nms application phs

8/9/2019 NMS Application PHS

1/17

NEW MEXICO DEPARTMENT OF PUBLIC SAFETY

STATE POLICE DIVISION

APPLICATION FOR

COMPETITIVE EXAMINATION

Name

Date


2/17

READ the following information before completing this application.

y All information contained on this application is subject to verification.y A polygraph examination and background investigation are required of successful applicants.y Any omission, misstatements, or falsifications will be cause for rejection of this application, elimination from

further completion, removal of your name from an eligibility list, or discharge from employment.

y The information provided by you on this application will used to determine your qualifications for employment.y Use black ink and print.

Name:

Address:STREET CITY STATE ZIP

Home telephone: ( ) Business telephone: ( ) Ext.

Date of Birth / / Age

MINIMUM QUALIFICATIONS:place your initials on the line provided at the end of each qualification statement IF you possess

that qualification.

I certify that I:

am a citizen of the United States of America_____

am twenty-one (21) years of age or older_____

have a valid drivers license_____

have never been convicted of any felony_____

have never been convicted of a misdemeanor involving moral turpitude (theft, criminal sexual misconduct, etc.)_____

have never been convicted of DWI or similar offense with in 36 months of today_____

am not a chronic, illegal user of nor illegally dependent upon any controlled substance_____

have not been dishonorably discharged from the armed services of the United States_____

am willing to serve anywhere in New Mexico and transfer to meet the needs of the Department____

am willing to work irregular hours, beyond regular shifts, and overtime.____have not been dishonorably discharged from the armed services of the United States_____

am willing to serve anywhere in New Mexico and transfer to meet the needs of the Department____

am willing to work irregular hours, beyond regular shifts, and overtime.____

By my signature, I certify that I meet these minimum qualifications. I realize that any falsification, misrepresentation, or omission will

cause rejection of this application, elimination from further competition, removal of my name from any eligibility list, or discharge

from employment.

Date

Applicants Signature

DEPARTMENT OF PUBLIC SAFETY IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

The information requested below is in compliance with regulation issued by the Equal Employment Opportunity Commission underTitle VII of the Civil Rights Act of 1964. Answers will be confidential and will not be used for purposes other than Equal

Employment Opportunity reporting. This information is requested for statistical reporting purposes ONLY.

SEX: Male Female

RACE: Anglo Hispanic Native American Black Oriental Other (explain) ___________________


3/17


STATE POLICE DIVISION

PERSONAL HISTORY STATEMENT

Name

Date


4/17

GENERAL INSTRUCTIONS

Use black ink and hand print clearly. If a question does not apply to you so state with N/A.

An oral interview, polygraph examination, and background investigation will be conducted on the basis of your Personal History

Statement in order to determine your suitability for employment by the State Police. The Department of Public Safety will exercise al

reasonable efforts to keep the material contained herein confidential. Therefore, it is your responsibility to read and respond to each

question carefully. Information falsified or omitted will result in the termination of the selection process or that applicant.

Name:LAST FIRST MIDDLE

Date of birth: Place of birth: SSN: CITY STATE

By what other names have you been

know? (maiden name, aliases, nicknames)

Address:STREET CITY STATE ZIP

Mailing address (if different than above):

Home telephone: ( ) Business telephone: ( ) Ext.

Email Address: ___________________________________________ Requested Duty Location:_____________________________

REQUIRED DOCUMENTS

The following items must accompany Personal History Statement. (COPIES ONLY)

y Bureau of Vital Statistics birth certificate y Military discharge

(Bring original in at Polygraph testing) yDD-214 (military separation papers)

y High school diploma or equivalency (GED) (Notarized) y Last two (2) years tax returns

y Social Security card (Notarized) y College/university transcripts

y Valid drivers license (Notarized) y Credit bureau history

CERTIFICATION: I hereby certify that the facts set forth in this Personal History Statement Form are true and complete to the bes

of my knowledge, I understand that if employed, any omissions, misstatements, or falsifications of statements may lead to dismissal.

Applicants Signature Date

SUBSCRIBED AND SWORN TO before me this Day of 20

Notary Public

My commission expires:

Note: When this form is complete, with all documents attached, mail to:

New Mexico Department of Public Safety

New Mexico State PoliceTraining and Recruiting Bureau4491 Cerrillos RoadSanta Fe, NM 87505


5/17

RESIDENCE

In chronological order (present to past) list each and every place you have resided in the past 10 years.

