CITY OF CHARLESTON POLICE DEPARTMENT
BACKGROUND INVESTIGATION QUESTIONNAIRE
Applicant:___________________________________________________________
Instructions: You, the applicant must complete the questionnaire; no one else may complete the Questionnaire
for you. This document must be typed. A ll questions must be answered. If a question does not pertain to you write “N/A” in the space
provided. Attach additional pages to the document if additional space is necessary to complete your answers.
This Questionnaire is due at the time of your testing date. Failure to return this Questionnaire could delay
progression through the application/testing process. This questionnaire and any attachments become the
property of the City of Charleston, South Carolina.
GENERAL INFORMATION
1. Full Name (first, middle, last): ____________________________________________
2. List ALL other names you have used or by which you have been known, officially or unofficially, including
nick names, monikers, former names, maiden names, abbreviations:
_________________________________________________________
3. Date of Birth: _________________________________________________________
4. Social Security Number: ________________________________________________
5. Driver’s License Number: _____________________________State: _____________
6. Are you a United States Citizen?  Yes  No
7. List All Current Telephone Numbers and Email Address:
Home: __________________________ Work: ________________________
Cell: ____________________________ Email: ________________________
BQI4-2013
2
Current Home Address:
Street Address: _____________________________________________________
City: _____________________________State:____________ Zip:____________
8. Vehicle Information:
Make: _______________ Model:_____________ Year: _______Color:________
VIN:___________________________License Plate:____________ State:______
9. Place of Birth:_________________________________________________________
10. Father’s Full Name and Address:
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
11. Mother’s Full Name and Address:
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
12. List All Siblings:
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________________________State:_____________Zip: __________
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________________________State:_____________Zip: __________
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________________________State:_____________Zip: __________
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________________________State:_____________Zip: __________
BQI4-2013
3
List ALL persons with which you have had a significant relationship with (if different from your spouse) in the
last five years. This includes but is not limited to past or current fiancés, relationships that lasted over three
months, relationships that produced a child, or relationships where you cohabitated. (attach a separate sheet if
additional space is needed):
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
List Names, Ages and Addresses of Children over the age of 17:
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
List Names, Ages and Addresses of Children over the age of 17:
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
List Names, Ages and Addresses of Children over the age of 17:
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
Phone: ______________ Cell: ___________ Email: _______________________
13. Spouse’s Full Name and Place of Employment (if applicable):
Name: ____________________________________________________________
Place of Employment: _______________________________________________
Work Schedule: ____________________________________________________
Work Phone: __________________ Cell:____________ Email: ______________
14. Spouse’s maiden name and all other names that your spouse has been known by (if applicable):
_____________________________________________________________________
15. Date of Marriage: ______________________________________________________
16. Place of Marriage: _____________________________________________________
BQI4-2013
4
17. List Names, Ages and Addresses of Children from this Marriage over the age of 17:
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________State:_____________Zip: _______Email:_____________
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________State:_____________Zip: _______Email:_____________
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________State:_____________Zip: _______Email:_____________
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________State:_____________Zip: _______Email:_____________
18. List all Former Marriages (attach a separate sheet if additional space is needed):
Ex-Spouse’s Name: ________________________________________________
Address: _________________________________________________________
Phone: ______________ Cell:______________ Email:_____________________
Date of Marriage: _________________ Date of Divorce: ___________________
List Names, Ages and Addresses of All Children from this Marriage over age 17:
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________State:_____________Zip: _______Email:_____________
Ex-Spouse’s Name: ________________________________________________
Address: _________________________________________________________
Phone: ______________ Cell:______________ Email:_____________________
Date of Marriage: _________________ Date of Divorce: ___________________
List Names, Ages and Addresses of All Children from this Marriage over age 17:
Name: _____________________________________________Age:__________
Address:__________________________________________________________
City:______________State:_____________Zip: _______Email:_____________
19. Has an Ex Parte or Other Type of Restraining Order Ever Been Placed Against You?
 Yes  No
If “Yes”, explain: ___________________________________________________
20. Do you have any tattoos?  Yes  No
If “Yes” describe and list locations:
__________________________________________________________________
BQI4-2013
5
21. List all clubs, group associations, or organizations that you belong or have had an affiliation with. Exclude
those that would indicate race, religion, color, sex or national origin.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
22. List the Full Names of all Adults that have resided in the same household with you in the past ten (10) years
(attach a separate sheet if additional space is needed):
Name: ____________________________________________________________
Relationship: ______________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
From Date: ________________________ To Date: ________________________
Persons Current Address: _____________________________________________
City:_________________________ State: __________________ Zip: ________
Phone: ______________ Cell: ___________ Email: _______________________
Name: ____________________________________________________________
Relationship: ______________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
From Date: ________________________ To Date: ________________________
Persons Current Address: _____________________________________________
City:_________________________ State: __________________ Zip: ________
Phone: ______________ Cell: ___________ Email: _______________________
Name: ____________________________________________________________
Relationship: ______________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
From Date: ________________________ To Date: ________________________
Persons Current Address: _____________________________________________
City:_________________________ State: __________________ Zip: ________
Phone: ______________ Cell: ___________ Email: _______________________
Name: ____________________________________________________________
Relationship: ______________________________________________________
Address: __________________________________________________________
City: ___________________________ State: _____________ Zip: ___________
From Date: ________________________ To Date: ________________________
Persons Current Address: _____________________________________________
City:_________________________ State: __________________ Zip: ________
Phone: ______________ Cell: ___________ Email: _______________________
EDUCATION
23. Do you possess a  G.E. D.,  High School Diploma, or  College Degree? (check all that apply):
Received G.E.D. or High School Diploma from: __________________________
Received College Degree from: ________________________________________
BQI4-2013
6
24. List all Colleges or Universities that you have attended (attach a s eparate sheet if additional space is
needed):
Name: ___________________________________________________________
Address:__________________________________________________________
City:_________________________________State:_____________Zip: _______
Phone: ___________________________ Email: __________________________
Name: ___________________________________________________________
Address:__________________________________________________________
City:_________________________________State:_____________Zip: _______
Phone: ___________________________ Email: __________________________
Name: ___________________________________________________________
Address:__________________________________________________________
City:_________________________________State:_____________Zip: _______
Phone: ___________________________ Email: __________________________
Name: ___________________________________________________________
Address:__________________________________________________________
City:_________________________________State:_____________Zip: _______
Phone: ___________________________ Email: __________________________
25. Give a brief explanation of any academic or disciplinary problems in which you were involved while in
College (including academic suspension):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
26. List and Explain ALL Contacts that you had with college security:
__________________________________________________________________
__________________________________________________________________
SKILLS AND TRAINING
27. List any special skills or training that you have received or are licensed for.
__________________________________________________________________
__________________________________________________________________
28. List all foreign or sign languages in which you are fluent:
__________________________________________________________________
__________________________________________________________________
EMPLOYMENT HISTORY
Important Notice: You must list every job you have held in the last ten (10) years regardless of whether you
feel they are relevant to the position for which you are applying. F ailure to do s o will result in automatic
disqualifications. Failure to complete all required information, Names, Addresses, Dates, Phone Numbers, Etc.
may limit our ability to assess your suitability for hire, and eliminate you from further consideration.
BQI4-2013
7
29. List all dates of unemployment in the last ten (10) years. Include the length of unemployment and efforts
to seek employment.
Unemployed: From Date: _____________________ To Date: ________________
Efforts seeking employment: __________________________________________
Unemployed: From Date: _____________________ To Date: ________________
Efforts seeking employment: __________________________________________
Unemployed: From Date: _____________________ To Date: ________________
Efforts seeking employment: __________________________________________
Unemployed: From Date: _____________________ To Date: ________________
Efforts seeking employment: __________________________________________
30. List ALL jobs you have held, including part time, temporary, and volunteer work in the last ten (10) with
the most recent position held and work back (attach a separate sheet if additional space is needed).
