greene county peace officer basic training...please feel free to contact the program at greene...
TRANSCRIPT
![Page 1: GREENE COUNTY Peace Officer Basic Training...Please feel free to contact the program at Greene County Career Center at 937-372-6941, and speak with either myself (extension 139) or](https://reader034.vdocuments.us/reader034/viewer/2022051906/5ff8ef04b352b52afc3843a8/html5/thumbnails/1.jpg)
GREENE COUNTY
Peace Officer Basic Training
Dear Academy Applicant:
Welcome to the field of Law Enforcement! It is our pleasure to provide you with information on the Peace
Office Basic Training course offered through the Greene County Career Center in Xenia, Ohio. We look
forward to traveling with you on your journey into the exciting, yet demanding, arena of police work.
Enclosed please find our information/application packet for the upcoming academy course offerings for
2017-18.
Please feel free to contact the program at Greene County Career Center at 937-372-6941, and speak with
either myself (extension 139) or Becky Bond (extension 204) if you need additional assistance. We
encourage you to visit our website at www.greeneccc.com. You will find academy information, related
law enforcement links and general information on financial aid and other services provided by the Greene
County Career Center.
The Peace Officer Basic Training program is eager to put you on the path to realize your dreams of
becoming an Ohio Peace Officer.
Sincerely,
Michael Hild Sr.
Michael Hild Sr., Commander
Greene County Career Center
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Revised 02/21/17 2
Greene County Peace Officer Basic Training Academy
The Greene County Criminal Justice Training Academy (GCCJTA) strives for professional distinction in
providing state-of-the-art law enforcement training. All training at GCCJTA adheres to the standards set
forth by the Ohio Attorney General’s office and the Ohio Peace Officer Training Commission. Our
instructors come from noted regional law enforcement agencies and provide infinite years of law
enforcement experiences and intuition. Greene County Criminal Justice Training Academy is honored to
be partnered with area law enforcement agencies in the form of an Advisory Board and resource bank of
elite instructors and trainers who lead by example.
Our academy is approximately 750 hours which sets our standards above the minimum state requirement
of 695. Our training offers the Basic Peace Officer course and the following certifications:
Oleoresin Capsicum (OC) Certification
ASP Certification
Taser (User Certification)
Single Officer Response to an Active Shooter
Recruits are responsible to meet all scheduled training hours and provide their own transportation to the
training sites. Attendance is mandatory for all class sessions. The program of training includes
classroom, simulation and field training. The final classroom date is subject to change. The majority of
the training will take place at Greene County Criminal Justice training sites; the rest will be at locations
around Greene County.
Before submitting your application, please evaluate your personal and business commitments and
resources. Compliance with all of the rules and policies set forth by the Academy are mandated. Absence
from classes must be made up at the student’s expense. Attendance and participation in all facets of training
is compulsory and failure to act in accordance with these standards will result in a request for your
resignation or dismissal from the academy.
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Revised 02/21/17 3
SWORN OFFICERS:
Persons who hold a current oath of office with any Ohio law enforcement agency are automatically eligible
for the Basic Police Academy.
A physical assessment and oral interview are required.
Verify physical fitness to safely function in all phases of the academy’s strenuous training (verified
by a licensed physician to include disability, chronic illness, pregnancy, etc.)
OPEN ENROLLMENT RECRUITS
Those applicants who are not affiliated with a law enforcement agency must meet the following minimum
standards:
Have a valid Driver’s License
Have NO Felony convictions, warrants or investigations pending
Have NO conviction for any offense stemming from a domestic violence charge, this includes
guilty or no contest pleas to lesser charges when the original charge was domestic violence or drug
charge.
Have NO convictions for any drug offense
Be in violation of Ohio’s Child Support Enforcement Laws
Be certified by a licensed physician as able to participate in all phases of the academy’s strenuous
and stressful training (includes disability, chronic illness, pregnancy, etc.)
Successfully pass the entry level physical fitness assessment at 15% of the OPOTA academy
completion standard
It is strongly recommended that open enrollment applicants have previous knowledge or experience in the
criminal justice field. Applicants will be asked in an oral interview how they have prepared themselves for
entrance into the Basic Police Academy, and preference will be given to candidates who can demonstrate
appropriate preparation.
