Fillable PoliceDepartment VIPSApplicationForm (First) (FullMiddle) (Town of Purcellville)

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PoliceDepartment VIPSApplicationForm (First) (FullMiddle) (Town of Purcellville)

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The PoliceDepartment VIPSApplicationForm (First) (FullMiddle) (Town of Purcellville) form is 7 pages long and contains:

3 signatures
38 check-boxes
160 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Purcellville

BROWSE TOWN OF PURCELLVILLE (VA) FORMS

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

VIPSApplicationForm



VIPSApplicationUpdated3.30.17

1



PoliceDepartment

Name:(Last)



(First)



 (FullMiddle)



MaidenName/Alias: SocialSecurityNumber:



PhysicalAddress(NoPostOfficeBox):



HomeTelephoneNumber: WorkTelephoneNumber:



PersonalEmailAddress: WorkEmailAddress:



Doyouhaveanyweb/homepages?Ifso,provide

webaddressandlengthoftimeyou’vehadthe

web/homepage.



Areyouaparticipantinacommercialwebsitesuch

as“Facebook”orsimilarsites?Ifso,provideweb

addressandlengthoftimeyou’vebeenamember.



Operator’sLicense(i.e.Driver’sLicense)andstate

licensewasissued:

ExpirationDateonLicense:



CommercialDriver’sNumberandStateLicense

wasissued:

ExpirationDateonLicense:



DateofBirth(Month/Day/Year): CityandStateofBirth:



CurrentHeight,Weight,andRace(requiredfor

recordscheck):

ColorofHair: ColorofEyes:







VIPSApplicationForm



VIPSApplicationUpdated3.30.17

2



PoliceDepartment

EmploymentHistory



FullNameofEmployer: CurrentOccupation:



AddressofEmployer:



LengthofTimeatCurrentEmployment:



Years______Months______

MayweContactYourCurrentEmployer?



YesNo

Haveyoubeendemotedorsuspendedfromyour

currentemployment?Fromanyprevious

employments?



YesNo

ProvideDetailsforAllDemotionsandSuspensions

(Dates/Reasons):

Haveyoubeenfiredfromanyemployment?



YesNo



Details:



DoyouhaveaFederalSecurityClearance?



YesLevel____________



No

HistoryofSecurityClearances



Suspended:YesNo



Revoked:YesNo

ExplainReasonsforSuspension/RevocationofSecurityClearancetoIncludeDates:







VIPSApplicationForm



VIPSApplicationUpdated3.30.17

3



PoliceDepartment

VolunteerServiceHistory



Name(Organization/Agency): Location(City,State): Position: Dates:

1.

2.

3.

ReasonforLeavingEachVolunteerPosition

1.

2.

3.

Haveyoupreviouslyappliedforandbeendenied

anytypeofvolunteerpositionwithinLoudoun

County?



YesNo

Haveyouappliedforanylawenforcementrelated

positions?



YesNo

Education

CurrentlevelofEducation:

GEDHSDiplomaAssociatesDegree



Bachelor’sDegreeCollege:_______________________Major:_________________

Master’sDegreeCollege:_______________ ________Major:_________________

PhD.College:_______________________Major:_________________



MilitaryService

(Active,Reserves,NationalGuard)



BranchofService:__________________________



YearsofService:___________________________



TypeofDischarge:_________________________



HighestGrade/Rank:_______________________



DisciplinaryAction

HaveyoueverbeenCourtMartialed?



YesNo



Ifyes,dateandreason:



Non‐judicialPunishment(dateandreason)

PolygraphHistory

Haveyouevertakenapolygraph?YesNo



NameofDepartment/Agency:



DateandReasonforpolygraph



VIPSApplicationForm



VIPSApplicationUpdated3.30.17

4



PoliceDepartment

CitizenshipandResidency



AreyouaUnitedStatesCitizen?

YesNo



AreyouaresidentoftheTownofPurcellville?

YesNo

PermanentResidentAlienInformation



CountryofBirth:___________________________



DateofEntryintoU.S.:__ ____________________



PermanentResidentAlienNumber:



DriverLicenseHistory



Hasyourlicenseeverbeenrevokedorsuspended?

YesNo

Ifyes,providedetails.



ListotherstateswhereyouhadaDriver’sLicense

issued:

1.

2.

