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
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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: ________________________________________________________________________
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 #2
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 #3
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
Section VII References & Acquaintances
Please list the names and contact information for three (3) adults (family members and
previous employers excluded) who have known you for at least five (5) years. Individuals
listed may be asked to provide information about your character, ability, experience and/or
personality.
*************************************************************************************
REFERENCE #1
Name: ___________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone: _______________ Cell Phone: _____________ Years Known: __________
Occupation: __________________________________________________________________________
Business Address: _____________________________________________________________________
Business Phone: __________________________ Email Address: __________________________
How do you know this person? __________________________________________________________
*************************************************************************************
REFERENCE #2
Name: ___________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone: _______________ Cell Phone: _____________ Years Known: __________
Occupation: __________________________________________________________________________
Business Address: _____________________________________________________________________
Business Phone: __________________________ Email Address: __________________________
How do you know this person? __________________________________________________________
*************************************************************************************
REFERENCE #3
Name: ___________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone: _______________ Cell Phone: _____________ Years Known: __________
Occupation: __________________________________________________________________________
Business Address: _____________________________________________________________________
Business Phone: __________________________ Email Address: __________________________
How do you know this person? __________________________________________________________
*************************************************************************************
Please list the names and contact information for three (3) acquaintances who have known
you for at least five (5) years, are NOT related to you, are NOT reference and are NOT former
employers. Names listed should be those who have seen you frequently over the last year.
*************************************************************************************
ACQUAINTANCE #1
Name: ___________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone: _______________ Cell Phone: __________ Years Known: _________________
Occupation: __________________________________________________________________________
Business Address: _____________________________________________________________________
Business Phone: __________________________ Email Address: __________________________
How do you know this person? __________________________________________________________
*************************************************************************************
ACQUAINTANCE #2
Name: ___________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone: _______________ Cell Phone: __________ Years Known: _________________
Occupation: __________________________________________________________________________
Business Address: _____________________________________________________________________
Business Phone: __________________________ Email Address: __________________________
How do you know this person? __________________________________________________________
*************************************************************************************
ACQUAINTANCE #3
Name: ___________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone: _______________ Cell Phone: __________ Years Known: _________________
Occupation: __________________________________________________________________________
Business Address: _____________________________________________________________________
Business Phone: __________________________ Email Address: __________________________
How do you know this person? __________________________________________________________
Section VIII Additional Information and Candidate Affidavit
Please complete the following questions and sign the candidate affidavit IN INK.
*************************************************************************************
Have you ever used illegal marijuana? Yes No
Have you ever used any illegal drug other than marijuana? Yes No
Have you ever been involved in the sale or distribution of illegal drugs? Yes No
Have you ever filed for bankruptcy?
Yes No
If “yes,” please give details
Have you ever been sued? Yes No
If “yes,” please give details (i.e. description, case name, case number):
Have you ever been party to a lawsuit? Yes No
If “yes,” please give details (i.e. description, case name, case number):
At the time of application, is the matter still pending? Yes No
*************************************************************************************
I hereby swear and affirm that each statement and all information in, or supplementing, this
application are complete, true, and accurately recorded to the best of my knowledge. I understand
that providing false, misleading, and/or incomplete information on this application is grounds for
disqualifying me from eligibility for appointment or my dismissal if discovered subsequent to my
appointment.
All statements in this application are subject to verification.
Signature Date
Please return completed application to the Niles Fire and Police Commission 7000 W. Touhy Niles, IL
60714 with all copies of certifications and copies of transcripts by due date.
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