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
BQI4-2013
8
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
Business Name: ____________________________________________________
Address:__________________________________________________________
City: _______________________State:___________ Zip: __________________
Start Date:__________________ End Date:______________________________
End Salary: _________Supervisor:_____________________________________
Supervisor’s Phone Number: _____________Cell Phone:___________________
Email:____________________________________________________________
Brief Job Description: _______________________________________________
Reason for leaving:__________________________________________________
BQI4-2013
9
31. Have you ever been fired from, terminated from, or asked to resign from a job?
 Yes  No
If “Yes" explain. ___________________________________________________
__________________________________________________________________
__________________________________________________________________
MILITARY RECORD
Read and answer this section carefully, even if you have never served in the military.
32. Sign the following statement if you have never served in any branch of the armed services, including the
National Guard or Military Reserves. If you have served in the military skip to the next question.
I swear or affirm that I have never served in ANY branch of the armed services at any time.
Signature:________________________________ Date:____________________
33. Are you currently participating in any military reserve or National Guard program?
 Yes  No
If “Yes” Branch of Service: ___________________________________________
MOS: ________________________ Date of Enlistment: ___________________
Initial Rank:___________________ Current Rank:________________________
Commander: _____________________ Phone:___________________________
Address: __________________________________________________________
Email:____________________________________________________________
List all duty stations and assignments:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
34. List all prior military experience, attach a copy of your DD-214 (Long Form):
Branch of Service: __________________________________________________
MOS: ________________________ Date of Enlistment: ___________________
Initial Rank:___________________ Current Rank:________________________
Commander: _____________________ Phone:___________________________
Address: __________________________________________________________
Email:____________________________________________________________
List all duty stations and assignments:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
List any medals or awards received:_____________________________________
__________________________________________________________________
List and explain all disciplinary problems while in the military, article 15’s, UCMJ
convictions, demotions, etc.
__________________________________________________________________
BQI4-2013
10
DRIVING RECORD
35. List ALL traffic summons, tickets, or citations you have ever received for the past ten (10) years, regardless
of disposition, i.e. Expunged etc. (Attach a separate sheet if additional space is needed):
