APPLICANT’S COPY: DO NOT RETURN WITH APPLICATION
Important Testing Information
Dear Applicant,
Thank you for applying for a position with the City of Madison Police Department. This letter contains
important information. You should read this letter carefully to be sure you understand the procedure that will
be used during this initial phase of the process (an important part of being a Police Officer is attention to
detail).
The Police Department will receive more applications than there are available positions. As a result, the Police
Department has established a competitive application process. This application process is designed to ensure
that the selection of new recruits will be accomplished in a fair and objective manner. You must take this test
for your application to be further considered.
The Physical Agility Test will be administered at 9:00 a.m., Saturday, May 23, 2020, at Madison Consolidated
Junior High School at 701 Eighth Street, Madison, Indiana, 47250. You must present your valid driver’s
license for identification. The physical fitness requirements are attached.
The Written Aptitude Test will begin 30 minutes after the end of the physical agility test. The written test
portion will take approximately 90 minutes and you must achieve a score of 70% or higher to pass the test.
Each applicant must meet the minimum requirements of each test to continue the testing process.
There are facilities available for changing clothes.
APPLICANT’S COPY: DO NOT RETURN WITH APPLICATION
MADISON POLICE DEPARTMENT
GENERAL INFORMATION
FOR
POLICE OFFICER EMPLOYMENT
GENERAL STATEMENT OF DUTIES: Police officers are responsible for the protection of life and property, the
prevention of crimes and the preservation of peace and order within an assigned beat (geographical area).
They must patrol their beat while enforcing laws, ordinances and regulations, arresting violators, investigating
accidents, complaints, securing evidence, and performing any and other duties as required.
QUALIFICATIONS: Applicants must meet the following requirements and provide the requested material for
their application to be processed.
1. Be twenty-one (21) years of age but not have reached age thirty-six (36), or meet the requirements
defined in IC 36-8-4-7.
2. Must be a US Citizen.
3. Possess a valid driver’s license and provide a copy of such with the application.
4. Include a copy of their Birth Certificate with their application.
5. Be a High School graduate or have a GED certificate. Include a copy of such with the application
along with a copy of any college credits or degree(s).
6. Shall have no felony conviction or a conviction of Domestic Battery.
7. Pass a drug-screening test.
8. Successfully pass each phase of the selection process, which includes a written aptitude and
physical agility test.
9. Pass a physical and psychological test.
10. When requested, submit a complete credit history report.
WORKING SCHEDULE: Consists of three (3) eight (8) hour per day shifts. First shift hours are from 6:00am to
2:00pm, second shift hours are from 2:00pm to 10:00pm, and third shift hours are 10:00pm to 6:00am. All
shifts have rotating days off. Work schedules are subject to last minute changes.
NEED FOR CONTINUING EDUCATION: New employees will be required to successfully complete a fifteen (15)
week training program at the Indiana Law Enforcement Academy within one year of employment.
AVERAGE ANNUAL SALARY: Starting probationary patrolman salary is $49,012.00. Certified academy
graduates' starting salary is $50,012.00. After one year of service the salary is increased by $1,000.00. Other
benefits include shift pay, holiday pay, clothing allowance, cell phone stipend, and medical / dental benefits.
Academy graduates will be issued a patrol vehicle upon hiring. Non academy graduates will be issued a patrol
vehicle upon completion of the Indiana Law Enforcement Academy and the Madison Police Department Field
Training Program.
CERTIFICATION OF APPLICATION AND AUTHORIZATION TO RELEASE
INFORMATION FORMS MUST BE SIGNED AND NOTARIZED FOR THE APPLICATION
TO BE CONSIDERED.
APPLICANT’S COPY: DO NOT RETURN WITH APPLICATION
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
I wish to be considered for employment as a Sworn Police Officer with the Madison Police Department.