Training Equipment and Uniforms
All police academy recruits will wear the designated uniform of the day. This will consist of a Navy Blue
shirt bearing the Greene County Criminal Justice Academy logo, khaki pants, black shoes, black belt and a
navy blue ball cap bearing the logo, No exceptions. The academy will provide each recruit with instructional
materials, books, two academy shirts, and a ball cap. Recruits are responsible for the following additional
items by the first day of class:
Khaki pants/slacks
Pens, paper and at least four three ring large notebook binder
Duty belt with level two holster and handcuff case with one pair of handcuffs, key, keepers or belt
stays, ammo pouches, ASP baton and holder
Lists of training equipment and suggested types and vendors will be supplied following the physical
assessment, oral review board, and your acceptance into the academy.
Firearms will be a 9mm, or .40 caliber and must be approved by the Academy Commander.
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Revised 02/21/17 4
Academy Conduct
All recruits, instructors and persons associated with the Greene County Criminal Justice Academy will
display professional, mature and respectful behavior at all times. The Law Enforcement Code of Ethics
must be adhered to as of Day One of the Academy. Any disruptive, disrespectful or unsafe behavior will
not be tolerated and could result in disciplinary action to include dismissal from the academy with no refund
of monies paid. Academy recruits and personnel shall adhere to the guidelines and policies set forth in the
Student Handbook and will be required to sign a statement of understanding prior to beginning the academy.
Recruits are required to follow standards of personal appearance and hygiene:
o Hair for Men-military or tapered hair, off of the ears and no longer than collar length
o Hair for Women-if longer than shoulder length, must be pinned up or otherwise fastened
securely to head
o No afros, unless short and neatly barbered
o No unusual hair dyes permitted
o No braids, cornrows, etc. in the hair, except where braided in order to fasten securely to
the head (women only)
o No bandanas, hats or do-rags will be worn during classroom instruction
o Men are to be clean-shaven, with no beards, goatees or long sideburns. A mustache may
be worn so long as the ends of the mustache do not extend past the ends of the upper lip.
o No facial jewelry of any kind is permitted, including tongue piercings. No earrings are
permitted for men or women. There are to be no visible body piercings anywhere else on
the body; all jewelry (with the exception of wedding ring) is to be removed before the
physical contact portion of the training begins.
o All tattoos must be covered, particularly those of a vulgar or offensive nature. If the tattoos
are in an area that cannot be covered, it is highly recommended that the individual consider
having them removed.
o Student in the academy must present a clean, neat, professional appearance at all times.
Clothing may not have stains, tears or holes, and will be washed and wrinkle free.
o Students will not wear excessive cologne or perfume.
o Beginning with the first day of class, students will be required to keep a typed notebook,
to be submitted every month for inspection and grading.
Cost and Financial Assistance
Tuition is payable either up front, in a payment plan, through financial aid assistance, or a combination of
self-pay and financial assistance. All financial arrangements and/or fees must take place at least two
weeks prior to the starting date of the academy. Failure to comply with deadlines will prevent
you from participation in the academy. After enrollment and the beginning of the academy, failure to meet
scheduled payment dates will cause you to be terminated from the academy with no refund of monies paid
to date. Recruits sponsored and funded by an agency, must provide a letter of intent or purchase order on
company letterhead. Please contact Mr DeLange, Financial Aid Advisor, at [email protected] with
questions
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Revised 02/21/17 5
Physical Fitness Training
All prospective academy recruits will be required to pass a Pre-Academy Physical Fitness Assessment prior
to beginning academy training. Please review the Pre-Academy Physical Fitness Standards based on the
15th percentile of the Cooper Fitness Standards from the Ohio Peace Officer Training Commission. If
you fail to meet the Pre-Academy Physical Fitness Standards, you will be eliminated from the process.
Physical conditioning and the successful passing of the Final Physical Fitness Assessment at the end of the
academy are compulsory. Please review the Final Physical Fitness Assessment Standards based on the
50th percentile of the Cooper Fitness Standards from the Ohio Peace Officer Training Commission. If
you fail to meet the Final Physical Fitness Standards, you will not be able to sit for the state exam and must
repeat the entire academy. Although academy staff will condition each recruit during the academy, all are
encouraged to begin an exercise regimen prior to, during, and after the academy.
See Fitness Standards Table below.
Ohio Peace Officer Basic Training Program
Physical Fitness Standards
(50th Percentile*)
Age and Gender Minimum Scores
Pre-Academy
(15th)
Final (50th) Pre-Academy (15th) Final (50th)
Sit-ups (1min)
Push-ups (1 min)
1.5 Mile Run
Males (<-29)
32
19
14:34
Males (<-29)
40
33
11:58
Females (<-29)
23
9
17:49
Females (<-29)
35
18
14:07
Sit-ups (1min)
Push-ups (1 min)
1.5 Mile Run
Males (30-
39)
28
15
15:13
Males (30-39)
36
27
12:25
Females (30-39)
18
7
18:37
Females (30-39)
27
14
14:34
Sit-ups (1min)
Push-ups (1 min)
1.5 Mile Run
Males (40-
49)
22
10
15:58
Males (40-49)
31
21
13:11
Females (40-49)
13
5
19:32
Females (40-49)
22
11
15:24
Sit-ups (1min)
Push-ups (1 min)
1.5 Mile Run
Males (50-
59)
17
7
17:38
Males (50-59)
26
15
14:16
Females (50-59)
7
4* Modified
21:31
Females (50-59)
17
13* Modified
17:13
Sit-ups (1min)
Push-ups (1 min)
1.5 Mile Run
Males (60+)
13
5
20:12
Males (60+)
20
15
15:56
Females (60+)
2
1* Modified
23:32
Females (60+)
8
8* Modified
18:52
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Revised 02/21/17 6
*Based on, the Cooper Institute, Physical Fitness Specialist Course and Certification
Our instructors provide individualized support services in the area of fitness, goal setting, nutrition and
exercise so each recruit can focus on meeting personal and OPOTA standards.
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Revised 02/21/17 7
Submit the completed notarized application and copy of valid driver’s
license to:
Greene County Criminal Justice Training Academy
c/o Greene County Career Center
Adult Education Building
2960 West Enon Road
Xenia, Ohio 45385-9545
Applicants will receive a letter indicating the location, date and time they
will need to be available for the Physical Assessment entry examination
and oral interview.
.
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Revised 02/21/17 8
Greene County Criminal
Justice Training Academy
2960 West Enon Road
Xenia, OH 45385
Adult Education Department
Greene County Career Center
(937) 372-6941 ext. 204
AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN:
I hereby authorize any commissioned agent or representative of the Greene County Criminal Justice
Training Academy, bearing this release, or a copy thereof, within one (1) year of its date, to obtain any
information in your files pertaining to my employment, credit, support obligation records, or educational
records including, but not limited to, academic achievement, attendance, personal history, disciplinary
records, medical (per HIPPA requirements), fitness reports and military records. I hereby direct you to
release such information upon request to the bearer.
This request is executed with full knowledge and understanding that the information is for the official use
of the Greene County Criminal Justice Training Academy. Consent is granted for the Greene County
Criminal Justice Training Academy to furnish such information, as is described above, to third parties in
the course of fulfilling its official responsibilities.
I hereby release you, as the custodian of such records, and any government agency, school, college,
university, other educational institution, repository of military records, credit bureau, lending institution,
consumer reporting agency, police departments or retail business establishment, including its officers,
employees or related personnel, both individually and collectively, from any liability for damages of
whatever kind, which may at any time result to me, my heirs, family or associates because of compliance
with this authorization and request to release information, or any attempt to comply with it. Should there
be any question as to the validity of this release, you may contact me as indicated below.
FULL NAME___________________________________________________________________
(Signature)
DATE______________________________________________________________________
CURRENT ADDRESS__________________________________________________________
___________________________________________________________________________
TELEPHONE NUMBER________________________________________________________
________________________________________________________________Notary Public In and For
_________________County, Ohio My commission expires ______________________________
Witness ____________________________________ Date __________________
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Revised 02/21/17 9
Greene County Criminal
Justice Training Academy
2960 West Enon Road
Xenia, OH 45385
Adult Education Department
Greene County Career Center
(937) 372-6941 ext 204
MEDIA RELEASE
Date:__________________________ Subject:____________________________
I do hereby grant and give to Greene County Career Center, its successor and assigns (hereinafter referred
to as the school), the right to use, and to permit others to use my name, photograph, testimonial, voice
image, or likeness on printed material, printed film, film recording, video tape, or other sound and/or
visual device, both single and in conjunction with other persons or objects, for any and all purposes
including but not limited to, private or public presentations on the radio, television, in theaters,
newspapers, outdoor, direct mail, promotional literature, point-of-purchase material, signs, publicity, and
promotion related thereto.
I warrant that I have the right to authorize the foregoing uses and to hereby agree to withhold the School
harmless of any and all liability of whatever nature which may arise out of or result from such uses.
