criminal, in which I presently have, or have had an interest, excluding any medical malpractice cases or worker’s
compensation claims. Also included are Educational records, Selective Service, Police and Criminal, Motor vehicle and
Driving, Financial and Credit, and Polygraph Examinations.
This authorization is given in connection with a background investigation being conducted relative to my application for or
continued employment with the Lindale Police Department. 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 an investigation, which may provide
pertinent data for the Lindale Police Department, to consider my suitability for employment.
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 Lindale Police Department. I understand that all materials pertaining to this background investigation
become the property of the Lindale Police Department and will not be returned to me.
I agree to indemnify and hold harmless the person to whom this request is presented and his/her 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 confidential
information or source(s) of information will not be revealed to me.
A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an
original writing of my signature.
MUST BE SIGNED IN THE PRESENCE OF A NOTARY:
State of ________________________________:
County/City of__________________________:
Subscribed and sworn before me this ______________ day of _____________, 20______.
My commission expires _______________________, (Signature of Notary)_____________________________________.
Signature________________________________________
Street Address____________________________________
City, State, Zip Code_______________________________
2
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
LINDALE POLICE DEPARTMENT
105 BALLARD DRIVE LINDALE, TX 75771 PH. 903-882-3313 FAX 903-882-1054
Last Name
First Name
Middle Name
Sex
Race
DOB
Address
County
State
Zip Code
Position(s) Applied For:
PERSONAL HISTORY STATEMENT INSTRUCTIONS
Employees are exposed to confidential and law enforcement sensitive information. A thorough background investigation is
required to property evaluate the suitability of applicants for employment with the agency. Although it is an achievement to
reach the background phase of the hiring process, this is still a competitive process and does not, in any way guaranty
selection.
These instructions are provided as a guide to assist you in properly completing your Persona History Statement. It is essential
that the information is accurate in all respects so please read all instructions carefully before proceeding. The Personal History
Statement will be used as a basis for a background investigation that will determine your eligibility for becoming an employee.
1. Your application must be printed legibly in BLACK INK or typed. Answer all questions truthfully and accurately.
2. If a question is not applicable to you, enter N/A in the space provided.
3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is
accurate and in proper sequence before you begin.
4. You are responsible for obtaining correct and full addresses. If you are not sure of an address, personally verify
before making that entry on this history statement. Errors will not be viewed favorably. ALL ADDRESSES MUST BE
COMPLETE WITH ZIP CODES.
5. If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what question
number and page this refers to.
6. An accurate and complete form will help expedite your investigation. Omissions or falsifications will result in
disqualification.
7. You are responsible for furnishing any changes and/or updating your application as needed, such as address changes
or telephone changes in writing.
8. Any candidate submitting an incomplete application WILL NOT BE CONSIDERED FOR EMPLOYMENT. Your
application will be evaluated on completeness and neatness.
9. All documents requested must be submitted with application (photocopies are acceptable in most cases). Required
documents vary according to the position being sought and the history of the applicant. Hiring agency please check
off documents required – modify the list as necessary.
Completed Personal History Statement.
Copy of your Social Security Card.
Original certified copy of your birth certificate. (No photocopy)
Copy of your valid Texas driver license or a copy of another State’s driver license. Applicant must possess a valid
Texas driver license prior to employment.
Copy of your high school diploma or GED certificate or an honorable discharge from the armed forces of the United
States after at least twenty four months of active service.
Sealed original certified copy of your college transcript. (No photocopy)
Photocopy of your college diploma.
Copy of your Peace Officer Certificate from your police academy. (Peace Officer Applicants Only)
Copy of your Texas peace officer license and all training certificates awarded to you. (Peace Officer Applicant Only)
Copy of your DD-214 if applicable. Must Possess an honorable discharge with an RE-1 or RE-2 equivalent
enlistment code.
Telecommunicator
3
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
Original certified copy of you Naturalization papers N-550 or Certificate of Citizenship N-600, if applicable.
