1
An Equal Opportunity Employer
We do not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It
is our intention that all qualified applicants be given equal opportunity and that selection decisions
are based on job related factors.
All Police applicants must be Colorado POST certified.
General Instructions:
1. Print all information so that it is legible.
2. If an item does not apply to you, write N/A
3. A completed application is required
4. Any misstatements, misrepresentations or omissions by you, is cause for disqualification
from employment considerations.
5. All information is subject to verification.
Position in which you are applying
Name:
Last_____________________________ First______________________ Middle______________
Address________________________________City_________________ State______Zip_______
Home Phone________________ Cellular_________________ Business/Message_____________
Mailing Address (if different than above)_______________________________________________
Other name in which you have used, or have been known by (Please Explain)
Name: _________________________________________________________________________
Name: _________________________________________________________________________
Are you a citizen of the United States? _____
Are you at least 21 years of age? _____
Following the testing process, applicants who have scored the highest will be notified and will be
required to submit the following information.
1. Certified copy of birth certificate
2. Copy of Social Security Card
3. Copy of valid drivers’ license
4. Copy of High School Diploma or GED
5. Official College Transcripts (if applicable)
6. Military Discharge Form DD-214 (if applicable)
7. Copy of Colorado POST Law Enforcement Certificate (if applicable)
Buena Vista Police Department
713 East Main Street
P.O. Box 1310
Buena Vista CO 81211
719) 395-8654
719) 395-8655 fax
bvpd@buenavistaco.gov
2
Yes No General Information
Do you have any friends or relatives that are currently employed by the Buena
Vista Police Department?
Who / What relationship to you:________________________________________
Have you ever applied for any position with the Buena Vista Police Department?
Position(s) / Date(s) _________________________________________________
Have you ever been convicted of a crime? Provide details on a separate sheet.
Do you have a valid Colorado drivers’ license # ___________________________
Have you ever had your drivers’ license suspended or revoked?
Are you a certified Colorado Peace Officer? Certificate # ___________________
Are you able to perform the essential functions for the position in which you are
applying?
Are you willing to work shift work, including weekends, holidays and overtime?
Are you willing to submit to a credit history check?
Are you willing to consent to the following: Polygraph, Background investigation,
Drug test, Physical Examination and a Psychological Examination?
Have you ever bee a subject in a civil suit? Provide details on a separate sheet.
Are you presently an applicant or on an eligibility list for any other employer?
Please provide list.
Employer: __________________________ Position:_______________________
Employer: __________________________ Position:_______________________
Have you ever been discharged from a job, or asked to resign?
If yes, please explain: _______________________________________________
______________________________________________________________________________
Have you ever received any disciplinary action from an employer?
If yes, please explain: _______________________________________________
______________________________________________________________________________
3
Yes No
Are you now, or have you ever been engaged in any business as an owner,
partner, or corporate member?
If yes, please explain: _______________________________________________
______________________________________________________________________________
Have you ever served in the Armed Forces? If yes, indicate what branch and type
of discharge._______________________________________________________
______________________________________________________________________________
How many days have you missed from work within the past year? (Exclude
absences due to disability or those covered by FMLA)______________________
What type of Police work are you interested in? (Patrol, Investigations, Juvenile, ect.)___________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you ever used any illegal drugs; including, but not limited to Marijuana,
Hashish, Cocaine, LSD, Depressants, amphetamines, Tranquilizers, ect.?
If yes, what were the drug(s)?_________________________________________
______________________________________________________________________________
How many times?___________________________________________________
When was the last time?_____________________________________________
Do you associate with any person or persons who use illegal drugs?
If yes, please explain: _______________________________________________
______________________________________________________________________________
Have you ever been refused an auto insurance policy?
If yes, please explain: _______________________________________________
______________________________________________________________________________
4
Education
Circle highest grade completed GED 7 8 9 10 11 12 13 14 15 16 17 18
List all High schools attended (If GED, provide number, location and date)
High school attended: ______________________________________ From _______ to ________
Address:_______________________________________________________________________
High school attended: ______________________________________ From _______ to ________
Address:_______________________________________________________________________
List all College, University or institutes of higher learning attended.
Name: _________________________________________________ From_______to__________
Address________________________________________________________________________
Credit Hours____________________________________________________________________
Type of Degree__________________________________________________________________
Please describe any special qualifications and or skills:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Volunteer Services:
List all Law Enforcement related volunteer / reserve services:
Name of agency__________________________________ Dates of service__________________
Position _________________________ Duties_________________________________________
Name of agency__________________________________ Dates of service__________________
Position _________________________ Duties_________________________________________
Name of agency__________________________________ Dates of service__________________
Position _________________________ Duties_________________________________________
5
Employment History
List name of employers in consecutive order with present or last employer first. Account for all
periods of time, including military service and any periods of unemployment. If you were self-
employed. Give the firm name and business references.
**Note: A job offer may be contingent upon acceptable references from current and former
employers.**
Present or last employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
6
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
Employer: Dates:from to
Address Weekly Hours Worked
Telephone # Name of supervisor:
Duties:
Co-Worker: (list one)
Reason for leaving:
7
References
List three people who know you well enough to provide current and past information about you. Do
not list relatives or former employers.
Name:_________________________________________________ Years Known:____________
Your relationship:________________________________________________________________
Address:_______________________________________________________________________
Telephone:____________________ Cellular:_________________ Business:_________________
Name:_________________________________________________ Years Known:____________
Your relationship:________________________________________________________________
Address:_______________________________________________________________________
Telephone:____________________ Cellular:_________________ Business:_________________
Name:_________________________________________________ Years Known:____________
Your relationship:________________________________________________________________
Address:_______________________________________________________________________
Telephone:____________________ Cellular:_________________ Business:_________________
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Tell us why you are seeking employment with the Buena Vista Police Department. Also, please tell
us why you are qualified for the position.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9
Affidavit
Please read each statement carefully before signing.
I certify that all information provided in this employment application is true and complete. I
understand that any false information or omission may disqualify me from further consideration of
employment and may result in my dismissal if discovered at a later time.
I understand that the employer may request an investigative consumer report from a consumer
reporting agency. This report may include information as to my character, reputation, personal
characteristics, and mode of living obtained from interviews with neighbors, friends, former
employers, schools and others. I understand that I have the right to make written request within a
reasonable time for the disclosure of the name and address of the consumer reporting agency, so
that I may obtain a complete disclosure of the nature and scope of the investigation.
I authorize the investigation of any or all statements contained in this application. I also authorize,
whether listed or not, any person, school, current employer, past employers and organizations to
provide relevant information and opinions that may be useful in making a hiring decision. I release
such persons and organizations from any legal liability in making such statements.
I understand that if I am extended an offer of employment, it may be conditional upon my
successful passing of a complete pre-employment physical examination. I consent to the release of
any or all medical information as may be deemed necessary to judge my capability to do the work
for which I am applying.
I understand I may be required to successfully pass a drug screening examination. I hereby
consent to a pre and / or post employment drug screen as a condition of employment, if required.
I have read, understand, and by my own signature consent to these statements.
I understand that I am required to provide my Social Security Number and Date of Birth in order
that a thorough background investigation may be performed.
SSN:________________________________ DOB:____________________________________
Signature:______________________________________ Date:___________________________
Subscribed before me on this _________________ Day of ____________________ 20_________
County ________________ State __________. Notary_________________________________
My Commission Expires ___________________________________________________________