Page 1 of 7
GALVA POLICE DEPARTMENT
210 Front Street Galva, Illinois 61434
EMPLOYMENT APPLICATION
Print or Type
Date Completed:
Position Applied For:
Full-Time Part-Time Auxiliary
PERSONAL INFORMATION
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Date of Birth:
Social Security Number:
Home Telephone:
Cellular Telephone:
Are you a citizen of the United States?
Yes No
List all states you have lived in, including school, military, etc.:
POLICE EXPERIENCE
Are you a certified police officer in the State of Illinois?
Full-Time Part-Time No
Date of Certification:
Do you have any police experience excluding college?
Yes No IL 40 Hrs Firearm Certified
Describe experience:
EDUCATION
Do you have a High School Diploma or GED?
High School Diploma GED
If you have a GED, please provide date obtained and location:
Name of High School:
Location of High School:
Dates Attended:
Name of College:
Location of College:
Last Year Attended:
Degree or Major:
Other Formal Education or Trade School:
Location:
Dates Attended:
MEDICAL
Do you have any physical condition(s) that would prevent
you from performing the duties of a police officer?
Yes No
If yes, please describe and explain limitations:
Have you ever had any mental disorder(s) or serious
illness(es) in the past?
Yes No
If yes, please describe:
DRIVING HISTORY
Do you have a valid driver’s license?
Yes No
Driver’s License Number:
State:
Expiration Date:
Have you ever been charged with a motor vehicle violation(s)?
Yes No
If yes, list violation(s) and approximate date(s):
Has your driving privilege ever been suspended or revoked?
Yes No
If yes, please explain and list in what jurisdiction(s):
Have you held or applied for a driver’s license in another state?
Yes No
If yes, list the state(s):
Page 2 of 7
BACKGROUND INFORMATION
Have you ever legally changed your name?
Yes No
If yes, give previous name(s) and date of change:
Do you possess a valid IL Firearms Owners Identification?
Yes No
If yes, provide your identification number and expiration date:
Have you ever been refused an IL Firearms Owners Identification or
a firearm permit in another state?
Yes No
If yes, please explain:
Have you ever served in any branch of the U.S. military?
Yes No
If yes, provide the brand, dates, and discharge status:
Are you currently in the National Guard or Reserves?
Yes No
If yes, provide unit and commander’s name and contact number:
Have you ever applied for, or held, a law enforcement position?
Yes No
If yes, provide agency name and date:
Have you ever been convicted of a crime?
Yes No
If yes to the above question, please provide details including the offense(s), date(s) of offense(s), disposition(s), and jurisdiction(s):
Please write a short paragraph describing what characteristics you possess that would make you well suited for a law enforcement position:
Page 3 of 7
EMPLOYMENT
Current or most recent employer:
Supervisor’s Name:
Telephone Number:
Address:
City:
State:
Zip Code:
Dates of
Employment:
From:
To:
Full-Time Part-Time
Hours Worked:
Previous employer:
Supervisor’s Name:
Telephone Number:
Address:
City:
State:
Zip Code:
Dates of
Employment:
From:
To:
Reason for leaving:
Previous employer:
Supervisor’s Name:
Telephone Number:
Address:
City:
State:
Zip Code:
Dates of
Employment:
From:
To:
Reason for leaving:
Previous employer:
Supervisor’s Name:
Telephone Number:
Address:
City:
State:
Zip Code:
Dates of
Employment:
From:
To:
Reason for leaving:
Previous employer:
Supervisor’s Name:
Telephone Number:
Address:
City:
State:
Zip Code:
Dates of
Employment:
From:
To:
Reason for leaving:
Previous employer:
Supervisor’s Name:
Telephone Number:
Address:
City:
State:
Zip Code:
Dates of
Employment:
From:
To:
Reason for leaving:
Have you ever been fired, asked to resign, or terminated from any
employment or volunteer position?