Copy of current proof of automobile liability insurance.
Copy of a TCOLE approved Firearms Qualifications within the last 12 months.
10. If you have any questions, please contact your assigned background investigator or agency contact.
11. When submitting the completed documents, please place them in a sealed envelope marked Personal and
Confidential to your assigned background investigator or agency contact.
Before you begin to fill out this personal history statement, please ensure that you meet the following requirements. You
must meet all five of these requirements to qualify for licensure as a peace officer or telecommunicator in Texas and our
agency.
I am a citizen of the United States of America and can legally be employed.
I have earned a high school diploma, a GED or an honorable discharge from the armed services of the United States after
at least two years of active service.
I have never been convicted, plead guilty (nolo contender), not have I been on court-ordered community service/
probation or deferred adjudication for a Class A misdemeanor or a felony.
During the last ten (10) years, I have not been convicted, plead guilty (nolo contender), been on community service/
probation or deferred adjudication for a Class B misdemeanor in this state, other state, or while serving in the military.
I have never had a military court martial that resulted in a dishonorable or other discharge based on misconduct which
bars future military service.
DISQUALIFICATIONS
There are very few automatic bases for rejection. Even issues of prior misconduct, employee terminations, and arrest
are usually not, in and of themselves, automatically disqualifying. Hover, deliberate misstatements or omissions can and
often will results in your application being rejected, regardless of the nature or reason for the misstatements/omissions.
In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or
misrepresent job-relevant information from their prospective employer.
This personal history statement is a governmental document. Be truthful, as there are criminal consequences for lying
on a governmental document.
Once you begin:
• Type or neatly print, in ink, responses to all items and questions. If a question does not apply to you, write “N/A”
(not applicable) in the space provided for your response. If you cannot obtain or remember certain information,
indicate so in your response.
• If you need additional space for your answers, attach additional sheet as needed. Be sure to indicate what question
number and page this refers to.
Be as complete, honest and specific as possible in your response.
Disclosure of Medically Related Information
In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring process, applicants are not
expected or required to reveal any medical or other disability-related information about themselves in response to
questions on this form, or to any other inquiry made prior to receiving a conditional offer of employment.
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LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
SECTION 1: PERSONAL
1. Last Name
First
MI
Suffix
2. Other Names, including nicknames, you have used or been known by.
3. Street Address, (Apt, Unit)
City
State
Zip
4. Address if different from above.
5. Phone #. Home
Cell
Work Ext.
Fax
Other
6. Email: Home
Business
Other
7. Birth Place (City, County, State, Country)
8. DOB
9. Social Security Number
10. Drivers License #
11. Physical description
HT.
WT.
Hair Color
Eye Color
State:
Exp:
12. Have you ever attended a basic licensing course? YES NO
If yes, did you graduate: YES NO
A. Academy Name
From:
To:
PID#:
Location (City/State)
Name of Training Coordinator
Contact Number
B. Academy Name
From:
To:
PID#:
Location (City/State)
Name of Training Coordinator
Contact Number
13. Have you ever applied to any other law enforcement agency in the last ten years (City, County, State or Federal)?
• If, yes, list ALL agencies you have applied to, starting with the most recent (give complete and accurate
addresses).
• All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for each
agency.
• If you need additional space for your answers, attach additional sheet as needed. Be sure to indicate what
question number and page this refers to.
A. Name of Agency
Position Applied For
Date Applied
Address Number and Street
City
State
Zip
Background Investigators Name (If Known)
Contact Number Ext.
Email
Check each step in the process that you completed and your status:
Steps:
Application
Written
Physical Agility
Oral
Polygraph/CVSA
Background
Chief’s Oral Interview
Conditional Job Offer
Psychological Examination Date _________________
Medical Exam Date________________
Status:
Hired
On List
Withdrawn
Disqualified
5
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
B. Name of Agency
Position Applied For
Date Applied
Address Number and Street
City
State
Zip
Background Investigators Name (If Known)
Contact Number Ext.