I am a citizen of the United States, at least 21 years of age and have not reached 36 years of age, have a high school diploma or GED
Certificate, possess a valid driver’s license from current state of residence, have not been convicted of a Felony, Class A
Misdemeanor or Domestic Violence and have not been dishonorably discharged from the military.
I understand that I am required to be a resident of Jefferson County, Indiana or the five (5) adjoining counties within one (1) month
of appointment to the department.
I understand this position requires a security clearance from the Indiana Data and Communication System, which considers a
person’s character, past history, and criminal record.
Upon request, I understand I must participate in, and pass any of the following screenings:
1. Written Examination 2. Physical Agility Test 3. Oral Interview 4. Background Investigation
5. Polygraph Examination 6. Medical Examination 7. Psychological Evaluation 8. Drug Screen
I UNDERSTAND FAILURE TO ARRIVE AS SCHEDULED FOR ANY SCHEDULED EVENT WILL CAUSE MY
ELIMINATION FROM THE ENTIRE PROCESS
IMPORTANT EVENT AND DATE
THIS APPLICATON MUST BE RETURNED IN PERSON OR BY MAIL AND RECEIVED BY THE DEPARTMENT’S
CHIEF OF POLICE BY 4:00PM, May 15, 2020. (NO FAXES will be accepted)
APPLICANT’S COPY, DO NOT RETURN WITH APPLICATION
PHYSICAL FITNESS TEST REQUIREMENTS
The Indiana Law Enforcement Academy has established Physical Fitness Requirements for the basic Course Training
Program. Each new applicant to the I.L.E.A. will have to meet the following physical fitness standards in order to complete
the academy requirements for certification. The Madison Police Department has adopted these standards for applicants to
be eligible for employment. Each test is either pass or fail, and the applicant is required to successfully complete and pass
all tests to pass this phase of the process. Anyone requiring special accommodations should contact the Chief of Police
prior to the test.
1. Vertical JumpSixteen (16) inches minimum accepted. This measures leg power and consists of
measuring how high you can jump.
2. One-Minute Sit-UpsTwenty-nine (29) is the minimum accepted. This measures abdominal, or
trunk, muscular endurance. While lying on your back, knees bent, heels flat on the floor, with
fingers interlaced and held behind the head, touching elbows to knees, you will be given one (1)
minute to do as many knee bent sit-ups as you can.
3. 300 Meter RunSeventy-one (71) seconds minimum time allowed. This measures anaerobic
power, or the ability to make an intense burst of effort for a short time period or distance. This
component consists of sprinting 300 meters as fast as possible.
4. Maximum Push-UpsTwenty-five (25) is the minimum accepted. This measures the muscular
endurance of the upper body. This component consists of doing as many push-ups as possible until
muscular failure. The hands are placed shoulder width apart, fingers pointing forward. Some part
of the hands must lie within a vertical line drawn from the outside edge of the shoulders to the
floor. The administrator places one fist on the floor below the participant’s chest (sternum).
Starting from the up position (arms fully extended with elbows locked, both hands and both feet
only touching the floor), the participant must keep the back straight at all times and lower the body
to the floor until the chest (sternum) touches the administrator’s fist. The participant then returns
to the up position with the elbows fully locked. This is one repetition. Resting is permitted only in
the up position. There is no time limit.
5. 1.5 Mile RunSixteen (16) minutes and twenty-eight (28) seconds minimum time allowed to
complete the distance. This measures aerobic power and cardiovascular endurance (stamina over
time). To complete this component you must run/jog, as fast as possible, a distance of 1.5 miles.
To be eligible to continue on through the hiring process, you must meet the minimum
standards of each test given.
MADISON POLICE DEPARTMENT
621 West St.
Madison, Indiana 47250 APPLICATION FOR POLICE OFFICER
NOTE: COMPLETED APPLICATION MUST BE RETURNED BY 4:00PM, May 15, 2020.