Yes No
If yes to the above question, indicate from where and give details:
Page 4 of 7
ADDITIONAL INFORMATION
Please use this sheet as additional room explanation to any previous question or any other relevant information:
Page 5 of 7
RELEASE OF INFORMATION
I hereby authorize the
Galva Police Department, any consumer reporting agency, or other outside service
company engaged by said official, to obtain, prepare, use,
and furnish information concerning my current
and/or former employment, education, general credit reputation, health, personal characteristics, and mode
of living.
I respectfully request that you furnish to the Galva Police Department any and all information that you have
concerning me, my work record, medical condition, personality and/or my reputation. The information is to
be used to determine my qualification and fitness for a position with the City of Galva.
I hereby release you and/or your agency f
rom any liability and/or damage of any nature on account of
furnishing the above requested information.
Applicant Signature
Date
Witness Signature
Date
This release of information is for employment purposes for the City of Galva Police Department:
Galva Police Department
210 Front Street, PO Box 1
Galva, Illinois 61434
Page 6 of 7
CRIMINAL HISTORY DISQUALIFICATION CERTIFICATION
I, __________________________________, do hereby certify that I am employed or applying for a position
with the Galva Police Department. I also certify that I have never been convicted of a Felony crime(s) or
certain Misdemeanor crime(s) such as the listed acts in Public Act 91-
495 of the Illinois Compiled Statutes,
effective January 1, 20
00. I further understand that such convictions would prohibit me form the participation
and certification of training under the rules, regulations, and legislation of the State of Illinois. Furthermore, I
understand that I am mandated to self report any convictions listed under Public Act 91-495 of the Illinois
Compiled Statutes and that my failure to do so could result in a conviction of a Class 4 felony if I continue to
practice as a law enforcement officer after the conviction. I further certify that I have never been convicted of
Domestic Battery (720 ILCS 5/12-3.2 or 5/12-3.3).
Public Act 91-495 Disqualifying Convictions
720
ILCS
5/11-6
Indecent Solicitation of a Child
720
ILCS
5/11-9.1
Sexual Exploitation of a Child
720
ILCS
5/11-12-2
Aggravated Assault
720
ILCS
5/11-14
Prostitution
720
ILCS
5/11-17
Keeping a Place of Prostitution
720
ILCS
5/11-19
Pimping
720
ILCS
5/15
Criminal Sexual Assault
720
ILCS
5/16-1
Theft
720
ILCS
5/17-1
Deceptive Practices
720
ILCS
5/17-2
Impersonating Police or Veteran Organization
720
ILCS
5/28-3
Keeping a Gambling Place
720
ILCS
5/29-3
Bribery
720
ILCS
5/31-1
Resisting or Obstructing a Peace Officer
720
ILCS
5/31-6
Escape
720
ILCS
5/31-7
Aiding Escape
720
ILCS
5/32(a)(4)
Harassment of Jurors or Family of Jurors
720
ILCS
550/5
Manufacture/Delivery of Cannabis
720
ILCS
550/5.2
Delivery of Cannabis on School Grounds
Applicant Signature
Witness Signature
Print Name
Print Name
Date
Date
Page 7 of 7
APPLICATION CERTIFICATION
I certify that all answers given in this application are true and complete to the best of my knowledge. I
authorize a background investigation be conducted by the Galva Police Department to verify any and all
statements contained in this application for employment, and a check of my criminal history, as may be
necessary, in arriving at an employment decision.
In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand also that if hired, I am required to abide by all rules and
regulations of the Galva Police Department.
Applicant Signature
Date
◄◄◄OFFICE USE ONLY►►►
Criminal History
Date
Initials & ID
10-27
Date
Initials & ID
10-29
Date
Initials & ID
Notes:
Date Interviewed:
Interviewed By:
Hired:
□ Yes □ Full-Time □ Part-Time □ Auxiliary
Starting Date:
Starting Wage:
$
Per Hour
REV 08/2011
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome