Fill - Free fillable Hardeeville Police Department Employment Application (City of Hardeeville) PDF form

Hardeeville Police Dept.Employment

Application Revision Date: 10/20

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Hardeeville Police Department

Employment Application

This application must be completed in full and signed. Incomplete or unsigned applications will not

be considered. If more space is needed for any portion of this application, you may use an attached

sheet with a reference to the section and your additional information.

PERSONAL INFORMATION

M.I.: Date:

Apartment/Unit #:

Zip Code:

Last Name:

How did you hear about this position?

Are you authorized to work in the U.S.? Y

Are you able to provide proof that you are authorized to work in the United States?

Have y

ou ever worked under a different name?

Have you ever worked for the City of Hardeeville?

Y N

If yes, when?

Y N

If yes, when and for

what position?

Have you ever applied for a

job at the Hardeeville Police

Dept.?

Do you have any relatives

employed at the Hardeeville

Police Dept.?

Y N

If yes, provide

name and relation:

What hours and days can you work?

Are there specific times when you cannot work?

Can you perform the essential functions of the job you are applying for?

Y N

EDUCATION

Education Highest Level Completed

Name and State of

School

Degree Obtained and

Major

High School

1 2 3 4 GED

Trade/Technical

1 2 3 4

Undergraduate

1 2 3 4

Graduate/ Post-

Graduate

School

1 2

First Name:

Address:

City:

Phone Number:

Date Available:

Desired Salary:

State:

Position Applying For:

E-mail:

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LIST PROFESSIONAL OR TRADE CERTIFICATIONS

Name of Certification Issuing Organization Issue Date Expiration Date

FORMAL TRAINING (You may be required to provide verification)

Name of Training Presented By Date(s) Completed?

REFERENCES

Please List Three (3) Former Supervisors

Full Name:

Company:

Address:

Relationship:

Phone:

Email:

Full Name:

Company:

Address:

Relationship:

Phone:

Email:

Full Name:

Company:

Address:

Relationship:

Phone:

Email:

Hardeeville Police Dept. Employment

Application Revision Date: 10/20

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State: Date of Expiration:

No Permit Class A Class B

Do y

ou have a valid driver’s license?

Do you have a valid c

ommercial

driver’s license (CDL)?

Have you ever been discharged fr

om a job? If yes,

EXPERIENCE

Please List your Last Four (4) Employers

Phone:

Supervisor:

Employer Name:

Address:

Job Title:

Starting Salary: Ending Salary:

Responsibilities:

To: May

we contact your previous supervisor for a reference? From:

Reason for Leaving:

explain:

Hardeeville Police Dept. Employment

Application Revision Date: 10/20

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EXPERIENCE (Continued)

Phone:

Supervisor:

Employer Name:

Address:

Job Title:

Starting Salary: Ending Salary:

Responsibilities:

To: May we contact your previous supervisor for a reference? From:

Reason for Leaving:

Phone:

Supervisor:

Employer Name:

Address:

Job Title: Starting Salary: Ending Salary:

Responsibilities:

To: May we contact your previous supervisor for a reference? From:

Reason for Leaving:

Hardeeville Police Dept. Employment

Application Revision Date: 10/20

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EXPERIENCE (Continued)

Phone:

Supervisor:

Employer Name:

Address:

Job Title:

Starting Salary: Ending Salary:

Responsibilities:

To: May we contact your previous supervisor for a reference? From:

Reason for Leaving:

MILITARY SERVICE (If applicable) - Please provide copy of DD214

From: To:

Type of Discharge:

Branch:

Rank at Discharge:

If other than honorable, please explain:

Hardeeville Police Dept. Employment

Application Revision Date: 10/20

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INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS

Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or

convictions that resulted in referral to a diversion program.

Within the past 7 years, have you plead guilty or no contest to, or been convicted of any criminal

offense including traffic offenses other than the applicable expectations listed above?

Have you ever been arres

ted and are currently out on bail or on your own recognizance pending trial?

CRIMINAL OFFENSES ONLY: If you answered yes, to either of the above two questions, please provide the

date(s) and explain in accordance with the above instructions so that individual circumstances can be

considered.