MONTH AND YEAR

FROM TO

ADDRESS (NUMBER, STREET) CITY,STATE,ZIP

NAME OF PERSON RENTED FROM OR LIVE WITH ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)

MONTH AND YEAR

FROM TO



MONTH AND YEAR

FROM TO



MONTH AND YEAR

FROM TO



MONTH AND YEAR

FROM TO



MONTH AND YEAR

FROM TO



MONTH AND YEAR

FROM TO




6/17

EMPLOYMENT

List your complete work history, present to past (include part-time)

1EMPLOYER ADDRESS, CITY, STATE, ZIP EMPLOYER PHONE NO.

HOME BUSINESS

POSITION MONTH AND YEAR

FROM TO

REASON FOR LEAVING

BRIEF DESCRIPTION OF DUTIES IMMEDIATE SUPERVISORS NAME


HOME BUSINESS


FROM TO

REASON FOR LEAVING



HOME BUSINESS


FROM TO

REASON FOR LEAVING



HOME BUSINESS


FROM TO

REASON FOR LEAVING



HOME BUSINESS


FROM TO

REASON FOR LEAVING



7/17

EMPLOYMENT (cont.)


HOME BUSINESS


FROM TO

REASON FOR LEAVING



HOME BUSINESS


FROM TO

REASON FOR LEAVING



HOME BUSINESS


FROM TO

REASON FOR LEAVING


Were you ever terminated or asked to resign from employment? Yes No

If yes, explain:

Were you ever subjected to disciplinary action in connection with any employment? Yes No

If yes, explain:

Have you ever quit a job in lieu of being terminated? Yes No

If yes, explain:

Have you ever received any federal, state or local assistance payments to which you were not entitled? Yes No

If yes, explain:


8/17


9/17

EDUCATION AND TRAINING

HIGH SCHOOL AND ADDRESS Did you graduate from high school? Yes No

If no, do have a GED? Yes No

Issued by: Date:

COLLEGE/UNIVERSITY AND ADDRESS DATE ATTENDED MAJOR/MINOR CREDIT EARNED TYPE OF DEGREE DATE AWARDED

BUSINESS, TRADE, TECHNICAL,MILITARY SCHOOL AND ADDRESS

DATE ATTENDED MAJOR/MINOR CREDIT EARNED TYPE OF DEGREE DATE AWARDED

PROFESSIONAL LICENSE OR CERTIFICATE SERIAL NUMBER ISSUED BY DATE ISSUED EXPIRATION DATE

Special skills:

Other languages: Understand Speak Write

Understand Speak Write

Hobbies:

SUBVERSIVE AFFILIATIONS

Are you a member or have you ever been a member of any party or organization, political or otherwise,that now advocates the overthrow of the government of the United States or of the State of New Mexico

by force or violence or other unlawful means?

Yes No

If yes, explain:


10/17

RELATIVES

Give the names and complete mailing addresses of your parents, sisters, and brothers: also give the spouses parents, sisters, and

brothers, 16 and older.

1 NAME ADDRESS, CITY, STATE, ZIP

HOME PHONE WORK PHONE RELATIONSHIP OCCUPATION




















11/17

REFERENCES

Give the names and complete mailing addresses of six reliable persons, other than relatives or your past employers, who know you

well enough to give information about you.

1 NAME HOME ADDRESS, CITY, STATE, ZIP HOME PHONE

OCCUPATION BUSINESS ADDRESS, CITY, STATE, ZIP WORK PHONE












12/17


13/17

FINANCIAL STATUS

To what extent are you financially indebted (include child support and/or alimony obligations)?

Total monthly payments:

Have you ever had garnishments or assignments made on your wages or received a letter(s) of indebtedness? Yes No

If yes, explain:

Have you ever had anything (car, furniture, etc.) repossessed? Yes No

If yes, explain:

Have you ever declared bankruptcy or do you have a tax lean? Yes No

If yes, explain:

Have you ever been bonded? Yes No

If yes, explain:

Have you ever been refused a bond? Yes No

If yes, explain:

Are you a cosigner on an outstanding loan? Yes No

If yes, give details:

List vehicle descriptions of those vehicles which you own.

YEAR MAKE BODY TYPE COLOR LICENSE NO. YEAR AND STATE


14/17

ARREST INFORMATION

List entire history ofALL traffic Citations, Suspensions, Revocations to include all citations that were dismissed or found noguilty (add extra sheets if necessary). DO NOT ONLY USE RECORDS FROM THE MOTOR VEHICLE DEPARTMENT

DATE VIOLATION (SPECIFY CHARGE) LOCATION (CITY, STATE) DISPOSITION POLICE AGENCY

List all traffic accidents you have been involved in as a driver to include accident citations that were dismissed or found not guilty

(add extra sheets if necessary).