Email
Check each step in the process that you completed and your status:
Steps:
Application
Written
Physical Agility
Oral
Polygraph/CVSA
Background
Chief’s Oral Interview
Conditional Job Offer
Psychological Examination Date _________________
Medical Exam Date________________
Status:
Hired
On List
Withdrawn
Disqualified
C. Name of Agency
Position Applied For
Date Applied
Address Number and Street
City
State
Zip
Background Investigators Name (If Known)
Contact Number Ext.
Email
Check each step in the process that you completed and your status:
Steps:
Application
Written
Physical Agility
Oral
Polygraph/CVSA
Background
Chief’s Oral Interview
Conditional Job Offer
Psychological Examination Date _________________
Medical Exam Date________________
Status:
Hired
On List
Withdrawn
Disqualified
6
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
SECTION 2: RELATIVES AND REFERENCES
14. Immediately Family
• Provide all applicable information in the spaces below.
• Mark “N/A” if a category is not applicable or if the individual is deceased.
• If you need additional space for you answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to.
N/A
A. Father Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
N/A
B. Step-Father Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
N/A
C. Mother Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
N/A
D. Step-Mother Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
N/A
E. Spouse/ Domestic Partner Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
7
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
N/A
F. Father-in-Law Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
N/A
G. Mother-in-Law Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
N/A
H. Former Spouse(s)/
Cohabitant
Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
Year of Dissolution
Is there or has there been a restraining, emergency protective order or protective order in
effect at any time for this individual? YES NO
If yes, please explain.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
N/A
I. Former Spouse(s)/
Cohabitant
Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
Year of Dissolution
Is there or has there been a restraining, emergency protective order or protective order in
effect at any time for this individual? YES NO
If yes, please explain.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
8
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
N/A
J. Brothers and Sisters: List all living siblings, including half-siblings, foster siblings, etc…
1. Name
DOB
Male Female
Home Address
City
State
Zip
Work Address N/A
City
State
Zip
Home Phone
Cell
Work Phone N/A
Email
N/A
2. Name
DOB
Male Female
Home Address
City
State
Zip
Work Address N/A
City
State
Zip
Home Phone
Cell
Work Phone N/A
Email
N/A
3. Name
DOB
Male Female
Home Address
City
State
Zip
Work Address N/A
City
State
Zip
Home Phone
Cell
Work Phone N/A
Email
N/A
4. Name
DOB
Male Female
Home Address
City
State
Zip
Work Address N/A
City
State
Zip
Home Phone
Cell
Work Phone N/A
Email
N/A
5. Name
DOB
Male Female
Home Address
City
State
Zip
Work Address N/A
City
State
Zip
Home Phone
Cell
Work Phone
N/A
Email
9
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
N/A
K. Children List all of your living children, including natural, adopted, step, and/or foster care. Include any
other children who reside with you. Provide the name and contact information of the custodial parent of
guardian, if other than you.
1. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
2. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
3. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
4. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
5. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
6. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
7. Name
Custodial Guardian/Parent (If other than you.)
Male
Female
Home Address
City
State
Zip
DOB
Home or Cell Phone
Email
10
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
15. REFERENCES
List 7-10 people who you know well, such as social and family friends, co-workers, military acquaintances. Do not include
relatives, employers or housemates, or other individuals listed elsewhere.
A. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
B. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
C. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
D. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
E. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
11
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
F. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
G. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
H. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
I. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
J. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
K. Name
Address
City
State
Zip
Company/ Work Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this person?
12
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
SECTION 3: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.
16. Check applicable: High School Diploma GED Discharge documents from armed service with 2 years active duty
17. List High Schools Attended or where you obtained your GED.
A. Name
City
State
From
To
Did you graduate? Yes No
B. Name
City
State
From
To
Did you graduate? Yes No
C. Name
City
State
From
To
Did you graduate? Yes No
18. List all colleges or universities attended:
A. Name
City
State
From
To
Type of Degree Earned
Total Units Earned
B. Name
City
State
From
To
Type of Degree Earned
Total Units Earned
19. List any trade, vocational, or business schools/ institutes attended.
A. Name
From
To
Did you complete the course?
