pre-employment background questionnaire · “complete” applications will be utilized to conduct...

C E N T R A L F A L L S D E T E N T I O N F A C I L I T Y CO R P O R A T I O N

PR E -EM P L O Y M E N T BA C K G R O U N D Q U E S T I O N N A I R E

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Name Date

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY

I hereby consent to and authorize Central Falls Detention Facility Corporation (CFDFC) and all other state,

county, municipal and federal law enforcement agencies to search all available law enforcement records and

indices for criminal records, regarding me including, but not limited to, NCIC and to release CENTRAL FALLS

DETENTION FACILITY CORPORATION (CFDFC) and its agents from all liability for receiving and utilizing

this information.

Current Address:

Place of Birth:

Date of Birth:

Social Security Number:

Eye Color:

Hair Color:

Height:

Weight:

Name (print):

Other Names (Aliases, Maiden Name):

Signature of Applicant Date

Signature of Witness Date

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Name ___________________________________ _____ Date _______________________

AUTHORIZATION TO RELEASE INFORMATION AND WAIVER

As an applicant for a position with the Central Falls Detention Facility Corporation (CFDFC), I am requested

to provide information for use in determining my qualifications, moral character, honesty and suitability. I

hereby request and authorize the full disclosure of any and all records, files, reports, notes, opinions or any

other information you may have concerning me, in any format whatsoever, including information of a

confidential nature, to an authorized agent of the CFDFC. This includes, but is not limited to, the release of

all employment files or records, evaluations, disciplinary records, background investigation files, polygraph

results, psychological reports, medical records, and any and all internal affairs investigations, complaints or

grievances filed by or against me, training files, educational or school records and transcripts, civil service

test applications, test results, financial records, credit history, military records, arrest or criminal records,

including any investigative files or reports, court records, probation reports and photographs.

A photocopy or an electronic facsimile of this signed authorization form is to be considered as valid as the

original.

I understand that any information obtained by a personal history background investigation, which is

developed directly or indirectly, upon this release authorization will be considered in determining my

suitability for employment by the CFDFC.

I hereby release you, your organization, its representatives, agents and employees, and the CFDFC, its

representatives, agents and employees from any and all liability whatsoever, and/ or damages that may result

from furnishing the above information.

Applicant Signature

Staff Witness

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C E N T R A L F A L L S D E T E N T I O N F A C I L I T Y C O R P O R A T I O N

C O R R E C T I O N A L O F F I C E R P R E - E M P L O Y M E N T A P P L I C A T I O N

Applicant Name: Date of Birth:

Last First Middle

Address:

Street City State Zip Code

Phone Number: Email Address:

You are required to notify the Donald W. Wyatt Detention Facility Human Resource Department of any

change to the above information.

The Central Falls Detention Facility Corporation is an equal opportunity employer. Qualified applicants are

considered for employment without regard to race, color, gender, national origin, disability or veteran status

or any other legally protected status.

This application must be submitted in person at the Wyatt Training Center, 950 High Street Central Falls, RI.

You will be notified of the physical agility test date and time. Please review the physical fitness test

requirements and other recruitment information at: www.wyattdetention.com

This application is for the position of correctional officer at the Donald W. Wyatt Detention Facility

(CFDFC) in Central Falls, Rhode Island. All of the following information is required to be submitted with

your application in order for it to be considered “complete”:

Three (3) Current Letters of Recommendation (Must be signed, dated, include contact information)

Copy of Current Driver’s License

Copy of Driving Abstract

Copies of Vehicle Registration(s) and Proof of Insurance

Copy of Birth Certificate

Proof of Citizenship

Copy of Social Security Card

Copy of High School Diploma/G.E.D.

Official College Transcripts, if applicable

Copy of DD-214, if any military service

Current Credit History Report

http://www.wyattdetention.com/

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Print Name: Date:

I understand that appointment tendered to me will be contingent upon the results of a thorough background

investigation.

I further understand that during the application process and or background investigation, I am required to

report to the Donald W. Wyatt Detention Facility Training Department any changes in my personal history

covered in the pre-employment background questionnaire.

Prior to submitting my pre-employment background questionnaire, I have reviewed it carefully for

truthfulness, completeness and accuracy.

I hereby certify that all statements made in the pre-employment background questionnaire are true and

complete and I understand that any discrepancies, misstatements, omissions and or falsifications will be

cause for disqualification and for my name to be removed from the eligibility list or will be cause for further

review and or dismissal if an appointment was made. I authorize the facility to use my Social Security

number and date of birth for the purpose of conducting a pre-employment background investigation

including, but not limited to a BCI/criminal record check.