Charge:___________________________________________________________
Date: _____________________________________________________________
Agency: __________________________________________________________
Location: _________________________________________________________
Court where Filed:__________________________________________________
Disposition: _______________________________________________________
Charge:___________________________________________________________
Date: _____________________________________________________________
Agency: __________________________________________________________
Location: _________________________________________________________
Court where Filed:__________________________________________________
Disposition: _______________________________________________________
Charge:___________________________________________________________
Date: _____________________________________________________________
Agency: __________________________________________________________
Location: _________________________________________________________
Court where Filed:__________________________________________________
Disposition: _______________________________________________________
36. List ALL traffic accidents in which you were the driver of the vehicle involved.
Date of Accident: _____________Monetary Amount of Damage ($$):_________
Address Where Accident Occurred: ____________________________________
City: ______________________________ State: ___________Zip:___________
Party at Fault: ______________________________________________________
Circumstances Surrounding the Accident: ________________________________
__________________________________________________________________
Date of Accident: _____________Monetary Amount of Damage ($$):_________
Address Where Accident Occurred: ____________________________________
City: ______________________________ State: ___________Zip:___________
Party at Fault: ______________________________________________________
Circumstances Surrounding the Accident: ________________________________
__________________________________________________________________
Date of Accident: _____________Monetary Amount of Damage ($$):_________
Address Where Accident Occurred: ____________________________________
City: ______________________________ State: ___________Zip:___________
Party at Fault: ______________________________________________________
Circumstances Surrounding the Accident: ________________________________
__________________________________________________________________
37. List EVERY State in which you have been licensed to operate a motor vehicle.
State: __________________________ Year(s):___________________________
State: __________________________ Year(s):___________________________
State: __________________________ Year(s):___________________________
BQI4-2013
11
38. Has your license ever been suspended or revoked?  Yes  No
If yes, please give details (include when, where):
__________________________________________________________________
__________________________________________________________________
39. Have you ever been refused automobile insurance coverage or has it ever been cancelled?  Yes  No
If yes, please give details (include when, where):
__________________________________________________________________
__________________________________________________________________
40. List the Insurance Company and Agent currently holding an insurance policy on the vehicles you currently
own.
Company Name: ___________________________________________________
Agent: _______________________________ Phone: ______________________
Address: __________________________________________________________
City: _______________________________ State: ____________ Zip: ________
Vehicle(s) Covered: _________________________________________________
__________________________________________________________________
Company Name: ___________________________________________________
Agent: _______________________________ Phone: ______________________
Address: __________________________________________________________
City: _______________________________ State: ____________ Zip: ________
Vehicle(s) Covered: _________________________________________________
__________________________________________________________________
LAW ENFORCEMENT CONTACT
41. List ALL official contact you have had with any law enforcement agency or court system. This includes
municipal, county, state, and federal agencies or court systems, as well as military courts, military police
and military investigative units, including any judicial or non-judicial action in the military. L ist all
incidents where you were questioned, warned, issued a summons, detained, arrested, or convicted. T his
includes all infractions, ordinance violations, misdemeanors and felonies. Do not include traffic violations
covered previously (attach a separate sheet if additional space is needed).
Name of Agency or Court:____________________________________________
Date of Contact: ____________________________________________________
Name of Officer: ___________________________________________________
Reason of Contact: __________________________________________________
Charge (if any): ____________________________________________________
Sentence (if any): ___________________________________________________
Disposition of Incident: ______________________________________________
Name of Agency or Court:____________________________________________
Date of Contact: ____________________________________________________
Name of Officer: ___________________________________________________
Reason of Contact: __________________________________________________
Charge (if any): ____________________________________________________
Sentence (if any): ___________________________________________________
Disposition of Incident: ______________________________________________
BQI4-2013
12
42. Have you ever been fingerprinted?  Yes  No
If “Yes” please give details (include reason, when, where):
__________________________________________________________________
__________________________________________________________________
43. Have you ever been the victim of a crime? Yes  No
If “Yes” please explain:
__________________________________________________________________
__________________________________________________________________
44. Have you ever been reported to a law enforcement agency as a missing person or runaway?  Yes  No
If “Yes” explain:
__________________________________________________________________
__________________________________________________________________
45. Have you ever applied for a permit to carry a concealed weapon?  Yes  No
If “Yes” Name of Law Enforcement Agency:_____________________________
Date of Application: _________________________________________________
Was the request granted?  Yes  No
Explain the purpose for carrying the concealed weapon:_____________________
__________________________________________________________________
__________________________________________________________________
46. Do you currently have any unpaid fines, court costs, or court ordered restitution?
 Yes  No
If yes, give all details, including the law enforcement agency, location and court dates:
__________________________________________________________________
__________________________________________________________________
47. List any friends, associates or relatives, past and present, which have been convicted or a felony or
participate in a criminal act. G ive a brief explanation of your relationship to the person and the criminal
activity in which they are or were involved:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
48. Give a brief explanation of any neighborhood disputes in which you have been involved in, include names
of persons involved, dates and locations:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
49. Do you now, or have ever illegally used, possessed, supplied, or sold any narcotic or controlled substance
such as, but not limited to, marijuana, hashish, cocaine, LSD, methamphetamine, heroin, steroids,
pharmaceuticals, prescription drugs or drugs of similar nature? D rug use is not necessarily an automatic
disqualification. Intentionally omitting information or LYING will be cause for automatic disqualification.
