spencer police departmentpolice.spencer.in.gov/files/documents/spd_application.pdf ·...

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Spencer Police Department

Officer Application

Last Name: First:

Middle:

Maiden Name (if applicable):

Street Address:

City: County:

State: Zip Code:

Telephone:

HOME: WORK: CELL:

Email Address:

Position applied for: Full-time Officer Part-time Officer Reserve Officer Other: ___________________________________________

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PREREQUISITES: To complete and application for the Spencer Police Department you must meet the following requirements. Individuals who do not meet the basic requirements should not apply.

● Be a citizen of the United States. ● Be at least 21 years of age to attend the Indiana Law Enforcement Academy. ● Have obtained a high school diploma or General Educational Development (G.E.D.)

certificate. ● Have a valid driver’s license. ● Must be willing to work rotating shifts. ● After the prescribed training, the applicant must be able to perform all the job functions

of a Police Officer. ● Not, nor have ever been, a member of, or otherwise affiliated with, a group or

organization which advocates the overthrow of the United States Government or any of its subdivisions by force, violence, or other unlawful means.

● Must be able to pass a character, financial, and background check. ● Never have had a felony conviction for a crime in this state or any other state, or in the

military service, which has not been pardoned. ● Not have multiple misdemeanor or violation convictions so as to indicate a disregard for

the law. ● Not have a misdemeanor conviction which has not been pardoned, and which is serious

enough to cast doubt on his/her fitness to be a police officer, or which resulted in serious bodily injury to another person.

● Not have been convicted for a domestic violence violation. ● Not have been dishonorably discharged from the military services. ● Not have been discharged under other than honorable conditions, if the conditions would

cast doubt on his/her fitness to be a police officer. ● Not knowingly make a false statement in the application process or have made a false

statement in an internal investigation from a current/previous employer. ● Not have been suspended or discharged by an employer for reasons which would cast

doubt on his/her fitness to be a police officer. ● Not use illegal drugs within past 5 years or have a past history of illegal drug use, which

would cast doubt on his/her fitness to be a police officer. ● Not have a history of or use of legal drugs or alcohol to excess. ● Not have ever illegally manufactured, transported for sale, or sold a controlled substance. ● Not have been discharged or allowed to resign in lieu of discharge for reasons of moral

character or moral turpitude for acts or omissions of conduct that would cause a reasonable person to doubt his/her honesty and integrity.

● Be of good general character and reputation in the community. ● Not have his/her police certification suspended or revoked in any jurisdictions. ● Be willing to allow access to all current/previous employment records.

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APPLICATION INSTRUCTIONS: No exceptions will be made for anyone not meeting all requirements.

1. The application must be filled out by the applicant.

2. Answer all questions. If the question does not apply, state: “None” or “Does Not Apply”.

3. Place any additional information on a separate page(s) and attach to the application with appropriate reference marks.

4. Application must be legible and completed in black ink.

5. Sign, in black ink, Section 1 of the application, and the “Authorization for Release of

Information Agreement.”

6. Bring the completed application in a sealed envelope with you to the Physical Agility Test on September 9, 2017 at the Owen Valley High School.

It is important that you clearly and correctly indicate your mailing address, telephone numbers, and email address in the application. Applications will not be considered until complete in every respect. An incomplete application may be disqualified from consideration. Any misrepresentation of facts on the application will disqualify the applicant.

PLEASE DO NOT MAKE ANY INQUIRY REGARDING THE STATUS OF YOUR APPLICATION.

You will receive appropriate information concerning your application routinely in due time.

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

COMPLYING WITH ALL PROVISIONS OF

THE AMERICANS WITH DISABILITIES ACT.

.

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DO NOT, UNDER ANY CIRCUMSTANCES ALTER THIS APPLICATION IN ANY WAY Section 1: Certification of Completion

Photograph to be front view, head and shoulders, taken within the last 30 days. Other photographs are not acceptable.

I certify that:

1. All required items are included with the application. a. Certificate of Birth (copy only) or court documentation attesting to citizenship in the

absence of any official record. b. Photocopy of current driver’s license. c. Copy of high school diploma or G.E.D. d. Copy of high school transcripts. e. Copy of college diploma, if applicable. f. Copy of all college transcripts, if applicable (This should include all colleges you’ve

attended, regardless of whether or not you received your degree.) g. Copy of any special skills/achievement awards or documentation. h. Military – Copy of DD214 if veteran i. Photograph – 2 ½ X 2 ½ head and shoulders j. Authorization for Release of Information (Must have all 6 original forms signed and

notarized. k. Authorization to release internal affairs files if current or prior law enforcement.

2. I have personally completed this application.

3. I understand that I may be required to maintain residency within Owen County or an adjoining

county. I swear and affirm under penalty of perjury that all information contained in this application is true and accurate to the best of my knowledge. Signature: _________________________________________Date: ____________________

Mount or Insert Photograph

In

This space.

Affix securely

k. Authorization to release internal affairs files if current or prior law enforcement.

k. Authorization to release internal affairs files if current or prior law enforcement.

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Sections 2-8: Identifying Information

Section 2: Full Legal Name Provide your entire name in the spaces below. Indicate if you only have initials in your name. If you are a “Jr.,” “Sr.,” or “II,” etc…, enter this under Suffix.