____________________________________________________
Signature
____________________________________________________
Printed Name
____________________________________________________
Street Address
_____________________________________________________
City, State, Zip
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Revised 02/21/17 10
Greene County Criminal
Justice Training Academy
2960 West Enon Road
Xenia, OH 45385
Adult Education Department
Greene County Career Center
(937) 372-6941 ext. 204
DOMESTIC VIOLENCE INFORMATION FORM
Title 18, United States Code, Section 922 (g) (9) makes it illegal for anyone who has been convicted of a
misdemeanor crime of Domestic Violence to possess any firearm or ammunition “Misdemeanor Crime of
Domestic Violence” is generally defined as any offense, whether or not explicitly described in a statute as
a crime of Domestic Violence, which has, as its factual basis, the use or attempted use of physical force, or
the threatened use of a deadly weapon, committed by the victim’s current or former domestic partner, parent
or guardian. The term “convicted” is generally defined in the statute as excluding anyone whose conviction
has been expunged or set aside, or has received a pardon. Any person who has pled guilty or no contest to
a lesser charge when the original charge was domestic violence, ORC 2919.25, is not eligible to apply.
If you are affected by this statute, you may not possess any firearm or ammunition; therefore, you are not
eligible for positions in the uniform forces of the any Police Department. Please answer the following:
1.) Have you ever been convicted of a misdemeanor crime of Domestic Violence
within the meaning of the statute? YES_____ NO _____
2.) If you answered yes to Question 1, provide the following information with
Respect to the conviction:
Court/Jurisdiction: ____________________________________________
Docket/Case Number: _________________________________________
Statute/Charge:_______________________________________________
I hereby certify that, to the best of my knowledge and belief, all of the information provided by me is true,
correct, complete, and made in good faith. I understand that false or fraudulent information provided herein
may be grounds for disqualification for the position of Police Recruit with the Greene County Criminal
Justice Training Academy.
Applicant Name__________________________________________________________ Print or type
Signature____________________________________________Date________________
Witness_____________________________________________Date________________
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Revised 02/21/17 11
Greene County Criminal
Justice Training Academy
2960 West Enon Road
Xenia, OH 45385
Adult Education Department
Greene County Career Center
(937) 372-6941 ext. 204
TO: Child Support Enforcement Agency
RE:
Social Security #
The above named individual is an applicant for the position of police recruit with the Greene County
Criminal Justice Training Academy.
Would you please verify that this individual is current in his/her alimony and/or child support obligations.
If not current, would you please furnish the delinquent amount? A notarized release of information is
enclosed.
The applicant provided the following information concerning his/her obligations.
Obligee:
Children:
Thank you for your assistance.
Sincerely,
Michael Hild Sr.
Michael Hild Sr.
Academy Commander
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Revised 02/21/17 12
Greene County Criminal
Justice Training Academy
2960 West Enon Road
Xenia, OH 45385
Adult Education Department
Greene County Career Center
(937) 372-6941 ext. 204
TO: National Personnel Records Center
(Military Personnel Records)
9700 Page Blvd.
St. Louis Missouri, 63132
FROM: Name:
Date of Birth:
Social Security #:
Branch of Service:
Dates of Service:
The above named individual is an applicant for the position of Police Recruit with the Greene County
Criminal Justice Training Academy, Xenia, Ohio.
Would you please verify the above information and forward his/her complete military history records
(excluding medical). The necessary authorization for the release of this information is enclosed.
Thank you in advance for your assistance.
Sincerely,
Michael Hild Sr.
Michael Hild Sr.
Academy Commander
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Type or print all information
GREENE COUNTY PEACE OFFICER BASIC TRAINING
PERSONAL INVESTIGATION WORKSHEET
HOW DID YOU LEARN OF THE CRIMINAL JUSTICE TRAINING ACADEMY? : _________________
INSTRUCTIONS: This application is to be filled out in complete detail. Failure to
provide information or give false information could result in your
rejection. If you need to make any corrections, please initial next
to each.