 Yes  No
BQI4-2013
13
If “Yes” complete the following information for each illegal substance:
Type of drug:_______________________________________________________
Number of Times: Used:______Possessed: _________ Supplied:_____ Sold:____
Date First Time: Used:_______Possessed: ________ Supplied:_____ Sold:_____
Date Last Time: Used:______Possessed: _________ Supplied:______ Sold:____
Type of drug:_______________________________________________________
Number of Times: Used:______Possessed: _________ Supplied:_____ Sold:____
Date First Time: Used:_______Possessed: ________ Supplied:_____ Sold:_____
Date Last Time: Used:______Possessed: _________ Supplied:______ Sold:____
Type of drug:_______________________________________________________
Number of Times: Used:______Possessed: _________ Supplied:_____ Sold:____
Date First Time: Used:_______Possessed: ________ Supplied:_____ Sold:_____
Date Last Time: Used:______Possessed: _________ Supplied:______ Sold:____
FINANCIAL
50. Have you ever filed for bankruptcy?  Yes  No
If “Yes” explain: ___________________________________________________
51. Do you have any liens or encumbrances on your personal property?  Yes  No
If “Yes” explain: ___________________________________________________
52. Have you ever had any debts turned over to a collections agency?  Yes  No
If “Yes” explain: ___________________________________________________
53. Have your wages ever been garnished?  Yes  No
If “Yes” explain: ___________________________________________________
54. Do you pay child support?  Yes  No
55. Is the child support court ordered?  Yes  No
56. Are your child support payments current?  Yes  No
If “No” explain: ____________________________________________________
57. Have you ever been delinquent with child support?  Yes  No
58. Do you owe overdue alimony?  Yes  No
If “Yes” explain: ___________________________________________________
59. Have you ever been delinquent on tax due to any City, State or the Federal Government?  Yes  No
If “Yes” explain: ___________________________________________________
60. Have you ever had a civil or criminal lawsuit filed against you?  Yes  No
If “Yes” explain: ___________________________________________________
BQI4-2013
14
61. List all business ventures in which you have a financial interest in:
Name of Business: __________________________________________________
Address of Business: ________________________________________________
City:______________________ State: __________________ Zip:____________
Name of Partners:___________________________________________________
Name of Creditors:__________________________________________________
Name of Business: __________________________________________________
Address of Business: ________________________________________________
City:______________________ State: __________________ Zip:____________
Name of Partners:___________________________________________________
Name of Creditors:__________________________________________________
Name of Business: __________________________________________________
Address of Business: ________________________________________________
City:______________________ State: __________________ Zip:____________
Name of Partners:___________________________________________________
Name of Creditors:__________________________________________________
RESIDENCY
62. Have you ever been evicted or asked to leave a rental house, apartment or other dwelling?  Yes  No
If “Yes” explain:____________________________________________________
__________________________________________________________________
63. List the address of place at which you have resided, on either a permanent or temporary basis for the past
ten (10) years. Starting with your current address.