Date: Time:

Candidate’s Full Signature:

It is recommended that you read the entire application before writing on it.

You MUST print all information clearly.

“Complete” applications will be utilized to conduct a pre-employment background investigation.

All documents will be reviewed and only those candidates meeting the criteria of the Central

Falls Detention Facility Corporation hiring practices will be considered further in the hiring

process.

Failure to provide all required information may result in disqualification from the hiring process.

Any discrepancies, misstatements, omissions and or falsifications will be cause for

disqualification and for your name to be removed from the eligibility list or will be cause for

further review and/or dismissal if an appointment was made.

HOW DID YOU HEAR ABOUT US? PLEASE LIST ALL THAT APPLY: MINIMUM QUALIFICATIONS:

CFDFC employee referral (provide name): Fluency in the English Language

Publication (provide name): Legal Resident of the United States

RI Dept. of Labor & Training High School Diploma or G.E.D.

Internet website: Driver’s License

College Recruitment:

RI Human Resources Outreach & Diversity Office

Job Fair (location):

Radio / Television (station):

Friend / Family Member

Other:

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P E R S O N A L IN F O R M A T I O N :

Candidate Name: Last Middle First Maiden D.O.B.

Candidate Nicknames or Aliases:

Candidate Current Address: Street City State Zip Code

Rent Own Parents Other

How long have you lived there? Years: Months:

List your current landlord’s name and telephone number:

Candidate Descriptors:

Height: Weight: Eye Color: Hair Color:

Candidate Place of Birth United States Citizen (Yes or No) Social Security Number

Candidate’s Driver’s License: State License Number

Home Phone Number: Cell Phone Number:

Are you currently registered with Employ Rhode Island or Network Rhode Island? Yes No

Are you currently unemployed? Yes No

Are you currently receiving food stamps or other public assistance? Yes No

Do you have any permanent tattoos on your body at this time?

If yes, please list and describe all of your tattoos:

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F A M I L Y IN F O R M A T I O N :

Marital Status: Single Married Separated Divorced Annulled

Spouses Name: Maiden Name:

Date of Birth: Address:

Telephone: Email:

Emergency Contact: Emergency Contact:

Address: Address:

Telephone: Telephone:

List the following information about your ex-spouse (if applicable), or any current or

former significant other with whom you are or previously have been in a dating

relationship:

Name: Date of Birth:

Address:

Telephone: Email:


Address:

Telephone: Email:

List the following information about your children:


Address:

Telephone: Email:


Address:

Telephone: Email:

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F A M I L Y IN F O R M A T I O N ( C O N T I N U E D ) :

Mother’s Name: Maiden Name:

Date of Birth: Address:

Telephone: Email:

Father’s Name: Date of Birth:

Address: Telephone:

Email:

Siblings Name: Date of Birth:

Address: Telephone:

Email:


Address: Telephone:

Email:


Address: Telephone:

Email:


Address: Telephone:

Email:


Address: Telephone:

Email:

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RE S I D E N C E :

Have you ever lived in another state? Yes No

State: From: (mm/dd/yy) To: (mm/dd/yy)

Address:

State: From: (mm/dd/yy) To: (mm/dd/yy)

Address:

Have you ever lived in another country? Yes No

Country: From: (mm/dd/yy) To: (mm/dd/yy)

Address:

Country: From: (mm/dd/yy) To: (mm/dd/yy)

Address:

List all current and former roommates. Use an additional sheet if necessary:


Address:

Telephone: Email:


Address:

Telephone: Email:


Address:

Telephone: Email:

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R E S I D E N C E ( C O N T I N U E D ) :

List all residences at which you lived for the last five [5] years (Do not include any

addresses prior to your fifteenth [15th] birthday):

Address: Street City State Zip Code

From (mm/dd/yy): To (mm/dd/yy):

With whom did you live? Telephone:


Landlord’s Name: Telephone:
















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RE F E R E N C E S :

List three (3) personal references (DO NOT include any relatives by blood or marriage, or

any current law enforcement personnel):

Name:


Telephone: Email:

Name:


Telephone: Email:

Name:


Telephone: Email:

Do you know any former or current employees of the Donald W. Wyatt Detention Facility?