DATE VIOLATION (SPECIFY CHARGE) LOCATION (CITY, STATE) DISPOSITION POLICE AGENCY

Have you ever been Investigated,Suspected, Arrested or Charged with an offense by any Law Enforcement

agency, either as an adult or a juvenile?Yes No

Original charge: Final charge:

Approximate date: Police agency:

Court: Disposition:

Details leading to arrest or charge:

Additional arrest or charges (add extra page if necessary)?

Are you now a dependant in any criminal action? Yes No

Arrest or charge (add extra page of necessary)? Yes No

Original charge: Final charge:

Approximate date: Police agency:

Court: Disposition:

Details leading to arrest or charge:


15/17

MILITARY SERVICE

Have you ever served in the armed forces of the United States? Yes No

If yes, what branch?

Have you complied with Selective Service registration laws? Yes No

If no, explain:

Selective Service number

Give period or periods of active military service:

FROM TO RANK HELD SERIAL NUMBER

Type of discharge(s) or separation (honorable, dishonorable, general under honorable, undesirable):

Reason for discharge or separation from armed services:

Were you ever charges with a violation of the Uniform Code of Military Justice? Yes

No

If yes, explain:

Were you ever the subject of disciplinary action in the National Guard or other military reserve organizations? Yes No

If yes, explain:

Last Commanding Officer Phone number


16/17


NEW MEXICO STATE POLICE DIVISION

CONTRACT FOR RELEASE OF INFORMATION

I, _____________________________________having legal capacity to contract. In consideration of the processing of my application foremployment with the Department of Public Safety, New Mexico State Police Division, do hereby contract, covenant, and agree with the Departmenof Public Safety, New Mexico State Police Division for the benefit of the Department of Public Safety, New Mexico State Police Division, myseland the persons or entities herein protected as follows:

I recognize that it is essential that the investigation of my background disclose all information, which may be relevant to my fitness for selection andappointment as an employee of the Department of Public Safety, New Mexico State Police Division. I am aware that my duties will bring me intocontact with sensitive and confidential information. _______________.

initials

I therefore recognize and voluntarily state that the interest of the Department of Public Safety, New Mexico State Police Division in obtaininginformation which may be relevant to my fitness for employment requires that a guarantee of confidentiality be extended by the Department of PublicSafety, New Mexico State Police Division to persons or entities supplying information concerning my background to the Department of PublicSafety, New Mexico State Police Division. _______________.

initials

I further recognize, believe, and voluntarily state that this interest outweighs my right under the Constitution and laws of the United States and theState of New Mexico to inspect, obtain summaries of, or otherwise be apprised of information obtained by virtue of a guarantee of confidentiality by

the Department of Public Safety, New Mexico State Police Division in the course of my background investigation; or to learn the identity of personsor entities supplying this information. _______________.

initials

I RECOGNIZE THAT I AM WAIVING ALL RIGHTS OF ACCESS TO THIS INFORMATION AND THE IDENTITY OF THE PERSONS ORENTITIES SUPPLYING IT, EXCEPT AS QUALIFIED HEREIN. _______________.

initials

I do hereby knowingly, voluntarily, and intelligently waive this right. _______________.initials

I AM ALSO WAIVING MY RIGHT OF ACTION, CAUSE OF ACTION, OR OTHER MEANS OF REDRESS I MAY HAVE AGAINST ANYPERSONS OR ENTITY SUPPLYING THIS INFORMATION, WHICH MIGHT ARISE FROM SUPPLYING INFORMATION CONCERNINGMY BACKGROUND TO THE DEPARTMENT OF PUBLIC SAFETY, NEW MEXICO STATE POLICE DIVISION UNDER A GUARANTEEOR CONFIDENTIALITY. _______________.

initials

I DO NOT waive my right to be free from discrimination based on race, color, creed, sex, age, national origin, or my exercise or First Amendmentrights. However, I hereby agree that, should I ever pursue any right of action, cause of action, or other means of redress, in which the informationobtained in the course of the investigation of my background by the Department of Public Safety, New Mexico State Police Division, under aguarantee of confidentiality, or the identity of the persons or entities supplying this information, might be considered relevant, not privileged, and

admissible evidence, or calculated to lead to the discovery of admissible evidence, in an action alleging discrimination, my ability to discover andattempts to discover this information will be limited to a request for in camera inspection by the Court or other body having jurisdiction over theaction. _______________.

initials

I agree and understand that the provisions of this agreement are contractual in nature and not mere recitations. I further agree to be liable for thereasonable value of legal services utilized by the Department of Public Safety, New Mexico State Police Division, as well as all court costs incurredin obtaining damages for my breach of this contract, and that I will be liable for these items even if only nominal damages are recovered by theDepartment of Public Safety, New Mexico State Police Division in such an action. _______________.

initials

All agreements and understanding concerning the subject matter of this Contract are embodied and expressed herein and have not been modified byany express or implied promises or representations, written or oral, no expressly mentioned herein.