YES NO
Type of School or training
City
State
B. Name
From
To
Did you complete the course?
YES NO
Type of School or training
City
State
C. Name
From
To
Did you complete the course?
YES NO
Type of School or training
City
State
SECTION 3: EDUCATION continued.
20. Have you ever been placed on academic discipline, suspended or expelled from any high school, college/university,
business or trade school? YES NO
If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or
education institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation of
circumstances.
13
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
SECTION 4: RESIDENCE
21. LIST OF RESIDENCE
• List all residences during the last ten years or since age 17. Provide complete addresses (include markers such
as Street, Drive, Road, East, West, etc., and unit or apartment number.) Do no use P. O. Boxes.
• If the residence is a military base, identify name of base in address, nearest city, state, and zip code. DO NOT
LIST military barracks mates unless you shared individual quarters.
• If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to.
A. Current residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you live
B. Former Residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you lived
Reason for Moving
C. Former Residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you lived
Reason for Moving
D. Former Residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you lived
Reason for Moving
14
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
E. Former Residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you lived
Reason for Moving
F. Former Residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you lived
Reason for Moving
G. Former Residence (Number and street)
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City, State, Zip
Email
N/A
Names of those with whom you lived
Reason for Moving
22. Provide contact information for all housemates listed in Question 21 with whom you have resided during the past 10
years, or since the age of 17. DO NOT list anyone for whom you have already provided contact information. If you need
additional space for you answers, attach additional sheets as needed. Be sure to indicate what question number and
page this refers to.
A. Name
Contact Number
Current Address
City
State
Zip
Nature of relationship (friend, relative, landlord, housemates only)
Email
B. Name
Contact Number
Address
City
State
Zip
Nature of relationship (friend, relative, landlord, housemates only)
Email
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LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
C. Name
Contact Number
Address
City
State
Zip
Nature of relationship (friend, relative, landlord, housemates only)
Email
D. Name
Contact Number
Address
City
State
Zip
Nature of relationship (friend, relative, landlord, housemates only)
Email
E. Name
Contact Number
Address
City
State
Zip
Nature of relationship (friend, relative, landlord, housemates only)
Email
F. Name
Contact Number
Address
City
State
Zip
Nature of relationship (friend, relative, landlord, housemates only)
Email
23. Have you ever been evicted or asked to leave a residence? YES NO
24. Have you ever left a residence owing rent? YES NO
If you answered yes to Questions 23 and/ or 24, please explain (include when, where and circumstances).
SECTION 5: EXPERIENCE AND EMPLOYMENT
25. JOB EXPERIENCE
• Have you EVER served as a Peace Officer, Jailer or Telecommunicator in another state OR another country?
YES NO
If YES, list below
• List ALL jobs you have had in the last ten years, including part-time, temporary, self-employment and volunteer.
(Begin with your most current. IF more space is needed, continue your response on page 33.)
• If you have military experience, including reserve duty, enter your military base, assignments, or unit of
assignment. Include ALL military services.
• List ALL periods of unemployment in excess of 30 days.
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LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
A. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
B. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
C. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
17
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
D. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
E. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
F. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
18
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
G. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
H. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
I. Name of employer or military unit
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties/ Assignments
F-T
P-T
Temp
Self-Employed
Volunteer
Name(s) of Co-Workers
Co-Worker(s) Phone Numbers
Would there be a problem if we contact your current
employer? YES NO
If yes, explain
PERIOD OF UNEMPLOYMENT
Check applicable: Student Between Jobs Leave of Absence Travel Other
From
To
19
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
26. Have you ever been disciplined at work? (This includes written warnings, formal letters of
reprimands, suspensions, reductions in pay, reassignments or demotions?