I. PERSONAL HISTORY
A. Name in full
________________________________________________________________________________
Last First Middle Maiden
B. Social Security Number: _____________________
C. Present Residence:
________________________________________________________________________________
Street/P.O. Box #/Apt. #
________________________________________________________________________________
City State ZIP Telephone #
D. List all names you have used including nicknames. If you have used any surnames other than
your true name; please list during what period and under what circumstances these names were
used. If you have legally changed your name, give the date, place and court. (This information
is being collected to assist the department in conducting a thorough background investigation,
i.e. felony convictions check).
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
E. Birth Date (Month, Day, Year): _______________________________
Place of Birth (City, State): __________________________________
Attach a copy of your certified Birth Certificate.
It will be used to verify your age for requirements and pension purposes.
F. Are you a U.S. Citizen? _______________
Page 1
II. FAMILY HISTORY
List all family members (living and deceased) in the following order: Parents, Step-Parents, Foster
parents, guardians, brothers, sisters, children, in-laws, and ex-spouse(s). (If additional space is needed
attach a separate page.
Relationship Name Address City, State Zip Telephone
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
III. PREVIOUS RESIDENCE
A. List chronologically (most recent first) all of your residences in the past ten (10) years. Include
addresses while attending school, if away from home, and all military addresses including off
military base.
Date (From-To) Address City, State, ZIP
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
IV. EXTRACURRICULAR ACTIVITIES
List past or present membership in clubs, organizations or volunteer work:
Name and Address Type (Social, Fraternal, Professional, etc.) Membership Period/Office
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Page 2
V. SUBVERSIVE ORGANIZATIONS
YES NO Are you now or have you ever been a member of or affiliated with any organization,
association, movement, group or combination of persons which advocates the overthrow of
our constitution form of government, or which has adopted the policy of advocating or
approving the commission of acts of force or violence to deny other persons their rights under
the Constitution of the United States or which seeks to alter the form of government of the
United States by unconstitutional means? If you answered yes, describe the circumstances.
Attach a separate sheet to provide a full detailed statement.
VI. MILITARY RECORD
A. Are you registered for selective services? ________________
Selective Service Number: ____________________________
B. Have you ever served on active duty in the armed services of the U.S.? ______________________
Branch of Service: ___________________________________
Dates of Active Duty (Month, Day, Year): _______________________________________________
Type of Discharge*: ________________________________________________________________
C. Are you currently in the U.S. Reserve or National Guard? _____________. If yes, what is your
obligation (if any), unit, and locations? ________________________________________________
________________________________________________________________________________
D. While in service, were you ever convicted of any offenses? ____________. If yes, give details:
________________________________________________________________________________
________________________________________________________________________________
Attach copies of all DD214 long forms or their equivalent.
*No applicant will be automatically rejected because of a less than honorable discharge (except a
Dishonorable), but the discharge may be considered with other information. If discharge is less
than Honorable, explain on a supplemental page.
Page 3
VII. EMPLOYMENT HISTORY
Starting with the present or most recent employer, list employment history for the past five (5) years.
If more, attach a supplemental page.