Address: __________________________________________________________
City:________________County:_______________ State: ______ Zip:________
From Date: ___________________ to Date: _____________________________
Landlord’s Name: ________________________________ Phone: ____________
Address: __________________________________________________________
City: __________________ State: _________________ Zip: ________________
Address: __________________________________________________________
City:________________County:_______________ State: ______ Zip:________
From Date: ___________________ to Date: _____________________________
Landlord’s Name: ________________________________ Phone: ____________
Address: __________________________________________________________
City: __________________ State: _________________ Zip: ________________
Address: __________________________________________________________
City:________________County:_______________ State: ______ Zip:________
From Date: ___________________ to Date: _____________________________
Landlord’s Name: ________________________________ Phone: ____________
Address: __________________________________________________________
City: __________________ State: _________________ Zip: ________________
Address: __________________________________________________________
BQI4-2013
15
City:________________County:_______________ State: ______ Zip:________
From Date: ___________________ to Date: _____________________________
Landlord’s Name: ________________________________ Phone: ____________
Address: __________________________________________________________
City: __________________ State: _________________ Zip: ________________
Address: __________________________________________________________
City:________________County:_______________ State: ______ Zip:________
From Date: ___________________ to Date: _____________________________
Landlord’s Name: ________________________________ Phone: ____________
Address: __________________________________________________________
City: __________________ State: _________________ Zip: ________________
REFERENCES
64. List three individuals who have knowledge of your character: Excluding all relatives and former employers.
Name:______________________________ Phone: ________________________
Address: _____________________________ Email:_______________________
City:__________________________ State:______________ Zip:_____________
Name:______________________________ Phone: ________________________
Address: _____________________________ Email:_______________________
City:__________________________ State:______________ Zip:_____________
Name:______________________________ Phone: ________________________
Address: _____________________________ Email:_______________________
City:__________________________ State:______________ Zip:_____________
65. List any additional information you would like to provide that relates to your background that you feel is
important to this investigation.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I certify that I have read and understand the contents of this document, and that I have not deliberately
falsified or omitted any information. I acknowledge that deliberate falsifications, omissions or
misstatements shall be grounds for disqualifications.
Signed:_________________________________ Date:____________________________
BQI4-2013
16
CITY OF CHARLESTON
POLICE DEPARTMENT
BACKGROUND INVESTIGATION WAIVER
AND
RELESASE OF PERSONAL IINFORMATION AUTHORIZATION
I, ______________________________________________, am applying for the position of
_______________________________________________ with the Charleston South Carolina Police
Department.
I understand that, in order to gauge my fitness for the position, the City of Charleston must conduct a thorough
and complete background investigation.
I understand that, to facilitate a thorough and complete background investigation and to ensure complete candor
on the part of those providing the necessary information, I must:
A.) Consent to an investigation by the City of Charleston concerning my background;
B.) Waive any and all claims I might otherwise have against those individuals who conduct the
investigation, or those who cooperate and provide information to the City; and
C.) Waive my right to review the complete background investigation.
WHEREFORE
I, for and in consideration of the City of Charleston’s consideration of my application for the position, do
hereby specifically authorize the City of Charleston to conduct a thorough and complete background
investigation on me for the purpose of gauging my fitness for the position.
I understand this background investigation is required because of the nature of the particular position that I have
made application in that it involves sensitive position or that I may be working in an area where confidentiality
and security is important.
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, may be considered in determining my
suitability for employment by the City of Charleston, South Carolina, whether the position sought is paid or
unpaid position, voluntary or educational in nature.
I, do he reby authorize a review and full disclosure of all records concerning myself to any duly authorized
officer, employee or agent of the City of Charleston, South Carolina, and it’s Police Department, whether the
said records are of public, private or confidential nature.
I, do hereby authorize full and complete disclosure of any and all records of educational institutions; financial or
credit institutions, including records of loans, records of commercial or retail credit agencies, to include credit
reports and/or ratings; and other financial statements and records wherever filed; medical and psychiatric
treatment or consultation, including hospitals, clinics, private practitioners, and the U.S. Veterans
Administration; current employment and previous employment records, including but not limited to any prior or
current law enforcement agency employers, including background reports, efficiency ratings, complaints or
grievances filed by or against me; records and recollections of attorneys at law, or of other counsel, whether
representing me or another person in any case, either criminal or civil, in which I presently have or have had an
interest; traffic and criminal history records; and records referred to in this paragraph shall include, but are not
BQI4-2013
17
limited to papers, documents, recordings and photographs, whether on pa per or stored/transmitted
electronically.
I also hereby authorize access to any and all social networking account(s) that have been created under my
name and/or email address(s) related to web based internet (Facebook, Twitter, MySpace, etc.) Refusal to allow
access to social networking site account(s) created under my name and/or email address(s) shall be grounds for
dismissal from the testing process.