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The City will

consider the nature of the crime, its seriousness, the substantial relation to the position’s functions and

qualifications, the number of occurrences, the applicant’s age at the time of the crime, the time elapsed since

the crime, the applicant’s entire work and educational history, employment references and recommendations,

and the business necessity of any exclusion when required by law.

DISCLAIMER & SIGNATURE

I certify that the facts set forth in this application for employment are true and complete to the best of my

knowledge. I understand that if I am employed, false statements on this application shall be considered

sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior

educational and employment history. I understand that by signing this application, I am giving my permission

to contact the references listed on this application of employment.

I understand that employment at the City of Hardeeville is “at will”, which means that either I or this company

can terminate the employment relationship at any time, with or without prior notice, and for any reason not

prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or

executive of this company, other than the City Manager, has authority to alter the foregoing.

Signature: Date:

Yes No

Hardeeville Police Dept. Employment

Application Revision Date: 10/20

Equal Employment Opportunity Disclosure Form

Please complete this EEO-1 Data Sheet. The City of Hardeeville is subjected to certain record keeping

and reporting requirements for the administration of civil rights laws and regulations. To comply with these

laws, we invite you to complete this form. Submission of this information is voluntary and refusal to

provide it will not subject you to any adverse treatment. The information obtained will be kept confidential,

separate from personnel files, and will not be used as the basis for any adverse employment decision.

Thank you for your cooperation.

Name Job Title

Last First Middle

Gender: Male Female

Race: Please mark all that apply.

Hispanic or Latino "Ethnicity": A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other

Spanish culture or origin, regardless of race.

White: A person having origins in any of the original peoples of Europe, the

Middle East, or North Africa.

Black: A person having origins in any of the black

racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any

of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian: A person having origins in any of the original peoples of the Far

East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India,

Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native: A person having origins in any of the

original peoples of North and South America (including Central America), and who maintain tribal

affiliation or community attachment.

Two or More Races: All persons who identify with more than one of the

above races, excluding those who identify themselves as Hispanic or Latino.

____________________________________________ _______________

Signature

Date

If you should have any questions regarding this form, please contact Human Resources.

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Hardeeville Police Dept. Employment

Application Revision Date: 10/2019

If applying for a Police Officer position, please continue.

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PERSONAL INFORMATION

Applicant’s Name:

Social Security Number:

Date of Birth:

Driver’s License Number:

I respectfully request and authorize you to furnish the Hardeeville Police Department with any and all

information that you may have concerning my work records, personal history, criminal record, civil process

record, school records, driving record, personal reputation, financial status, and credit status. This

information is to be used to assist the Hardeeville Police Department in determining my qualifications and

fitness for the position I am seeking.

I have read and understand the Hardeeville Police Department’s Applicant Dis-qualifiers and Selection

Process listed on the website.

By signing below, I hereby release you, your organization, or others from any liability or damage, which may

result from furnishing the information requested above.

Applicant’s Signature: Date:

Affidavit

State of:

County of:

Subscribed and sworn to before me this day of , 20

Notary Public

My Commission Expires:

HARDEEVILLE POLICE DEPARTMENT

Sam Woodward

Chief of Police

Hardeeville Police Dept. Employment

Application Revision Date: 10/2019

REFERENCES

Please List Three (3) Personal References

Full

Name:

Company:

Address:

Relationship:

Phone:

Email:

Full

Name:

Company:

Address:

Relationship:

Phone:

Email:

Full

Name:

Company:

Address:

Relationship:

Phone:

Email:

REFERENCES

Please List Three (3) Neighbor References

Full

Name:

Company:

Address:

Relationship:

Phone:

Email:

Full

Name:

Company:

Address:

Relationship:

Phone:

Email:

Full

Name:

Company:

Address:

Relationship:

Phone:

Email:

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Hardeeville Police Dept. Employment

Application Revision Date: 10/20

BACKGROUND QUESTIONNAIRE

Are you a U.S. citizen? Y N Are you a certified police officer? Y N

Y N Do you currently have any visible tattoos that may be deemed offensive,

obscene, controversial or political in nature?

If yes, please describe the tattoos and where the tattoo is located.