FROM / TO / EMPLOYER /TELEPHONE
_______________________________________________________________________________________________________________________________________
JOB TITLE / ADDRESS
_______________________________________________________________________________________________________________________________________
IMMEDIATE SUPERVISOR & TITLE / SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
REASON FOR LEAVING / HOURLY RATE OR SALARY
________________________________________________START $_____________PER_________________FINAL $_______________PER_______________________
//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
FROM / TO / EMPLOYER /TELEPHONE
_______________________________________________________________________________________________________________________________________
JOB TITLE / ADDRESS
_______________________________________________________________________________________________________________________________________
IMMEDIATE SUPERVISOR & TITLE / SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
REASON FOR LEAVING / HOURLY RATE OR SALARY
________________________________________________START $_____________PER_________________FINAL $_______________PER_______________________
//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
FROM / TO / EMPLOYER /TELEPHONE
_______________________________________________________________________________________________________________________________________
JOB TITLE / ADDRESS
_______________________________________________________________________________________________________________________________________
IMMEDIATE SUPERVISOR & TITLE / SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
REASON FOR LEAVING / HOURLY RATE OR SALARY
________________________________________________START $_____________PER_________________FINAL $_______________PER_______________________
//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
FROM / TO / EMPLOYER /TELEPHONE
_______________________________________________________________________________________________________________________________________
JOB TITLE / ADDRESS
_______________________________________________________________________________________________________________________________________
IMMEDIATE SUPERVISOR & TITLE / SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
REASON FOR LEAVING / HOURLY RATE OR SALARY
________________________________________________START $_____________PER_________________FINAL $_______________PER_______________________
//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
Page 4
VIII. PERSONAL REFERENCES
List for personal character references (Not related to you):
Name Address City, State, Zip Phone # Time Known
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
IX. SPECIAL SKILLS AND QUALIFICATIONS
List any experience, skills, abilities, or special qualifications that you feel would be relevant to the job
for which you are applying.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
X. ARRESTS AND CITATIONS
Show ALL arrests including felony, misdemeanor, juvenile, and traffic. Give date, place, and full
details, including the disposition of each incident.
(Employment of persons with criminal records will be in accordance with the attached Policy
Statement of Employment and ex-offenders on page eight (8).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you presently involved in an active Criminal or Civil proceeding? YES _______ NO _______ if you
answered yes, please explain: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Page 5
Have you ever been fingerprinted for any reason? (job application, gun permit, etc.) YES ______ NO ______
If yes, give date, place and full details of occurrence.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
XI. VEHICLE OPERATOR’S LICENSE: (Driver’s, Chauffeur's, etc.) Give the following information concerning
any vehicle operator’s license you have held or now hold. Submit a copy of your driver’s license with
your application.
Type of License State of Issue Exp. Date License Number
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
XII. CREDIT REFERENCES AND OBLIGATIONS
Give names and addresses of the individuals, companies, or others to whom you are indebted and the
extent of your debt (including any loans on which you are a co-maker, mortgages, open credit
accounts, etc.)
Name Address Type of Debt Amount of Debt
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
XIII. EDUCATIONAL BACKGROUND
NAME AND LOCATION_________________________________________________________________________________________________
HIGH SCHOOL YEARS COMPLETED DID YOU GRADUATE? COURSE OF STUDY
_______________________________________________________________________________________________________________________
COLLEGE MAJOR DEGREE
_______________________________________________________________________________________________________________________
OTHER
_________________________________________________________________________________________
SIGNATURE: _________________________________________ DATE: _____________________________
Page 6
If you answer yes to any of these questions, use a separate sheet of paper to explain.
1. Have you ever been asked or given the opportunity to resign from any position? YES _____ NO _____
2. Have you ever been counseled, reprimanded, suspended, or terminated from any position?
YES _____ NO _______
3. Have you ever taken a polygraph or voice stress analyzer? YES _______ NO _______
4. Have your driver’s license ever been suspended or revoked? YES ______ NO ______
5. Have you ever been placed on probation for any offenses, sealed or expunged records included?
YES ______ NO ______
6. Have you ever been the subject or suspect or a police investigation? YES _____ NO ______, if yes,
explain in detail as to what offense, jurisdiction, date, outcome or results of the investigation on a
separate sheet of paper.
7. For past or present Law Enforcement Officers:
Have you ever been the subject of an internal investigation? YES ______ NO ______
8. Have you applied, or do you presently have an application on file, or are you going through a hiring
process, with any other Law Enforcement Agency? YES ______ NO ______
9. Have you ever illegally possessed, used or sold drugs, including marijuana? YES ______ NO ______
10. Have you possessed, injected, inhaled, swallowed, or ingested by any other means, any illegal drug?
YES ______ NO ______
11. Have you ever been convicted of a Domestic Violence related crime? Domestic Violence means any
assault, aggravated battery, battery, sexual assault, sexual battery, stalking, aggravated stalking, or any
criminal offense resulting in physical injury or death of one family or household member by another
who is or was residing in the same single-family dwelling unit. YES ______ NO ______
12. Have you ever been a party to a Domestic Violence injunction or petition? YES ______ NO ______
13. Have you ever been involved in any Domestic Violence incident where the police responded and a
written police report of the incident was completed? YES ______ NO ______
14. Have you ever been involved in any Domestic Violence incident where the police responded and a
written report was not completed? YES ______ NO ______
Foreign Languages: E=Excellent G=Good F=Fair
Language Reading Speaking Understanding Writing
______________ E G F E G F E G F E G F
MADISON POLICE DEPARTMENT
Applicant’s Request/Waiver to Release Information:
I hereby authorize and request all persons to whom this request (original or reproduction) is presented, having
information or relating to or concerning me, to furnish such information to a duly appointed officer of the
Madison City Police Department.
I am aware that this information may be of a personal nature and may otherwise be protected from disclosure
by my constitutional, statutory or common-law privileges. I hereby expressly waive all privileges, which may
attach to such communication or disclosure and release all persons, firms and corporations from all claims, of
any nature as a result of said communication or disclosure.
Information to disclose:
Medical Records
Mental Records
Financial Records
Criminal History Check
Educational Records
Organizational Memberships
Past/Present Employment Records
*Any background material/information relevant to reputation and/or moral character.
*These records will be retained on file in the Madison Police Department, in the Office of the Chief of Police.
______________________________________ ________________________
Signature of Applicant Date
State of ________________)
) SS:
County of ______________)
Subscribed and sworn to before me, a Notary Public, in and for said county and state,
This __________ day of _______________, 20_____.
My Commission Expires:
_______________________________________
_____________________ Notary Public
_______________________________________
Printed
_______________________________________
County of Residence
NOTE: This page must be Notarized, signed, and returned with the application
Page 8
Because of the sensitive and important position of a police officer, the Madison Police Department must select
individuals who possess the best physical, mental, moral, and emotional character for the performance of police
duties. In order to best ascertain who those individuals are, it is necessary to gather as much information as
possible about each applicant which may have a bearing on their ability to perform. Several questions in this
application are designed to give the Department a complete background on each applicant. Those particular
responses to questions marked with an (*) asterisk shall not act as an automatic bar to selection but will be
considered along with the attendant facts. No question on this application is intended to secure information to
be used for unlawful discrimination.
******************************************************************************************
APPLICANT: PLEASE READ CAREFULLY BEFORE SIGNING. IF YOU HAVE
ANY QUESTIONS REGARDING THE FOLLOWING STATEMENT OR ANY
QUESTIONS CONTAINED IN THIS APPLICATION, PLEASE ASK EITHER THE
CHIEF OF POLICE OR THE MAJOR OF THE MADISON POLICE DEPARTMENT.
*****************************************************************************
I certify that the information contained in this application is correct and complete to the best of my knowledge. I
agree to inform the Department of any additional information relating to questions raised on the application,
which occurs subsequent to my completion of the application. I realize that misrepresentation of fact of the
failure to update any information relating to questions on the application may be cause for rejection of this
application or dismissal after employment. Final employment is contingent upon satisfactory completion of all
pre-employment procedures including interview, examinations, verification of all relevant information, and all
post-employment examinations which may include but are not limited to physical and psychological
examinations and any applicable statutory provisions. I acknowledge that I have read the above statement and
fully understand the same.
SIGNATURE: ________________________________ DATE: _____________________
State of ________________)
) SS:
County of ______________)
Subscribed and sworn to before me, a Notary Public, in and for said county and state,
This __________ day of _______________, 20_____.
My Commission Expires:
_______________________________________
_____________________ Notary Public
_______________________________________
Printed
_______________________________________
County of Residence
NOTE: This page must be Notarized, signed, and returned with the application
Page 9