Fill - Free fillable MPD Application (City of Madison) PDF form

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 Jump—Sixteen (16) inches minimum accepted. This measures leg power and consists of

measuring how high you can jump.

2. One-Minute Sit-Ups—Twenty-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 Run—Seventy-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-Ups—Twenty-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 Run—Sixteen (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_______________________

//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////

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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

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