YOUR FULL NAME _______________________________________________________________
(LAST) (FIRST) (MIDDLE)
ANY OTHER NAMES YOU HAVE USED __________________________________________
MAIDEN NAME: ________________________ NICKNAME: __________________________
PRESENT ADDRESS: ___________________________________________________________
(STREET AND APT. #)
______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
LIST ADDITIONAL ADDRESSES WHERE YOU MAY BE CONTACTED:
______________________________________________________________________________
TELEPHONE NUMBERS: (HOME) _________________ (WORK) _____________________
SOCIAL SECURITY #: _________________________ BIRTHDATE: ____________________
BIRTHPLACE: _________________________________________________________________
ARE YOU A U.S. CITIZEN: _______ YES _______ NO HEIGHT _____ WEIGHT ______
HAIR COLOR ________ EYE COLOR _________
SCARS/MARKS/TATTOOES ___ SPECIFY LOCATION ____________________________
MARITAL STATUS: ____________________________________________________________
(MARRIED, SINGLE, SEPERATED, DIVORCED)
SPOUSE’S FULL NAME: ________________________________________________________
SPOUSE’S SOCIAL SECURITY #: __________________ BIRTHDATE: ________________
SPOUSE’S ADDRESS (IF DIFFERENT): ___________________________________________
(STREET AND APT. #)
______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
SPOUSE’S EMPLOYER: ________________________________________________________
(NAME OF COMPANY)
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Revised 02/21/17 14
EMERGENCY CONTACT, NAME AND PHONE NUMBER #1 _________________________________
EMERGENCY CONTACT, NAME AND PHONE NUMBER #2 _________________________________
CHILDREN’S NAME(S) AND AGES(S):
NAME AGE
1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
IF PREVIOUSLY MARRIED, LIST FORMER SPOUSE’S NAME & ADDRESS
NAME: _______________________________________________________________________
(LAST) (FIRST) (MIDDLE)
ADDRESS: ____________________________________________________________________
(STREET AND APT. #)
______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
WHEN / WHERE DIVORCED? ____________________________________________________
WHAT METHOD OF PAYMENT WILL YOU BE USING FOR YOUR TUITION? CASH _______
THREE PAYMENT PLAN _______ VISA/MASTERCARD _______ FINANCIAL AID: _______
CHECK IF YOU KNOW WHAT PLAN YOU WILL BE USING OR IF YOU HAVE PREVIOUSLY USED ANY
OF THE FOLLOWING:
VA _________ PELL _________ BVR _______ TRA/TAA ________ WIA_______
GREENEWORKS _______ WORKPLUS _______
WHAT DO YOU SEE YOURSELF DOING ONE YEAR FROM NOW? _________________________________
_____________________________________________________________________________________________
WHAT DO YOU SEE YOURSELF DOING FIVE YEARS FROM NOW? ________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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PREVIOUS RESIDENCES
LIST IN CHRONOLOGICAL ORDER ALL PREVIOUS ADDRESSES WITHIN THE PAST 5 YEARS.
DATES (FROM MONTH/YEAR TO MONTH/YEAR) _________________________________
ADDRESS: ____________________________________________________________________
(STREET AND APT. #)
______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
OWNED OR RENTED? _________________________________________________________
MORTGAGE HOLDER OR LANDLORD ? _________________________________________
DATES (FROM MONTH/YEAR TO MONTH/YEAR) _________________________________
ADDRESS: ____________________________________________________________________
(STREET AND APT. #)
______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
OWNED OR RENTED _________________________________________________________
MORTGAGE HOLDER OR LANDLORD ? _________________________________________
DATES (FROM MONTH/YEAR TO MONTH/YEAR) _________________________________
ADDRESS: ____________________________________________________________________
(STREET AND APT. #)
_____________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
OWNED OR RENTED? _________________________________________________________
MORTGAGE HOLDER OR LANDLORD ? _________________________________________
DATES (FROM MONTH/YEAR TO MONTH/YEAR) _________________________________
ADDRESS: ____________________________________________________________________
(STREET AND APT. #)
______________________________________________________________________________
(CITY) (STATE) (ZIP CODE)
OWNED OR RENTED? _________________________________________________________
MORTGAGE HOLDER OR LANDLORD ? _________________________________________
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Revised 02/21/17 16
RELATIVES
PARENTS’ NAMES AND ADDRESSES:
MOTHER’S NAME: ____________________________________________________________
(LAST) (FIRST) (MIDDLE)
ADDRESS: ____________________________________________________________________
(CITY) (STATE) (ZIP CODE)
FATHER’S NAME: _____________________________________________________________
(LAST) (FIRST) (MIDDLE)
ADDRESS: ____________________________________________________________________
(CITY) (STATE) (ZIP CODE)
TELPPHONE NUMBERS: _______________________________________________________
(MOTHER) (FATHER)
DO YOU HAVE ANY RELATIVES CURRENTLY WORKING IN OR RETIRED FROM
LAW ENFORCEMENT ? IF SO, PLEASE LIST THEIR NAME AND DEPARTMENT/AGENCY:
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Revised 02/21/17 17
PLEASE LIST SIX REFERENCES INCLUDING NAME, ADDRESS AND TELEPHONE NUMBER:
THREE PERSONAL REFERENCES (NOT RELATIVES)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
THREE PROFESSIONAL REFERENCES
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PHYSICAL AND PSYCHOLOGICAL
DO YOU HAVE ANY PHYSICAL OR PSYCHOLOGICAL LIMITATIONS OR INJURIES (RECENT OR OLD)
THAT MIGHT RESTRICT YOUR FULL PARTICIPATION IN THE ACADEMY? Yes____ No______
ARE YOU DISABLED IN ANYWAY?