YES
NO
27. Have you ever been fired, released from probation or asked to resign from any place of
employment?
YES
NO
28. Were you ever involved in a physical/ verbal altercation with a supervisor, co-worker, or
customer?
YES
NO
29. Have you ever resigned without giving two weeks notice?
YES
NO
30. Have you ever resigned in lieu of termination?
YES
NO
31. Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual
orientation, harassment, etc.) by a co-worker, superior, subordinate or customer?
YES
NO
32. Were you ever the subject of a written complaint at work?
YES
NO
33. Have you ever been counseled at work due to tardiness or absences?
YES
NO
34. Did you ever receive an unsatisfactory performance review?
YES
NO
35. Have you ever sold, released, or given away legally confidential information?
YES
NO
36. Have you ever called in sick when you were neither sick not caring for a sick family member?
If yes, how many sick days have you used in the past five years which were not due to illness?
YES
NO
37. If you answered yes to any of Questions 26-36, explain (include when, where, and circumstances; indicate which
question this refers to.
38. Has you work performance ever been affected by your use of alcohol or drugs?
YES
NO
When?
What intoxicant were you using?
Name of Employer
39. In the past ten years, have you been warned by an employer about your drinking or drug
habits and their impact on your performance?
YES
NO
When?
Name of Employer
SECTION 6: MILITARY EXPERIENCE (Complete for all branches of military served. Add pages if necessary)
40. Are you required to register for the Selective Service?
YES
NO
If yes, have you registered
YES
NO
If no, explain: ____________________________________________________________________________________
41. Branch of Service
Date of Service From
To
42. Type of Discharge:
Entry Level
Honorable
General
Other than Honorable
Re-Entry Code listed on your DD-214
43. Are you currently participating in one of the following?
If checked, date obligation ends:
Military Reserve National Guard
44. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as court
martial, captain’s mast, office hours, company punishment)?
YES
NO
45. Were you ever denied a security clearance or had a clearance revoked, suspended or
downgraded, either military or any other federal, state, or municipal clearance?
YES
NO
If you answered YES to Questions 44 and/or 45, explain the circumstances and include dates
20
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
SECTION 7: FINANCIAL
46. INCOME AND EXPENSES
For each of the following questions fill in the amounts to the nearest dollar.
A. From your employer(s), what is your take home monthly income? $___________________
B. Do you have income other than from your salary or wages?
YES
NO
If yes, fill in amount: $_________________________ per month
Explain:_____________________________________
C. Approximately how much do you spend each month?
$________________________
Estimate your monthly living expenses, including housing, utilities, credit cards or other load payments, food, gas and car
maintenance, entertainment, etc. as well as any other obligations you may have.
47. Have you ever filed for or declared bankruptcy (Chapter 7, 11,or 13)?
YES
NO
48. Have any of your bills ever been turned over to a collection agency?
YES
NO
49. Have you ever had purchased goods repossessed?
YES
NO
50. Have your wages ever been garnished?
YES
NO
51. Have you ever been delinquent on income or other tax payments?
YES
NO
52. Have you ever failed to file income tax or cheated/ lied on an income tax form?
YES
NO
53. Have you ever had an employment bond refused?
YES
NO
54. Have you ever avoided paying any lawful debt by moving away?
YES
NO
55. Have you ever defaulted on a loan, including a student loan?
YES
NO
56. Have you ever borrowed money to pay for a gambling debt?
If, yes, do you currently have any outstanding debts as a result of gambling?
YES
YES
NO
NO
57. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase
fraudulent documents, etc.)?
YES
NO
58. Have you ever failed to make or been late on a court-ordered payment (e.g., child support,
alimony, restitution, etc.)?
