Hardeeville Police Dept. Employment
Application Revision Date: 10/20
1
PERSONAL INFORMATION
First Name:
Last Name:
M.I.:
Date:
Address:
City:
State:
Zip Code:
Phone Number:
E-mail:
Date Available:
Desired Salary:
Position Applying For:
How did you hear about this position?
Are you authorized to work in the U.S.?
Y
N Have you ever worked under a different name?
Y
N
Are you able to provide proof that you are authorized to work in the United States?
Y
N
Have you ever worked for the City of Hardeeville?
Y
N
If yes, when?
Have you ever applied for a
job at the Hardeeville Police
Dept.?
Y
If yes, when and for
N
what position?
Do you have any relatives
employed at the Hardeeville
Police Dept.?
What hours and days can you work?
Y
N
If yes, provide
name and relation:
Are there specific times when you cannot work?
Can you perform the essential functions of the job you are applying for?
Y
N
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.
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
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
2
REFERENCES
Please List Three (3) Former Supervisors
Full Name:
Relationship:
Company:
Phone:
Address:
Email:
Full Name:
Relationship:
Company:
Phone:
Address:
Email:
Full Name:
Relationship:
Company:
Phone:
Address:
Email:
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?
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
3
Responsibilities:
Do you have a valid driver’s license? Y N
Do you have a valid commercial driver’s license (CDL)?
Have you ever been discharged from a job? If yes, explain:
State: Date of Expiration:
No Permit Class A Class B
Employer Name: Phone:
Address: Supervisor:
Job Title:
Starting Salary: Ending Salary:
From: To: May we contact your previous supervisor for a reference?
Reason for Leaving:
EXPERIENCE
Please List your Last Four (4) Employers
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
4
Responsibilities:
Responsibilities:
EXPERIENCE (Continued)
Employer Name: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending Salary:
From: To: May we contact your previous supervisor for a reference?
Reason for Leaving:
Employer Name: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending Salary:
From: To: May we contact your previous supervisor for a reference?
Reason for Leaving:
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
5
Responsibilities:
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, please explain:
MILITARY SERVICE (If applicable) - Please provide copy of DD214
EXPERIENCE (Continued)
Employer Name: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending Salary:
From: To: May we contact your previous supervisor for a reference?
Reason for Leaving:
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
6
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?
Yes No
Have you ever been arrested and are currently out on bail or on your own recognizance pending trial?
Yes
No
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:
click to sign
signature
click to edit
Hardeeville Police Dept. Employment
Application Revision Date: 10/2019
7
American, or other
Hispanic or Latino "Ethnicity": A person of Cuban, Mexican, Puerto Rican, South or Central
Spanish culture or origin, regardless of race.
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.
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.
If applying for a Police Officer position, please continue.
Equal Employment Opportunity Disclosure Form
click to sign
signature
click to edit
Hardeeville Police Dept. Employment
Application Revision Date: 10/2019
8
HARDEEVILLE POLICE DEPARTMENT
Sam Woodward
Chief of Police
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:
click to sign
signature
click to edit
REFERENCES
Please List Three (3) Personal References
Full
Name:
Relationship:
Phone:
Email:
Company:
Address:
Full
Name:
Relationship:
Phone:
Email:
Company:
Address:
Full
Name:
Relationship:
Phone:
Email:
Company:
Address:
REFERENCES
Please List Three (3) Neighbor References
Full
Name:
Relationship:
Phone:
Email:
Company:
Address:
Full
Name:
Relationship:
Company:
Phone:
Email:
Address:
Full
Name:
Relationship:
Company:
Phone:
Email:
Address:
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
9
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
10
BACKGROUND QUESTIONNAIRE
Are you a U.S. citizen?
Y
N Are you a certified police officer?
Y
N
D
o you currently have any visible tattoos that may be deemed offensive,
Y
N
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:
Date:
Address:
Date:
Address:
Date:
Address:
Date:
Address:
Date:
Address:
Have you ever served in the Military?
Y
N
P
rovide 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.
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
11
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?
Y
N
Was your license
Y
N
suspended?
Have you ever been in an automobile crash as the driver?
Y
N
If yes, explain by providing how many crashes and
whether you were at fault:
Please check all illegal substances that you have used in the last 10 years
Marijuana
Hashish/Purified Cannabis Resin
Cocaine
Crack/Chemically Purified Cocaine
Speed/Amphetamine
Ecstasy
Khat/Catha Edulis
Heroin
Morphine
Psychedelic Mushrooms
PCP/Phencyclidine
Sleeping Pills/Barbiturate
Ice/Crystal Meth/Methamphetamine
Nerve Medicine/Neurontin
Steroid/Synthetic Steroid Hormone
LSD/Lysergic Acid Diethylamide
Inhalants (includes amyl nitrate)
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:
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
12
Have you ever been convicted of domestic
violence? If yes, please provide date and reason:
H
ave 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:
Hardeeville Police Dept. Employment
Application Revision Date: 10/20
13
Have you ever resigned from a job while under
investigation or resigned in lieu of being fired for
any reason? If yes, please explain:
H
ave 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:
Ha
ve you ever had conflicts with a fellow
employee? If yes, explain:
H
ave 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 consist 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