3.

TrafficCitations



Listalltrafficcitations(excludingparking)receivedbyOffense/Date/Location/Departmentbelow:

OffenseDateLocationDepartment

1.

2.

3.

4.

5.

CriminalHistory



ListallCriminalCharges/Offensesyouhavebeenchargedwithregardlessofthefinaloutcomeofany

courtproceedings.Includealladultorjuvenileoffenses.

OffenseDateLocationPoliceAgencyDisposition

1.

2.

3.

4.

5.



VIPSApplicationForm



VIPSApplicationUpdated3.30.17

5



PoliceDepartment

FinancialResponsibility



1. Areyoulivingwithinyourfinancialmeans?YesNoIfno,providedetailsbelow.



2. Haveyoueverpetitionedforbankruptcy(personal/business)YesNoIfyes,provide

detailsbelow.



3. Haveyouwrittenanynon‐sufficientfundscheckswithinthepastfiveyears?

YesNoIfyes,providedetailsbelow.



4. Anycurrentorpreviouscreditliensagainstyourvehicle(s)and/orproperty?

YesNoIfyes,providedetailsbelow.



5. Haveyoubeensuedincivilcourt?YesNoIfyes,providedetailsbelow.



6. Haveyou

receivedfinancialcounseling?YesNoIfyes,providedetailsbelow.







VIPSApplicationForm



VIPSApplicationUpdated3.30.17

6



PoliceDepartment

Drug/SubstanceUse



Haveyoueverused,abused,orexperimentedwith

anyofthefollowingsubstances?Ifyes,provide

detailsastoperiodoftimeused,approximately

numberoftimespersubstanceand anycomments

youwishtoprovide.



YesNoMariju ana /Hashish



YesNoCocaine/Crack



Yes

NoAmphetamines/Barbiturates



YesNoSteroids



YesNoLSD /PCP/otherHallucinogens



YesNoAerosolInhalants/Glue



YesNoOthersubstances



YesNoExcessiveuseofalcohol



Providedetailsoftreatmentreceivedduetouseof

drugs

/substances.Spacemayalsobeusedto

explainuseofdrugs/substances.

NOTICE

Duringyourpersonalinterviewyouwillbe

requiredtosignthisapplicationforminfrontofa

representativeofthePurcellvillePolice

Department.Bysigningthisform,youare

confirmingthatallinformationistrueand

accurate.

SignatureofApplicant



Useadditionalpaper(ifneeded)forcommentsanddetailsforaboveinformation.



click to sign

signature

click to edit



VIPSApplicationForm



VIPSApplicationUpdated3.30.17

7



PoliceDepartment

References

(Pleaseprovideatleastoneprofessionalanddonotincludefamilymembersorpastsupervisors)

Name: Phone#: Relationship: BestTimetoCall:

1.



2.



3.





Non‐DisclosureNotice

GeneralOrder116.5–VolunteersinPoliceService(VIPS)reflectsrequirementsregardingconfidentiality 

ofpolicerecords/information.ThisNon‐DisclosureNoticeaugmentsthisrequirement.



I____________________________________________understandasavolunteerImayhaveaccessto

confidentialrecordssuchascriminalhistoriesorinvestigations,asmydutiesmaydictate.Aspartofmy



orientation,Ihavebeenmadeawareoftherestrictionsofdisclosureofsuchrecordstounauthorized

personnel.

PertheaboveGeneralOrder,Iunderstandthatsubsequentdisclosureofanyconfidential information, 

verballyorinwriting,shallbegroundsforimmediatedismissalandpossiblecri minalprose cution.

Inaddition,Iamaware

thatVIPSpersonnelarenotauthorizedtoreleaseanycriminalhistory

informationtoanyoneoutsideofthePurcellvillePoliceDepartment.

ThisformwillbeplacedinmyVIPSpersonnelfolder.



___________________________________________ _______________________________________

SignatureofVIPSSignatureofParentorGuardianofMinor

___________________________________________ _______________________________________

PrintedfullnameofVIPSPrinted

fullnameofParentorGuardian

______________ ______________

DateformsignedDateformsigned

click to sign

signature

click to edit

click to sign

signature

click to edit

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PoliceDepartment VIPSApplicationForm (First) (FullMiddle) (Town of Purcellville)

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Completed 4 August 2020

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