YES
NO
59. Have you written three or more bad checks in a one-year period?
YES
NO
60. Are you in arrears on court ordered child support?
YES
NO
If you answered YES to any of the questions 47-60, explain the circumstances and include dates
21
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
SECTION 8: LEGAL
Disclosure of Citations, Arrests and Convictions
This section requires you to report detentions, arrest and convictions, including diversion programs and in some cases,
offenses that may have been pardoned. As a peace officer applicant, you are required to disclose this information,
unless specifically exempted by state or federal law.
• ALL detentions or arrests, whether they resulted in a conviction or not
• ALL convictions
• ALL diversion programs
• ALL citations (excluding traffic tickets) where you may have been detained and/ or received a Class C citation for
disorderly conduct, prostitution, assault, etc. without actual arrest.
If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what question
number and page this refers to.
61. Have you EVER been detained for investigation (not including traffic stops for traffic violations), held on suspicion,
questioned, fingerprinted, arrested, indicted, criminally charged or convicted of any misdemeanor or felony offense in
this state or in any other legal jurisdiction (including offenses punishable under the Uniform Code of Military Justice)?
YES NO
If yes, explain each incident.
A. Approximate Date
Arresting or detaining Agency
Criminal Charge
Disposition or Penalty
If yes, explain each incident.
B. Approximate Date
Arresting or detaining Agency
Criminal Charge
Disposition or Penalty
If yes, explain each incident.
C. Approximate Date
Arresting or detaining Agency
Criminal Charge
Disposition or Penalty
If yes, explain each incident.
D. Approximate Date
Arresting or detaining Agency
Criminal Charge
Disposition or Penalty
22
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
62. Have you ever been placed on court probation as an adult?
YES
NO
63. Have you ever been convicted of any charge that would prevent you from legally possession a
firearm or ammunition?
YES
NO
64. Were you ever required to appear before a juvenile court for an act which would have been a
crime if committed as an adult?
YES
NO
65. Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child
custody, paternity, support, etc.)?
YES
NO
66. Have the police ever been called to your home for any reason?
YES
NO
67. Have you or your spouse/partner ever been referred to Child Protective Services?
YES
NO
68. Have you ever been the subject of an emergency protective, restraining or ex-parte order?
YES
NO
69. Have you settled any civil suit in which you, your insurance company or anyone else on your
behalf was required to make payment to the other party?
YES
NO
70. Have you ever fraudulently received welfare, unemployment compensation, compensation or
other state or federal assistance?
YES
NO
71. Have you ever filed a false insurance or worker’s compensation claim?
YES
NO
If you answered YES to any of the questions 62-71, explain the circumstances and include dates, court case, document,
etc…
72. UNDETECTED ACTS – PART 1
Within the past seven years OR at any time after you were first employed in law enforcement, have you ever
committed any of the following misdemeanors?
A. Annoying/ obscene phone calls
YES
NO
B. Assault (use of force or violence upon another) (not while performing duties of a LEO)
YES
NO
C. Assault (use of force or violence upon a family member)
YES
NO
D. Brandishing a weapon (any type of weapon) (not while preforming duties of a LEO)
YES
NO
E. Carrying a concealed weapon without a permit
YES
NO
F. Contributing to the delinquency of a minor
YES
NO
G. Committing a theft of service (not paying for food or a room)
YES
NO
H. Driving under the influence of alcohol and/or drugs
YES
NO
I. Drunkenness in public (intoxicated to the point you could not care for yourself or others)
YES
NO
J. Hit and Run accident (no injuries)
YES
NO
K. Hunting or fishing without a license
YES
NO
L. Illegal gambling
YES
NO
M. Impersonating a peace officer
YES
NO
N. Indecent Exposure (including flashing or mooning)
YES
NO
O. Unauthorized Use of a Motor Vehicle (without owner’s permission)
YES
NO
73. UNDETECTED ACTS – PART 2
At any time in your life have you ever committed any of the following?