I understand that the City may in its sole discretion disclose to any appropriate law enforcement agencies and
other governmental authorities any information received in the course of the background investigation
indicative of conduct constituting any past, current or future felony or misdemeanor violations of any federal or
state law or local ordinance committed or planned by me.
I release, discharge, covenant not to sue and indemnify and hold harmless the City of Charleston, South
Carolina, and all of its employees, agents, and assigns, form and against any and all claims, causes of action,
losses, damages and/or liabilities of any kind or type resulting from or in connection with the performance or
use of the background investigation to any person or entity as may be authorized by the terms of this release or
at my written direction and consent.
I do he reby specifically authorize, request and direct any individual, including by not limited to my family,
friends, neighbors (past or present), and acquaintances (past or present), my employers (past or present), my
references, educational institutions of any kind, credit bureaus or consumer reporting agencies, medical
institutions or doctors, or any other person, institution, organization or governmental agency or instrumentality
(local, state, federal, military, or foreign), wherever situated, to completely and thoroughly answer any and all
questions concerning me posed by an official or employee of the City and to provide to the City, or any of its
officials or employees, any requested document, information, record or file concerning me.
I understand that, in the event I suffer any injury of any kind as a result of the individual’s cooperation with the
conduct of the background investigation or release of information to the City, I am herein forfeiting any and all
right to bring legal action against or seek redress in the courts from the individual, even if such injury or harm
occurs as a direct result of the individual’s negligence or actual malice or any other failure on the individual’s
part to satisfy any duty owed me.
I understand that, in the event I suffer any injury of any kind as a result of the City’s conduct of this background
investigation, I am herein forfeiting any and all right to bring legal action against or seek redress in the courts
from the City or any of its officials or employees. Even if such injury or harm occurs as a direct result of their
negligence or any other failure on their part to satisfy any duty owed me.
And, also for and in consideration of the City of Charleston’s consideration of my application for the position,
recognizing that complete candor on t he part of those from whom information is sought is ensured only by
maintaining the confidentially of a complete background investigation, I do hereby waive, release and forever
relinquish any right I might otherwise have pursuant to any provision of federal or state statute or regulation,
local ordinance or common law, to review and/or copy any background investigation report, including but not
limited to the final and any draft reports, and all written or otherwise recorded documents or data created,
compiled or collected in connection with such background investigation, completed on me or any part thereof.
For purposes of conducting the background investigation and gathering the information necessary to gauge my
fitness for the position, this Waiver and Release shall be effective for a period of 18 months from the date of my
execution hereof. A copy of the Waiver and Release shall be deemed as effective as the original. My waiver of
the right to review and copy the background investigation is perpetual.
BQI4-2013
18
This Waiver and Release of All Claims is intended to be as broad and inclusive as permitted by the laws of the
State of South Carolina and, if any portion hereof is held to be invalid, the balance shall, notwithstanding,
continue in full legal force and effect. My spouse (if any), heirs and legal representative, and any and all
successors and assigns, are bound by the terms of this Waiver and Release of All Claims. This Waiver contains
the entire agreement between the parties hereto and its terms are contractual and are not a mere recital.
I have carefully read the above and foregoing Waiver and Release consisting of three pages in its entirety. I
know and understand the contents thereof and do, of my own free will, sign this Waiver and Release indicating
my specific agreement to any and all terms.
___________________________________ ______________________________
Applicant Signature Date
____________________________________ ______________________________
Witness Date
(MUST BE NOTARIZED BELOW)
__________________________________________________________________________________________
STATE OF __________________________)
COUNTY OF ________________________)
SUBSCRIBED and SWORN to before me, a Notary Public, this _________ da y of
___________________________________, 20_______.
______________________________
Notary
My Commission Expires: ___________________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome