BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 1 of 7
REV 9/2018
Applicant Screening Questionnaire
The purpose of this questionnaire is to assist with the background investigation required to
determine if you meet the standards established by the Berryville Police Department. False or misleading
information will disqualify you from further consideration. Please do not leave any sections blank, if they
do not apply please indicate so. If you fail to complete any section, no further action will be taken on your
application. Thank you for your cooperation.
Date :
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How
were
y
ou
referred?

Name:

Last
First
Middle
Address:
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Telephone: (Home):
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(Work):
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
Date of Birth:
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Are
y
ou le
g
all
y
eli
g
ible to work in the U.S.?
Yes/ No
Do you have a valid driver’s license? Yes/ No
Issuin
State:
 O.L.#:

EDUCATION
N
ame and location of Hi
g
h School attended:

Did
y
ou
g
raduate?
Yes/ No
If not, have
y
ou passed a GED test?
Yes/ No
Colle
g
e or Universit
y
:

School & Location From/To Degree Area of Study
Other Education:

School & Location From/To Degree Area of Study
Please list an
y
qualification and skills:





BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 2 of 7
REV 9/2018
MILITARY EXPERIENCE
Years of Service:
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Branch:

Dischar
g
e: Honorable / General / Dishonorable Date:

An
y
Court Martial / Article 15 Proceedin
g
s?
Yes/ No
Explain:



Do you have any previous law enforcement, corrections, or dispatcher experience? Yes/ No
A
g
enc
y
:
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Years of Service:
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Reason for Leavin
g
:
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Do
y
ou currentl
y
hold a Vir
g
inia Law Enforcement Certification?
Yes/ No
If
y
es, date of Expiration:

DRIVING HISTORY
Has your operator’s license ever been suspended or revoked in Virginia or any other State? Yes/ No
If so, when and for what reason:

Please list all traffic char
g
es, tickets, summons’, etc. re
g
ardless of final disposition for
y
our entire drivin
g
histor
y
:
Date (
y
ear onl
y
):
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Char
g
e:

Location:
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Disposition:
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
Date (
y
ear onl
y
):
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Char
g
e:

Location:
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Disposition:


Date (
y
ear onl
y
):
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Char
g
e:

Location:

Disposition:


Date (
y
ear onl
y
):

Char
g
e:

Location:
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Disposition:
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
Date (
y
ear onl
y
):

Char
g
e:

BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 3 of 7
REV 9/2018
Location:

Disposition:


Have
y
ou ever been char
g
ed with reckless drivin
g
?
Yes/ No
Date:

Location:

Disposition:
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Have you ever been charged with a drunk driving related offense? Yes/ No
Date:
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
Location:

Disposition:

Have you ever been charged with a criminal offense? Yes/ No
Date:
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Char
g
e:

Location:
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Disposition:



DRUG USE
N
umber of times Date of last use Comments
Mari
j
uana:
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Cocaine:

LSD:

Mushrooms:
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PCP:
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Speed:
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Steroids:
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Heroine:
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Othe
r
:


OTHER LAW ENFORCEMENT APPLICATIONS
Have you previously filed an application with our agency? Yes/ No
Date:
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1. Date:

A
g
enc
y
:
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Result:

2. Date:
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A
g
enc
y
:


BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 4 of 7
REV 9/2018
Result:

3. Date:

A
g
enc
y
:


Result:

GENERAL COMMENTS
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






WORK HISTORY
Please start with
y
our current
j
ob and work back. Please fill out this section to include all militar
y
and voluntee
r
experience. Please be sure to include all requested information for each entr
y
.
Have you ever been dismissed or forced to resign a position?
Yes/ No
1. Emplo
y
e
r
:
Address:
Phone
N
umbe
r
: Fax:
Dates of emplo
y
ment: Fro
m
: to Hours per wee
k
:
Supervisor’s
N
ame:
Job Title: Startin
g
Salar
y
: Endin
g
Salar
y
:
Reason for Leavin
g
:
Work Description:
May we contact your current employer? Yes/ No
BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 5 of 7
REV 9/2018
2. Emplo
y
e
r
:
Address:
Phone
N
umbe
r
: Fax:
Dates of emplo
y
ment: Fro
m
: to Hours per wee
k
:
Supervisor’s
N
ame:
Job Title: Startin
g
Salar
y
: Endin
g
Salar
y
:
Reason for Leavin
g
:
Work Description:
May we contact your current employer? Yes/ No
3. Emplo
y
e
r
:
Address:
Phone
N
umbe
r
: Fax:
Dates of emplo
y
ment: Fro
m
: to Hours per wee
k
:
Supervisor’s
N
ame:
Job Title: Startin
g
Salar
y
: Endin
g
Salar
y
:
Reason for Leavin
g
:
Work Description:
May we contact your current employer? Yes/ No
4. Emplo
y
e
r
:
Address:
Phone
N
umbe
r
:
Fax:
Dates of emplo
y
ment: Fro
m
: to Hours per wee
k
:
Supervisor’s
N
ame:
Job Title: Startin
g
Salar
y
: Endin
g
Salar
y
:
BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 6 of 7
REV 9/2018
Reason for Leavin
g
:
Work Description:
May we contact your current employer? Yes/ No
Please list an
y
former address where
y
ou have resided in past 15
y
ears:
Address:
Address
Address
Address
Address
Address
Address
Address
CIVIL ACTION
Have you ever been sued? Yes/ No
Date:
Circumstances:
Have you ever declared bankruptcy? Yes/ No
Date:
Circumstances:
Have you ever had judgments placed against you? Yes/ No
Date:
Circumstances:
Have you ever had any debts go to collection? Yes/ No
Date:
Circumstances:
BerryvillePoliceDepartment
101 Chalmers Ct., Suite A, Berryville, Virginia 22611
policeadmin@berryvilleva.gov
(540) 955-3863 (540) 955-0207 (Fax)
W. Neal White – Chief of Police
PD FORM 000 Page 7 of 7
REV 9/2018
PLEASE LIST 5 PROFESSIONAL REFERENCES
N
AME OCCUPATION ADDRESS PHONE
1.
2.
3.
4.
5.
PLEASE LIST 5 PERSONAL REFERENCES
N
AME OCCUPATION ADDRESS PHONE
1.
2.
3.
4.
5.
Attention: This statement must be signed.
I certify that the statements made by me in this application are true, complete, and correct to the best of my
knowledge, and that misrepresentation or omissions may result in rejection of my application, permanent
ineligibility for appointments or dismissal,
___________________________________________ ___________________________
Signature of Applicant Date
click to sign
signature
click to edit
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