VIPSApplicationForm
VIPSApplicationUpdated3.30.17
1
PoliceDepartment
Name:(Last)
(First)
(FullMiddle)
MaidenName/Alias: SocialSecurityNumber:
PhysicalAddress(NoPostOfficeBox):
HomeTelephoneNumber: WorkTelephoneNumber:
PersonalEmailAddress: WorkEmailAddress:
Doyouhaveanyweb/homepages?Ifso,provide
webaddressandlengthoftimeyou’vehadthe
web/homepage.
Areyouaparticipantinacommercialwebsitesuch
as“Facebook”orsimilarsites?Ifso,provideweb
addressandlengthoftimeyou’vebeenamember.
Operator’sLicense(i.e.Driver’sLicense)andstate
licensewasissued:
ExpirationDateonLicense:
CommercialDriver’sNumberandStateLicense
wasissued:
ExpirationDateonLicense:
DateofBirth(Month/Day/Year): CityandStateofBirth:
CurrentHeight,Weight,andRace(requiredfor
recordscheck):
ColorofHair: ColorofEyes:

VIPSApplicationForm
VIPSApplicationUpdated3.30.17
2
PoliceDepartment
EmploymentHistory
FullNameofEmployer: CurrentOccupation:
AddressofEmployer:
LengthofTimeatCurrentEmployment:
Years______Months______
MayweContactYourCurrentEmployer?
YesNo
Haveyoubeendemotedorsuspendedfromyour
currentemployment?Fromanyprevious
employments?
YesNo
ProvideDetailsforAllDemotionsandSuspensions
(Dates/Reasons):
Haveyoubeenfiredfromanyemployment?
YesNo
Details:
DoyouhaveaFederalSecurityClearance?
YesLevel____________
No
HistoryofSecurityClearances
Suspended:YesNo
Revoked:YesNo
ExplainReasonsforSuspension/RevocationofSecurityClearancetoIncludeDates:

VIPSApplicationForm
VIPSApplicationUpdated3.30.17
3
PoliceDepartment
VolunteerServiceHistory
Name(Organization/Agency): Location(City,State): Position: Dates:
1.
2.
3.
ReasonforLeavingEachVolunteerPosition
1.
2.
3.
Haveyoupreviouslyappliedforandbeendenied
anytypeofvolunteerpositionwithinLoudoun
County?
YesNo
Haveyouappliedforanylawenforcementrelated
positions?
YesNo
Education
CurrentlevelofEducation:
GEDHSDiplomaAssociatesDegree
Bachelor’sDegreeCollege:_______________________Major:_________________
Master’sDegreeCollege:_______________ ________Major:_________________
PhD.College:_______________________Major:_________________
MilitaryService
(Active,Reserves,NationalGuard)
BranchofService:__________________________
YearsofService:___________________________
TypeofDischarge:_________________________
HighestGrade/Rank:_______________________
DisciplinaryAction
HaveyoueverbeenCourtMartialed?
YesNo
Ifyes,dateandreason:
NonjudicialPunishment(dateandreason)
PolygraphHistory
Haveyouevertakenapolygraph?YesNo
NameofDepartment/Agency:
DateandReasonforpolygraph
VIPSApplicationForm
VIPSApplicationUpdated3.30.17
4
PoliceDepartment
CitizenshipandResidency
AreyouaUnitedStatesCitizen?
YesNo
AreyouaresidentoftheTownofPurcellville?
YesNo
PermanentResidentAlienInformation
CountryofBirth:___________________________
DateofEntryintoU.S.:__ ____________________
PermanentResidentAlienNumber:
DriverLicenseHistory
Hasyourlicenseeverbeenrevokedorsuspended?
YesNo
Ifyes,providedetails.
ListotherstateswhereyouhadaDriver’sLicense
issued:
1.
2.
3.
TrafficCitations
Listalltrafficcitations(excludingparking)receivedbyOffense/Date/Location/Departmentbelow:
OffenseDateLocationDepartment
1.
2.
3.
4.
5.
CriminalHistory
ListallCriminalCharges/Offensesyouhavebeenchargedwithregardlessofthefinaloutcomeofany
courtproceedings.Includealladultorjuvenileoffenses.
OffenseDateLocationPoliceAgencyDisposition
1.
2.
3.
4.
5.
VIPSApplicationForm
VIPSApplicationUpdated3.30.17
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PoliceDepartment
FinancialResponsibility
1. Areyoulivingwithinyourfinancialmeans?YesNoIfno,providedetailsbelow.
2. Haveyoueverpetitionedforbankruptcy(personal/business)YesNoIfyes,provide
detailsbelow.
3. Haveyouwrittenanynonsufficientfundscheckswithinthepastfiveyears?
YesNoIfyes,providedetailsbelow.
4. Anycurrentorpreviouscreditliensagainstyourvehicle(s)and/orproperty?
YesNoIfyes,providedetailsbelow.
5. Haveyoubeensuedincivilcourt?YesNoIfyes,providedetailsbelow.
6. Haveyou
receivedfinancialcounseling?YesNoIfyes,providedetailsbelow.