__________________________________________________________________________________________
HAVE YOU EVER RECEIVED MENTAL HEALTH TREATMENT? Yes______ No______
IF YES, PLEASE EXPLAIN:___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
DO YOU SUFFER FROM POST TRAUMATCI STRESS DISORDER (PTSD)?
_____________________________________________________________________________________________
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Revised 02/21/17 18
EDUCATION
IF YOU PROGRESS TO THE NEXT STEP OF THE HIRING PROCESS, COPIES OF YOUR HIGH SCHOOL
TRANSCRIPTS OR GED CERTIFICATE AND COLLEGE TRANSCRIPTS WILL BE REQUIRED.
LAST HIGH SCHOOL ATTENDED: _______________________________________________
ADDRESS: ____________________________________________________________________
(STREET) (CITY) (ZIP CODE)
DATE OF GRADUATION (MONTH/YEAR): ________________________________________
IF YOU DID NOT GRADUATE AND OBTAINED A GED PLEASE FURNISH THE FOLLOWING
INFORMATION:
DATE RECEIVED: _________________________ STATE RECEIVED: __________________
COLLEGES ATTENDED:
NAME: _______________________________________________________________________
ADDRESS: ____________________________________________________________________
(CITY) (STATE)
DATES ENROLLED: ___________________________________________________________
GRADE POINT AVERAGE: ______________ CREDIT HOURS EARNED: _______________
MAJOR: ________________________________ DEGREE: _____________________________
DATE OF GRADUATION (MONTH/YEAR): ________________________________________
NAME: _______________________________________________________________________
ADDRESS: ____________________________________________________________________
(CITY) (STATE)
DATES ENROLLED: ___________________________________________________________
GRADE POINT AVERAGE: ______________ CREDIT HOURS EARNED: _______________
MAJOR: ________________________________ DEGREE: _____________________________
DATE OF GRADUATION (MONTH/YEAR): ________________________________________
LIST ANY ADDITIONAL POST HIGH SCHOOL TRAINING: ___________________________
_________________________________________________________________________________
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Revised 02/21/17 19
EMPLOYMENT
LIST CHRONOLOGICALLY ALL EMPLOYMENT FOR THE PAST 5 YEARS INCLUDING PART-TIME AND
TEMPORARY EMPLOYMENT. ALL TIME MUST BE ACCOUNTED FOR. IF UNEMPLOYED, LIST DATES.
ALL ADDRESSES MUST BE COMPLETE, INCLUDING ZIP CODES. PLEASE LIST PRESENT EMPLOYER
FIRST.
EMPLOYER: __________________________________________________________________
ADDRESS: ____________________________________________________________________
(#) (STREET) (CITY) (STATE) (ZIP CODE)
DATES OF EMPLOYMENT: _____________________________________________________
TYPE OF WORK: _________________________ SUPERVISOR: ________________________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER: __________________________________________________________________
ADDRESS: ____________________________________________________________________
(#) (STREET) (CITY) (STATE) (ZIP CODE)
DATES OF EMPLOYMENT: _____________________________________________________
TYPE OF WORK: _________________________ SUPERVISOR: ________________________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER: __________________________________________________________________
ADDRESS: ____________________________________________________________________
(#) (STREET) (CITY) (STATE) (ZIP CODE)
DATES OF EMPLOYMENT: _____________________________________________________
TYPE OF WORK: _________________________ SUPERVISOR: ________________________
REASON FOR LEAVING: _______________________________________________________
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Revised 02/21/17 20
EMPLOYER: __________________________________________________________________
ADDRESS: ____________________________________________________________________
(#) (STREET) (CITY) (STATE) (ZIP CODE)
DATES OF EMPLOYMENT: _____________________________________________________
TYPE OF WORK: _________________________ SUPERVISOR: ________________________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER: __________________________________________________________________
ADDRESS: ____________________________________________________________________
(#) (STREET) (CITY) (STATE) (ZIP CODE)
DATES OF EMPLOYMENT: _____________________________________________________
TYPE OF WORK: _________________________ SUPERVISOR: ________________________
REASON FOR LEAVING: _______________________________________________________
HAVE YOU APPLIED FOR EMPLOYMENT WITH A POLICE DEPARTMENT?