Yes No

List all former and current Wyatt employees that you are acquainted with, related to,

know as a friend or know through a friend. Use an additional sheet of paper if necessary:

Name: Contact Number:

Relationship:


Relationship:


Relationship:

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R E F E R E N C E S ( C O N T I N U E D ) :

List law enforcement references, if any:

Name: Agency:

Rank: Telephone #:

Email:

Name: Agency:

Rank: Telephone #:

Email:

Name: Agency:

Rank: Telephone #:

Email:

E M P L O Y M E N T :

List all information regarding your employment for the last five (5) years. Use a separate

sheet of paper if necessary:

Company: Telephone:


Supervisor’s Name: Dates of Employment:

Position: Reason for Leaving:

Duties:

Weekly Schedule: Weekly Hours:

Co-worker’s Name: Telephone:

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Company: Telephone:




Duties:



Company: Telephone:




Duties:



Company: Telephone:




Duties:



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E M P L O Y M E N T ( C O N T I N U E D ) :

Have you ever been investigated by your employer for improper conduct, illegal activities

or equal employment violations which resulted in your being found in violation of any

policies, regulations, rules or any state or federal laws? Yes No

If yes, explain the circumstance to include date and employer:

Have you ever received a formal written reprimand, been terminated, suspended, fired,

asked to resign or resigned in lieu of termination by an employer? Yes No

If yes, explain the circumstance to include date and employer:

Have you ever quit a job without giving sufficient (2-3 weeks) notice at any job? Yes No

If yes, explain the circumstance to include number of times, dates, employer, when and why:

Have you ever participated in any internship program with any law enforcement agency?

Yes No

If yes, list the agency, your supervisor’s name, telephone number, email address and length of

time you spent as an intern:

Have you ever taken a polygraph exam? Yes No

Date: Location:

Reason:

Date: Location:

Reason:

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L A W E N F O R C E M E N T AP P L I C A T I O N S :

Have you ever applied for any position at the Donald W. Wyatt Detention Facility?

Yes No

Position applied for: Date:

List all police departments, correctional facilities or any other law enforcement agencies (not

including this application) that you have applied to. If you are unable to list all the departments, use

a separate sheet of paper and attach it to this questionnaire. Attach any copies of applications.

Agency: Date Applied:


Telephone: Fax Number:

Hiring Status:

How far did you make it in the process?




Hiring Status:





Hiring Status:


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LA W E N F O R C E M E N T AP P L I C A T I O N S ( C O N T I N U E D ) :




Hiring Status:





Hiring Status:





Hiring Status:





Hiring Status:


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M I L I T A R Y :

List all military service in which you have served.

Branch: Unit:

Entry Date: Discharge Date:

Service Number: Highest Rank:

Commanding Officer’s Name:

Telephone:

Have you ever been investigated for any criminal activity while in the military or military reserves?

Yes No

If yes, please explain:

Have you ever engaged in any activities in another country that would be considered illegal in the

United States? Yes No


Have you ever applied to and been rejected for military service? Yes No

Date: Branch:

Why was your application refused?

Have you ever been reduced in pay grade or been the subject of any judicial or non-judicial

disciplinary action while in the military, National Guard or military reserves?

Yes No

If yes, explain the circumstance to include dates, violations and penalties:

Have you ever received an “other than” honorable discharge? (i.e.: OTH/Medical) Yes No

If no, explain:

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CO U R T S :

Have you ever been charged with or convicted of a criminal offense? This includes charges

that have been dismissed, dropped or reduced. Yes No

If yes, provide the following information, use additional sheets if necessary:

Date: Charges:

Agency:

Disposition:

Description of Events or Circumstances:

Date: Charges:

Agency:

Disposition:


Date: Charges:

Agency:

Disposition:


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CO U R T S ( C O N T I N U E D ) :

Pursuant to Rhode Island General Law 12-1.3-4, law enforcement applicants must disclose

expunged records. Provide the following information if you have had any charges

expunged:

Date: Charges:

Agency:


Date: Charges:

Agency:


Are you now or have you ever been involved as a plaintiff or defendant in any civil court

action? Yes No

If yes, please provide the following information:

Date of Claim: Court Location:

Plaintiff Defendant

Description or Circumstances:

Date of Claim: Court Location:

Plaintiff Defendant

Description or Circumstances:

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CO U R T S ( C O N T I N U E D ) :

Are you required to pay child support and/or alimony, either by mutual agreement or by a

court order? Yes No

If you answered yes to the above question, have you ever been held in contempt by any

court for failure to pay child support and/or alimony? Yes No


Have you ever had a restraining order or a no contact order against you for any reason?

Yes No


Have you ever filed for bankruptcy? Yes No

If yes, please provide the following information:

Date: Court Location:

Results:

DR U G S :

Have you ever remained at a private gathering or party where illegal drugs,

pills/prescription medication or narcotics were being used? Yes No

Have you ever allowed someone to use illegal drugs, pills/prescription medication or

narcotics including marijuana at your residence? Yes No

Have you ever purchased any illegal drug, pills/prescription medication, narcotics or

substance including steroids? Yes No

Drug Name Date Purchased Amount Purchased Personal Use or Other

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DR U G S ( C O N T I N U E D ) :

Have you ever purchased, sold, supplied, manufactured, cultivated, ingested, inhaled or

injected any form of illegal drug, pills/prescription medication, narcotic or substance

including steroids? Yes No

Please provide the following information. Do not leave any blank spaces.