VIPSApplicationForm
VIPSApplicationUpdated3.30.17
6
PoliceDepartment
Drug/SubstanceUse
Haveyoueverused,abused,orexperimentedwith
anyofthefollowingsubstances?Ifyes,provide
detailsastoperiodoftimeused,approximately
numberoftimespersubstanceand anycomments
youwishtoprovide.
YesNoMariju ana /Hashish
YesNoCocaine/Crack
Yes
NoAmphetamines/Barbiturates
YesNoSteroids
YesNoLSD /PCP/otherHallucinogens
YesNoAerosolInhalants/Glue
YesNoOthersubstances
YesNoExcessiveuseofalcohol
Providedetailsoftreatmentreceivedduetouseof
drugs
/substances.Spacemayalsobeusedto
explainuseofdrugs/substances.
NOTICE
Duringyourpersonalinterviewyouwillbe
requiredtosignthisapplicationforminfrontofa
representativeofthePurcellvillePolice
Department.Bysigningthisform,youare
confirmingthatallinformationistrueand
accurate.
SignatureofApplicant
Useadditionalpaper(ifneeded)forcommentsanddetailsforaboveinformation.

click to sign
signature
click to edit
VIPSApplicationForm
VIPSApplicationUpdated3.30.17
7
PoliceDepartment
References
(Pleaseprovideatleastoneprofessionalanddonotincludefamilymembersorpastsupervisors)
Name: Phone#: Relationship: BestTimetoCall:
1.

2.

3.

NonDisclosureNotice
GeneralOrder116.5VolunteersinPoliceService(VIPS)reflectsrequirementsregardingconfidentiality
ofpolicerecords/information.ThisNonDisclosureNoticeaugmentsthisrequirement.
I____________________________________________understandasavolunteerImayhaveaccessto
confidentialrecordssuchascriminalhistoriesorinvestigations,asmydutiesmaydictate.Aspartofmy
orientation,Ihavebeenmadeawareoftherestrictionsofdisclosureofsuchrecordstounauthorized
personnel.
PertheaboveGeneralOrder,Iunderstandthatsubsequentdisclosureofanyconfidential information,
verballyorinwriting,shallbegroundsforimmediatedismissalandpossiblecri minalprose cution.
Inaddition,Iamaware
thatVIPSpersonnelarenotauthorizedtoreleaseanycriminalhistory
informationtoanyoneoutsideofthePurcellvillePoliceDepartment.
ThisformwillbeplacedinmyVIPSpersonnelfolder.
___________________________________________ _______________________________________
SignatureofVIPSSignatureofParentorGuardianofMinor
___________________________________________ _______________________________________
PrintedfullnameofVIPSPrinted
fullnameofParentorGuardian
______________ ______________
DateformsignedDateformsigned
click to sign
signature
click to edit
click to sign
signature
click to edit