A. Arson (Intentionally destroying property by setting a fire)
YES
NO
B. Assault with a Deadly Weapon (not while performing duties of a LEO)
YES
NO
C. Theft of a vehicle and/ or vehicle parts
YES
NO
D. Burglary (entering a structure or vehicle to commit a theft, assault, or felony)
YES
NO
23
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
E. Sexual Assault of a Child/ Molestation
YES
NO
F. Accessing, producing or possessing child pornography
YES
NO
G. Injury to a child/elderly/disabled person
YES
NO
H. Theft of Property (any form)
YES
NO
I. Intoxication Assault (with injuries)
YES
NO
J. Sexual Assault or sexual activity without consent of a person
YES
NO
K. Forgery (documents, checks, currency, money, etc.)
YES
NO
L. Hit and run accident (with injuries)
YES
NO
M. Hate Crime
YES
NO
N. Insurance Fraud
YES
NO
O. Theft any value over $750 or Firearm
YES
NO
P. Murder, homicide, or attempted murder
YES
NO
Q. Perjury
YES
NO
R. Possession, manufacturing, transporting of an explosive device
YES
NO
S. Robbery (Theft involving a weapon, force or fear)
YES
NO
T. Stalking
YES
NO
U. Blackmail/ Extortion
YES
NO
V. Any other Felony not listed
YES
NO
If you answered YES to any of the questions in section 72-73, fully explain the circumstances and include dates, person(s)
involved, resolution, etc… (Indicate the corresponding #/Letter for each explanation. Example 73 C)
Questions about your current and past recreational drug use that will cover the use of any drug, including the
unauthorized use of prescription drugs. Your answers should include, but not limited to, your use of any of the following
drugs.
Amphetamines/ Methamphetamines (Uppers, Speed, Crank, etc.)
Heroin/ Opium
Barbiturates (Downers)
Marijuana
Cocaine/ Crack Cocaine
Mescaline
Designer Drugs (Ecstasy, MDMA)
Morphine
GHB (Date Rape Drug)
PCP/ Angel Dust
Glue/ Inhalants
Quaaludes
Hallucinogens (Peyote, LSD, Mushrooms)
Steroids
Hashish
K2
24
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
74. Within the past three years, have you used any non-prescribed drug(s) as indicated above or unauthorized
prescription drugs?
If yes, give details, including drug(s) used and circumstances:
75. Prior to the past three years (check all that apply):
I have never used any drug recreationally
I have tried or used one or more drugs listed above, but only under limited circumstances
(for example, experimentation, at parties, concerts, special events, etc.).
If, checked, give details including drug(s) used, most recent date used, and circumstances.
76. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including
marijuana?
Sold
Manufactured
Purchased
Furnished
Cultivated
Carried or held for another
Any items check above, give details including drug(s) involved, over what time period(s) and circumstances.
SECTION 9: MOTOR VEHICLE OPERATION
77. Current Driver License #
State of Issue
Expiration Date
Name under which the license was granted
78. List other states where you have been licensed to operate a motor vehicle.
State of Issue
Type of License
Name on granted license
79. Have you ever been refused a driver’s license by any state?
YES
NO
If yes, explain (Include when, where and circumstances):
25
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
80. Has your driver’s license ever been suspended or revoked?
YES
NO
If yes, explain (Include when, where and circumstances):
81. List your current liability insurance on your vehicle(s).
A. Type of Coverage
Vehicle Make
Year
Vehicle License
Insured
Bonded
Cash Deposit
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
B. Type of Coverage
Vehicle Make
Year
Vehicle License
Insured
Bonded
Cash Deposit
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
C. Type of Coverage
Vehicle Make
Year
Vehicle License
Insured
Bonded
Cash Deposit
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
D. Type of Coverage
Vehicle Make
Year
Vehicle License
Insured
Bonded
Cash Deposit
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
82. List all traffic citations, excluding parking citations, you have received within the past seven years:
A. Nature of Violation
Location Street, City, State, Zip
Date Occurred
Agency Issuing Citation
Action Taken
Not Guilty
Guilty
Deferred/ Defensive Driving
Dismissed
B. Nature of Violation
Location Street, City, State, Zip
Date Occurred
Agency Issuing Citation
Action Taken
Not Guilty
Guilty
Deferred/ Defensive Driving
Dismissed
C. Nature of Violation
Location Street, City, State, Zip
Date Occurred
Agency Issuing Citation
Action Taken
Not Guilty
Guilty
Deferred/ Defensive Driving
Dismissed
D. Nature of Violation
Location Street, City, State, Zip
Date Occurred
Agency Issuing Citation
Action Taken
Not Guilty
Guilty
Deferred/ Defensive Driving
Dismissed
26
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
E. Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following?