I HAVE CAREFULLY READ THIS CONTRACT. I HAVE BEEN ADVISED THAT, SHOULD I HAVE ANY QUESTION CONCERNING THEMEANING OF THIS CONTRACT, I SHOULD CONSULT AN ATTORNEY. I HAVE SOUGHT ANY AND ALL ADVICE CONCERNING ITAND ITS CONSEQUENCES THAT I WISH. I FULLY UNDERSTAND THE PROVISIONS OF THIS CONTRACT AND MY OBLIGATIONS

AND LIABILITIES UNDER IT. I AM THEREFORE EXECUTING THIS CONTRACT AS MY FREE AND VOLUNTARY ACT.

APPLICANTS SIGNATURE DATE

SUBSCRIBED AND SWORN TO before me on this day of ,20


NOTARY PUBLIC

(SEAL)


17/17


NEW MEXICO STATE POLICE DIVISION

AUTHORIZATION FOR RELEASE OF INFORMATION

To Whom It May Concern:

I, __________________________________, have made application for employment with the Department of Public Safety, New

Mexico State Police Division and it is my understanding that a comprehensive investigation of my background will be conducted inconnection with my application. It is further my understanding that any history adversely reflecting on my qualification for being a

New Mexico State Police Officer disclosed by and such investigation may be cause for my disqualification for employment with the

Department of Public Safety, New Mexico State Police Division or my dismissal from the Department of Public Safety, New Mexico

State Police Division upon due consideration of the facts by the Chief of the Department of Public Safety, New Mexico State Police

Division or by any authorized representative appointed by him to act in his behalf.

I hereby give to the Department of Public Safety, New Mexico State Police Division or any duly authorized representative of theDepartment of Public Safety, New Mexico State Police Division the authority to conduct any comprehensive investigation of my

background the Department of Public Safety, New Mexico State Police Division deems necessary, including but not necessarily

limited to oral discussions with any persons concerning my background. Also, generally, I hereby authorize a review and full

disclosure of all records, or any part thereof, concerning myself by/to any authorized representative of the Department of PublicSafety, New Mexico State Police Division, whether said record are public or private including those which may be deemed to be of a

privileged or confidential nature. In particular, I hereby authorize the full and complete disclosure of any and all records pertaining to

my background, including but not necessarily limited to the records of educational institutions, financial or credit institutionscommercial or retail mercantile establishments and public utility companies; records of medical and psychiatric consultation and/or

treatment, including those of hospitals, clinics, private practitioners, the U.S. Veterans Administration, and generally all military

service medical records and other records of all military facilities; employment and pre-employment records, including background

investigations reports, the results of polygraph examination, efficiency ratings, disciplinary records, complaints or grievances filed byor against me; records and recollections of attorneys at law who have represented by myself in any case in which I presently have had

an interest.

Pursuant to Section 29-10-6-A of the New Mexico Record Information Act, I hereby appoint an authorized representative of theDepartment of Public Safety, New Mexico State Police Division, said representative to be designated by the Department of Public

Safety, New Mexico State Police Division, as an authorized agent for me for the purpose of inspecting any arrest record information

maintained by any law enforcement agency concerning me.

To the custodian of the records discussed herein, I hereby direct you to release such information to the bearer of this Authorization foRelease of Information or a copy thereof. A copy of this release form will be valid as an original hereof even thought that copy dose

not contain an original writing of any signature.

I hereby release the custodian or custodians of such records and the Department of Public Safety, New Mexico State Police Division

and the State of New Mexico, including any of their agents, employees or representatives in any capacity, from any and all claims of

liability or damage of whatever kind or nature which at any time could result to me, my heirs, assigns, associates, persona

representative or representatives of any nature because of the compliance by said custodian or custodians with the Authorization forRelease of Information and my request contained herein for this release or because of any of these records by the Department of

Public Safety, New Mexico State Police Division, or the State of New Mexico. This release is binding, now and in the future, on my

heirs, assigns, associates, personal representative or representatives of any nature.

This Authorization for Release of Information shall be valid until one year after the date of my signature as indicated below.

APPLICANTS SIGNATURE DATE

SUBSCRIBED AND SWORN TO before me on this day of ,20


NOTARY PUBLIC

(SEAL)

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