____________ IF YES, LIST NAME OF DEPARTMENT AND DATE OF APPLICATION:
DEPARTMENT DATE OF APPLICATION
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HAVE YOU EVER BEEN DENIED EMPLOYEMENT ANYWHERE ?____________________
FROM WHERE ? ___________________________________
PLEASE EXPLAIN: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Revised 02/21/17 21
MILITARY (ACTIVE DUTY ONLY)
BRANCH: ___________________ DATES OF ACTIVE SERVICE: ______________________
LAST DUTY STATION: _________________________________________________________
(NAME) (CITY) (STATE)
SERIAL #: ________________________ HIGHEST RANK ATTAINED: __________________
DISCIPLINARY ACTION / TYPE: ________________________________________________
______________________________________________________________________________
IF YOU ARE A FORMER OR CURRENT MEMBER OF THE RESERVES OR NATIONAL GUARD PLEASE
ANSWER THE FOLLOWING:
BRANCH: ___________________ HIGHEST RANK ATTAINED: _______________________
PRESENT DUTY STATION: _____________________________________________________
DATES OF SERVICE: ___________________________________________________________
ARE YOU REGISTERED WITH SELECTIVE SERVICE ? _____________________________
IF YOU ARE A MILITARY VETERAN AND PROGRESS TO THE NEXT STEP IN THE HIRING PROCESS, A
COPY OF YOUR DD214 WILL BE REQUIRED. ALSO, PERSONS REQUIRED TO BE REGISTERED WITH
SELECTIVE SERVICE WILL BE REQUIRED TO FURNISH PROOF OF REGISTRATION.
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Revised 02/21/17 22
FINANCIAL HISTORY STATEMENTS
YES
NO
1. HAVE YOU EVER HAD YOUR WAGES ATTACHED OR GARNISHED?
2. HAVE YOU EVER BEEN A DEFENDANT IN SMALL CLAIMS OR OTHER
CIVIL ACTION?
3. DO YOU HAVE ANY CIVIL ACTION PENDING AGAINST YOU?
4. HAVE YOU EVER HAD A JUDGEMENT RENDERED AGAINST YOU?
5. HAVE YOU EVER BEEN REFUSED AN INSURANCE POLICY?
6. HAVE YOU EVER HAD AN INSURANCE POLICY CANCELLED?
7. HAVE YOU EVER BEEN REFUSED CREDIT?
8. HAVE YOU EVER HAD ANY PROPERTY REPOSSESSED?
9. DO YOU CURRENTLY HAVE ANY ACCOUNTS UP FOR COLLECTION?
10. IF YOU ARE OBLIGATED TO PAY CHILD SUPPORT AND/OR ALIMONY,
ARE YOU CURRENT IN YOUR PAYMENT?
IF YOU ANSWERED YES TO ANY OF THE PREVIOUS QUESTIONS (1-10) OR NO TO #10 PLEASE EXPLAIN
BELOW:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Revised 02/21/17 23
TRAFFIC RECORD
INCLUDE A LEGIBLE COPY OF YOUR DRIVER’S LICENSE
DRIVERS LICENSE # __________________________ STATE ISSUED __________________
LIST ALL TRAFFIC VIOLATIONS (EXCEPT PARKING TICKETS) FOR WHICH YOU HAVE BEEN
CONVICTED IN THE PAST 10 YEARS:
DATE POLICE AGENCY CHARGE COURT OF
DISPOSITION
HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED? ____________________
IF YES, PLEASE EXPLAIN: ______________________________________________________
DO YOU OWN AN AUTOMOBILE, OR HAVE ONE AT YOUR DISPOSAL? _____________
IF YES, PLEASE ANSWER THE FOLLOWNG QUESTIONS:
YEAR ___________ MAKE ___________________ MODEL _________________________
INSURANCE COMPANY/AGENT ________________________________________________
TYPE OF COVERAGE ___________________________ HIGH RISK? ___________________
CRIMINAL RECORD
HAVE YOU EVER BEEN ARRESTED? ______________ DATE OF ARREST______________
REASON FOR ARREST? __________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
LIST ALL CRIMINAL VIOLATIONS FOR WHICH YOU HAVE BEEN CONVICTED OR ADJUDICATED:
DATE POLICE AGENCY CHARGE COURT OF
DISPOSITION
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Revised 02/21/17 24
DRUG HISTORY
EXAMINE THE FOLLOWING LIST OF DRUGS AND SUBSTANCES TO DETERMINE YOUR ILLEGAL
USAGE, IF ANY, IN EACH PARTICULAR CATEGORY. PLEASE CHECK APPROPRIATE RESPONSE TO
EACH QUESTION:
Drug Type Yes No
HALLUCINOGENIC DRUGS
MARIJUANA
HASHISH/HASH OIL
THC
LSD
PCP
DMT
PEYOTE
MESCALINE
STIMULANTS
COCAINE (ALL FORMS)
AMPHET AMINES
DEPRESSANTS
BARBITURATES
TRANQUILIZERS
OTHER NARCOTIC SUBSTANCES
OPIUM
MORPHINE
HERION
CODEINE
METHODONE
DILUDID
DEMEROL
HARMFUL INTOXICANTS
ORGANIC SOLVENTS
(THINNER, CLEANING FLUID,
GASOLINE, PLASTIC CEMENT,
ETC.)