Please list all the languages you can speak:

Please list all the languages you can write:

Is your driver’s license in danger of being revoked or

suspended in any state? If yes, list the state and

reason:

List the states where you obtained a driver’s

license. Include the license number and date:

Please list previous residences for the past ten years. List the dates, street address, city,

state, and zip code.

Date: Address:

Have you ever served in the Military? Y N

Provide a list of all commendations awarded during your term of service:

If you were ever a subject of a military/criminal investigation, state the nature of the investigation and the

conclusion.

If you are a member of the National Guard or Military

Reserve, provide the unit name, location and

describe your obligation.

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Hardeeville Police Dept. Employment

Application Revision Date: 10/20

List all traffic citations received in the last five years. Include the offense and date:

Have you ever operated a motor vehicle while

under the influence of alcohol or any drug/narcotic?

If yes, explain and list month/year:

Have you ever been arrested for operating a motor

vehicle while under the influence of alcohol or any

drug/narcotic? If yes, provide date, month/year and

place of arrest:

Were you

convicted?

Y N

Did you plead guilty

or nolo contendere?

suspended?

Was your license

Y N

Have y

ou ever been in an automobile crash as the driver?

yes,

explain by

providing how many

rashes

and

whether

you

were at

fault:

Please check all illegal substances that you have used in the last 10 years

Marijuana Khat/Catha Edulis Ice/Crystal Meth/Methamphetamine

Hashish/Purified Cannabis Resin Heroin Nerve Medicine/Neurontin

Cocaine Morphine Steroid/Synthetic Steroid Hormone

Crack/Chemically Purified Cocaine Psychedelic Mushrooms LSD/Lysergic Acid Diethylamide

Speed/Amphetamine PCP/Phencyclidine Inhalants (includes amyl nitrate)

Ecstasy Sleeping Pills/Barbiturate

If you checked any of the above, please list number

of times and the last time used:

Have you ever taken medication not prescribed to

you? If yes, describe drug, number of times and

last time used:

Have you sold, held or passed illegal drugs

or substances? If yes, describe drug, number

of times and last time used:

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Hardeeville Police Dept. Employment

Application Revision Date: 10/20

Have you ever been convicted of domestic

violence? If yes, please provide date and reason:

Have you ever sexually harassed someone or

been a part of a sexual harassment lawsuit? If yes,

please describe in detail:

Do you have any racial, ethnic, religious, sexual, or

other prejudices that will affect your job

performance? If yes, please describe:

Have you ever been a subject of a lawsuit? If yes,

please explain your involvement:

Do you have any past due debts or filed

bankruptcy? If yes, please explain in detail:

Have you ever been arrested for a misdemeanor

or a felony, excluding minor traffic offences? If

yes, list offence charged, agency, state, date and

disposition of arrest:

Have you ever been convicted of a felony? If

yes, list offence charged, agency, state, date and

disposition of arrest:

Have you ever stolen anything? If yes, please

explain:

Have you ever stolen from an employer? If yes,

please explain:

Have you ever been involved in an investigation of

theft at any place of employment? If yes, please

explain:

Have you ever used your position for personal

gain? If yes, please explain:

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Hardeeville Police Dept. Employment

Application Revision Date: 10/20

Have you ever resigned from a job while under

investigation or resigned in lieu of being fired for

any reason? If yes, please explain:

Have you ever been discharged or asked to

resign from a job? If yes, please explain:

Have you ever received a written reprimand for

being late to work? If yes, please explain:

Have you ever had conflicts with a fellow

employee? If yes, explain:

Have you recently applied to any other

police agency? If yes, list agency and date:

Have you ever been rejected by a police

agency? If yes, list agency and reason

provided for rejection:

Please send application with copies of the following:

• Driver’s License

• Birth Certificate

• Social Security Card

• High School and College Diplomas

• 10-year driving record

• Resume

• Credit report that c

onsist of all credit reporting bureaus

(Applicants can get a free copy from www.annualcreditreport.com)

• Cover letter

• If prior military, DD214 is required

• Any prior law enforcement training certificates

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Hardeeville Police Dept. Employment

Application Revision Date: 10/20

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