Substance Yes/No Number of

Times

Approximate

Date

Marijuana

Salvia

Hashish

Speed

Methamphetamine

Heroin

Mushrooms

Peyote

LDS

Cocaine

Crack

PCP

Ice

Ecstasy/Molly

Mandrax/Quaaludes

Steroids

Amphetamines

Barbiturates

Adderall

Inhalants

Any substance you thought may be illegal

Prescription medication not prescribed to

you

Any other natural, manufactured and/or

synthetic drugs where its use could be

questionable

Other

If you answered yes to any substance listed above, provide an explanation of what, where, when

with whom and why:

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E D U C A T I O N :

List the following information regarding your education beginning with High School then

College (if applicable):

School Name:

Date Attended: Degree Major:

Graduation Date: Degree Earned:

School Name:



School Name:



T R A F F I C :

Starting with your most recent violation, list in chronological order all moving and non-

moving violations (i.e.: parking, speeding, red light violations, etc.) that you have received

and the disposition of the violation (i.e.: plead guilty, paid fine, ticket dismissed, etc.).

Please disclose any traffic stops during which warnings and/or no citations were issued. Use

additional pages if necessary.

Date: Violation:

City/State: Agency:

Disposition:

Describe Circumstance:

Date: Violation:

City/State: Agency:

Disposition:


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Date: Violation:

City/State: Agency:

Disposition:


Date: Violation:

City/State: Agency:

Disposition:


Have you ever been involved in any motor vehicle accidents? Yes No

Date: City/State:

Agency: At Fault: Yes No

Explain Circumstances:

Date: City/State:



Date: City/State:



Have you ever left the scene of a motor vehicle collision without reporting the incident to a

law enforcement entity within the jurisdiction which it happened? Yes No

Date: City/State:


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P O L I C E CO N T A C T S :

Please list all police contact (i.e.: reporting a crime, victim of crime, witness, etc.):

Date: Agency:

Location/Address:


Date: Agency:

Location/Address:


Date: Agency:

Location/Address:


Date: Agency:

Location/Address:


L I C E N S E /RE G I S T R A T I O N :

Has your license to operate a motor vehicle ever been suspended? Yes No

Date: State of Suspension:

Reason for Suspension:

List any vehicle(s) registered to you, along with any motor vehicle insurance policy

information:

State Registration Plate Insurance Provider / Policy Number

State Registration Plate Insurance Provider / Policy Number

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P E R S O N A L DE C L A R A T I O N S :

Have you ever had any contact with any inmate(s)/detainee(s), including visitations, letters

or phone calls to any correctional institutions? Yes No

Inmate’s Name: Date:

Correctional Institution:





Are you currently or have you ever been a member or associate of any gang (i.e., Street,

Motorcycle, etc.) Yes No


Have you ever had any negative contact with a Social Service Agency? (i.e.: DCYF) Yes No


Have you ever used any other name or alias at any time during your life? Yes No

Name/Alias: Date(s):

Name/Alias: Date(s):

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P E R S O N A L DE C L A R A T I O N S ( C O N T I N U E D ) :

Have you ever applied for a permit to carry a concealed weapon? Yes No

Date Applied: Permit Granted: Yes No

Weapon: Agency Applied To:

Reason for Permit:

List any foreign languages that you speak, read or write and your level of proficiency:

List your hobbies and interests:

Do you belong to any memberships, organizations or do volunteer work (past/present)?

Yes No


Explain your use of alcohol including the type used:

When is the last time you were intoxicated?

When was the last time you attended a party? What was the reason for the party?

Does anyone in your household currently use illegal drugs or prescriptions? Yes No


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P E R S O N A L DE C L A R A T I O N S ( C O N T I N U E D ) :

Have you ever been involved in any activity outside of the United States that would have

been considered illegal in the United States? Yes No


Have you ever intentionally or unintentionally viewed, possessed, downloaded or

distributed child pornography? Yes No

Have you ever filed a police complaint or called a law enforcement agency to complain

about the actions of an officer? Yes No

Is there anything in your background that you think would prevent you from being a

qualified correctional officer that has not been asked on this application? Yes No


Special Qualifications and Skills:

List any and all special qualifications and skills which pertain to the position you are applying for:

pre-employment background questionnaire · “complete” applications will be utilized to conduct...

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