ANY AEROSOL PROPELLANT
ANY FLUOROCARBON
REFRIDGERANT
ANY ANESTHETIC GAS
OTHER SUBSTANCES NOT PREVIOUSLY SPECIFIED
______________________________________________________________________________
[TYPE(S)]
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Revised 02/21/17 25
PLEASE ANSWER THE FOLLOWING QUESTIONS CONCERNING YOUR ILLEGAL DRUG ACTIVITIES. IF
YOU HAVE NEVER USED DRUGS ILLEGALLY, GO DIRECTLY TO QUESTION #11. (IF A QUESTION
DOES NOT APPLY, INSERT DNA):
1. AT WHAT AGE DID YOU FIRST USE DRUGS/TYPE(S)?__________________________
2. DATE (MONTH/YEAR) YOU LAST USED DRUGS/TYPE(S)? _____________________
3. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER PURCHASED/
TYPE(S)? ___________________________________________________________________
4. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER SOLD/
TYPE(S)? ___________________________________________________________________
5. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER TRANSPORTED/
TYPE(S)? _____________________________ WHEN? _____________________________
6. HAVE YOU EVER CULTIVATED MARIJUANA? _________________________________
AMOUNT? ____________________________ WHEN? _____________________________
7. HAVE YOU EVER ILLEGALLY OBTAINED ANY PRESCRIPTION DRUG AND IF SO,
LIST TYPE AND HOW OBTAINED? ____________________________________________
____________________________________________________________________________
8. HOW MANY CLOSE FRIENDS DO YOU KNOW WHO USE DRUGS AND WHAT
TYPES OF DRUGS DO THEY USE? ____________________________________________
____________________________________________________________________________
9. HOW MANY TIMES HAVE YOU GIVEN OTHERS MONEY TO BUY DRUGS?
WHAT TYPE(S)? ___________________________________________________________________
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Revised 02/21/17 26
10. EXTENT OF ILLEGAL DRUG USAGE (List specific drug at the bottom of this page):
Drug Category
More
than 50
times
20 to
50
times
10 to 20
times
2 to 10
times
One
time
HALLUCINOGENIC DRUGS
STIMULANTS
DEPRESSANTS
OTHER NARCOTIC SUBSTANCES
HARMFUL INTOXICANTS
11. DO YOU CONSUME ALCOHOLIC BEVERAGES? _______________________________
12. IF YOU ANSWERED YES TO #11, WHAT IS YOUR CONSUMPTION?:
PER WEEK ___________ TYPE(S)? ____________________________________________
13. HAVE YOU EVER SUCCESSFULLY COMPLETED A SUPERVISED DRUG AND/OR
ALCOHOL REHABILITATION PROGRAM? (IF YES, YOU WILL BE REQUIRED TO
FURNISH PROOF OF SUCCESSFUL COMPLETION UPON REQUEST) _____________
14. IF YOU ANSWERED YES TO #13, HAVE YOU REMAINED ALCOHOL AND/OR DRUG
FREE SINCE THE COMPLETION DATE OF YOUR PROGRAM: ___________________
IF NO, PLEASE EXPLAIN: ___________________________________________________
___________________________________________________________________________
___________________________________________________________________________
IF NECESSARY, USE THE FOLLOWING SPACE TO EXPLAIN OR ADD TO YOUR ANSWERS. MAKE
REFERENCE TO THE PARTICULAR PAGE NUMBER, SECTION, AND QUESTION:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Revised 02/21/17 27
CERTIFICATION
I CERTIFY THAT THE STATEMENTS HEREIN CONTAINED ARE TRUE TO THE BEST OF MY
KNOWLEDGE AND UNDERSTAND THAT ANY FALSE STATEMENTS OR OMISSIONS OF INFORMATION
MADE IN THIS APPLICATION MAY BE CAUSE FOR DISAPPROVAL OF MY APPOINTMENT OR FOR
DISCHARGE AFTER APPOINTMENT.
___________________________________ _______________________________
(SIGNATURE) (DATE)
____________________________, appeared before me on the day of year .
____________________________________
(NOTARY)
Notary Public in and for County, Ohio. My commission expires ____________________