Fill - Free fillable Section I Personal Information PDF form

Village of Niles

Fire and Police Commission

Director – Barry Mueller (847) 588-8085

7000 W. Touhy Ave., Niles, IL 60714

Section I – Personal Information

Name: ______________________________ _________________________ ___________________

Last Name First Name Middle

Address: ____________________ _____________________________ _______ __________

Street City State Zip

Email Address: ________________________________________________________________________

Home Phone: ___________________________ Cell Phone: _____________________________

SSN: ________________________________ Date of Birth: ___________________________

MM/DD/YYYY

Age: ________________________________

Have you been legally known by any other name or alias (ex. maiden name)?:

_____________________________________________________________________________________

Are you a United States citizen? Yes No

Are you legally eligible for employment in the U.S.? Yes No

Are you registered with the U.S. Selective Service? Yes No

Have you earned 60 or more college credits? Yes No

If “yes,” what college did you attend and how many credits do you currently have:

What academy did you attend to obtain state certification as a law enforcement officer?

_______________________________________ Date of Graduation: _________________________

Are you currently working for a department? Yes No

What department? _________________________________________________________________

If you separated from a department which department _____________________________________

Separation date ____________________________________________________________________

Please list previous residences for the last ten years:

Previous Residence 1: ___________________________ _____________________________________

Address

_________________________ __________ ____________ _________________________

City State Zip Dates

Previous Residence 2: ___________________________ _____________________________________

Address

_________________________ __________ ____________ _________________________

City State Zip Dates

Previous Residence 3: ___________________________ _____________________________________

Address

_________________________ __________ ____________ _________________________

City State Zip Dates

Section II – Family Information

Please list members of your immediate family who are still living (mother, father, sisters, brothers):

Name

Relationship

Address

Occupation

Section III – Educational History

Please list the schools you have attended, including high school(s) and college(s):

Name of School

City, State

Dates Attended

Graduated?/GPA

________ to _______

MM/YY MM/YY

Yes No

GPA_____________

________ to _______

MM/YY MM/YY

Yes No

GPA_____________

________ to _______

MM/YY MM/YY

Yes No

GPA_____________

________ to _______

MM/YY MM/YY

Yes No

GPA_____________

________ to _______

MM/YY MM/YY

Yes No

GPA_____________

________ to _______

MM/YY MM/YY

Yes No

GPA_____________

Degree/Certificate(s) Earned

Date

_____________________________________________________________

_______________

_____________________________________________________________

_______________

_____________________________________________________________

_______________

_____________________________________________________________

_______________

Please list any job related licenses/certifications you have earned (ex. EMT, HAZ-MAT)

(copies of these licenses/certifications must be included with this application):

_____________________________________________________________________________________

Section IV – Military History

Have you ever served in the U.S. Military? Yes No

If “no,” continue to the next page of this application.

If “yes,” which branch? _________________________________________________________________

List periods of active service: _________________ to ___________________

MMDDYY MMDDYY

_________________ to ___________________

MMDDYY MMDDYY

Date and location of entrance to active duty: __________ ___________________________________

Date Location

Date and location of discharge: _________ ______________________________________

Date Location

Highest rank held: _____________________________________________________________________

Rank at discharge: _____________________________________________________________________

Type of discharge: _____________________________________________________________________

How many years of continuous, active duty have you served?__________________________________

Are you now or were you ever a member of the U.S. reserve forces? Yes No

If “yes”: _______________ ____________________ ___________________ _________________

Active/Inactive Branch Unit Rank

___________________________________________ _______________________________________________________________________

Address Dates of Service

Are you now or were you ever a member of the National Guard? Yes No

If “yes”: _____________ ______________________ ____________________ __________________

State Regiment Unit Rank

___________________________________________ _______________________________________________________________________

Type of Discharge Dates of service

Section V – Driving & Criminal History

Has your driver’s license ever been revoked or suspended? Yes No

If “yes,” explain:

Have you ever had an operator’s or chauffeur’s license in another state? Yes No

If “yes,” which state: ___________________________________________________________________

Have you ever been refused an operator’s or chauffeur’s license in another state? Yes No

If “yes,” which state: ___________________________________________________________________

Please list any and all accidents and traffic citations issued in the last five years:

Have you ever been convicted of an offense other than a traffic violation? Yes No

If “yes,” please complete the section below.

Date

Agency

Crime Charged

Disposition of Case

Have you ever been placed on probation?: Yes No

If “yes,” please explain:

Have you ever been convicted of a felony?: Yes No

Section VI – Employment History

Are you currently on any eligibility lists? Yes No

If “yes,” please list agencies:

Have you ever been placed on an eligibility list and not hired? Yes No

If “yes,” please give details:

Section VI – Employment History, cont.

Please list previous employment for the last ten (10) years, beginning with your most recent

or current employer. Provide dates for periods of unemployment if applicable.

*************************************************************************************

CURRENT/MOST RECENT EMPLOYER

Name: _____________________________________ Type of Business: _______________________

Address: ___________________________________________________________________________

Phone: _________________________________ Your title: _____________________________

Name and title of supervisor: ____________________________________________________________

Description of duties: __________________________________________________________________

___________________________________________________________________________________

Dates of employment: ________________________________________________________________

Full Time: _________ Part time: _________ Salary: __________________________

Reason(s) for leaving: __________________________________________________________________

_________________________________________________________________________________

OK to contact employer? Yes No

PREVIOUS EMPLOYER #1

Name: _____________________________________ Type of Business: _______________________

Address: ________________________________________________________________________