(Check all that apply)
Failed to appear
Failed to complete conditions of court
Failed to pay at required time
If checked, explain circumstances:
83. Have you been involved as the driver in a motor vehicle accident within the past seven years?
If yes, give details.
YES
NO
A. Date
Location (Street, City, State, Zip)
Police Report
Law Enforcement Agency
Injury
Non- Injury
YES
NO
At Fault
Not At Fault
B. Date
Location (Street, City, State, Zip)
Police Report
Law Enforcement Agency
Injury
Non- Injury
YES
NO
At Fault
Not At Fault
C. Date
Location (Street, City, State, Zip)
Police Report
Law Enforcement Agency
Injury
Non- Injury
YES
NO
At Fault
Not At Fault
D. Date
Location (Street, City, State, Zip)
Police Report
Law Enforcement Agency
Injury
Non- Injury
YES
NO
At Fault
Not At Fault
E. Date
Location (Street, City, State, Zip)
Police Report
Law Enforcement Agency
Injury
Non- Injury
YES
NO
At Fault
Not At Fault
84. Have you ever driven a vehicle without auto insurance, as required by law?
YES
NO
If yes, give reason
Date
Location (Street, City, State, Zip)
85. Have you ever been refused automobile liability insurance or a bond, or had policy cancelled?
YES
NO
If yes, give reason
Insurance Company
Date
Location (Street, City, State, Zip)
86. Use this space for additional information you would like to include regarding your driving record.
87. Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other group
that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,
gender, sexual preference, or disability? YES NO
27
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
88. Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise, street
gang, or any other group that advocates violence against individuals because of their race, religion, political affiliation,
ethnic origin, nationality, gender, sexual preference, or disability? YES NO
89. Since the age of 17, have you ever been involved in an anger-provoked physical fight,
confrontation or other violent act?
YES
NO
90. Have you ever hit or physically overpowered a spouse, romantic partner or family member?
YES
NO
If you answered yes to any of Questions 87-90, give details dates and circumstances; indicate corresponding number.
SECTION 11: MEDIA SITES
91. Have you ever had a social media site (i.e. Facebook, Myspace, Twitter, LinkedIn, etc.)?
YES
NO
92. List all social media sites, blogs or websites you have created. (Provide website URL and your username)
SECTION 12: CERTIFICATION
93. I hereby certify that I have personally completed and initialed each page of this form and any supplemental page(s)
attached and that all statements made are true and complete to the best of my knowledge and belief. I understand that
any misstatement of material fact may subject me to disqualification; or, if I have been appointed, may disqualify me
from continued employment.
Signature of Applicant
__________/__________/__________
Date
Sworn to and subscribed before me, this the __________ day of __________________, ____________
Notary Public in and for, State of ____________________
Printed Name of Notary
My commission expires _______/_________/________
Notary Seal or Stamp
Signature of Notary
28
LPD new phs 10/2018 Initial this page to indicate that you have provided complete and accurate information:_______
ADDITIONAL SPACE
• Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g.,
additional family members, schools, residences, employers, explanations to questions, etc.)
• Identify the corresponding question and specific items being referenced.
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AUTHORIZATION RELEASE OF INFORMATION This release, when presented (CITY OF LINDALE)

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Completed 12 April 2021

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