Last Name: First:

Middle:

Suffix:

Section 3: Date of Birth

Month/Day/Year:

Section 4: Place of Birth

City: County: State:

Country:

Section 5: Other Names Used

Give other names you have used and the period of time you used them [for example: maiden name, name(s) by a former marriage, former name(s), alias(es), nickname(s)]

Section 6: Other Identifying Information

Height: (ft.) (in.) Weight: (lbs.) MALE FEMALE

Hair Color: Eye Color:

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Section 7: Driver’s License Information

License State: License Number: Expired? Yes No

If yes, explain:

Have you held a license in any other state? Yes No


If yes, explain:


If yes, explain:

Section 8: Telephone numbers Provide your telephone numbers and the time of the day that you are most likely available at these numbers. Include the Area Code and extension, where applicable.

Work Telephone: Time(s): to

Home Telephone: Time(s): to

Cellular Phone: Time(s): to

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Section 9: Where You Went to School List the schools you have attended from oldest to most recent, beyond Junior High School. ATTACH TRANSCRIPTS FOR ALL Use the “Where You Went to School Supplement” included in this packet for additional entries.

A. Dates of Activity

From (Month/Year): To (Month/Year): School Type: High School

Accredited College / University / Military College

Vocational / Technical / Trade School

School Name: School Street Address:

City: State: Zip Code:

Course of Study:

Number of Hours Completed: GPA on 4.0 Scale:

Degree/Diploma/Other:

Date Awarded (Month / Year):

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B. Dates of Activity






Course of Study:



Date Awarded (Month/Year):

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C. Dates of Activity






Course of Study:



Date Awarded (Month/Year):

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Section 10: Employment Activities Provide a detailed chronological list of your employment activities from oldest to most recent. You should list all full-time work, part-time work, military service, self-employment, other paid work, and all periods of unemployment. All time periods must be accounted for without breaks. If unemployed indicate in the employer name line. Provide a reason for being unemployed in the “reason for leaving” box. Use the “Your Employment Supplement” included in this packet for additional entries.


From (Month/Year): To (Month/Year):

Employer Name:

Position Title: Duties:

Employer’s Street Address:


Employer’s Telephone Number:

Supervisor’s Name:

Supervisor’s Telephone Number:

Reason for Leaving: If discharged or resigned to prevent being discharged provide a full explanation as an attachment to this application.

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Employer Name:








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C. Dates of Activity


Employer Name:








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D. Dates of Activity


Employer Name:








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Section 11: Military Record If you have served in the United States military, you are required to attach a copy of your DD214 from to this application.

Have you served in the United States military? Yes No

Are you eligible to re-enlist? Yes No

(If no, explain on a separate sheet and attach to this application) Have you served in the United States Merchant Marine? Yes No

Military Branch: Highest Rank:

Dates of Service (Month/Year):

Type of Discharge: List any citations and awards received:

List any discipline: (Example: court martial, article 15, captain’s mast, etc…)

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Section 12: Law Enforcement Have you ever been employed by a police department? Yes No Dates: Department (s) From To

When & where did you complete your basic law enforcement certification program?

Date law enforcement training was completed?

Total basic training hours completed? List any specialty training you have received.

Please list any/all reasons for leaving any aforementioned police departments. Yes No

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Are you eligible for rehire? Yes No If no, explain.

Were you ever disciplined? Yes No If yes, explain.

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Section 13: Police Record Report information regardless of whether the record in your case has been “sealed” or otherwise stricken from the court record. List vehicle incidents/accidents in which you have been involved as a driver.

Date Location What Happened

List all infraction-related tickets you have received including traffic and other related offenses.

Date Location Charges

Disposition


Disposition


Disposition

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List all misdemeanor arrests.


Disposition


Disposition


Disposition

List all felony arrests.


Disposition


Disposition

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Disposition

Have you ever been or are you currently involved as a plaintiff, defendant, petitioner, or respondent in any civil court action? If yes, explain. Yes No

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Section 14: Illegal Drugs & Drug Activity Have you ever illegally used any controlled substance, including, but not limited to: marijuana, cocaine, crack cocaine, hashish, narcotics, opium, morphine, codeine, heroin, amphetamines, depressants, barbiturates, methaqualone, tranquilizers, hallucinogenics, synthetic or prescription drugs?

Yes No

Date Type

Explain:

Have you ever been involved in the illegal purchase, manufacture, trafficking, production, transfer, shipping, or sale of any narcotic, depressant, stimulant, hallucinogen, or cannabis for your own intended profit or that of another? Yes No

Date Type

Explain:

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Section 15: Use of Alcohol Do you currently use alcohol? Yes No If yes, how often:

Section 16: Special Interest When did you first learn about the Spencer Police Department?

What motivated you to apply to become a Spencer Police Officer?

What is your long term career goal if employed as a Spencer Police Officer?

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Please list all organizations, past and present, with which you are or were involved. List the positions you hold or have held.

Describe what physical activities, including exercises, sports, personal fitness programs in which you engage and how often?

How long do you expect to be employed by the Spencer Police Department?

Section 17: Citizenship Mark the statement that reflects your current citizenship status. I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. I am a U.S. citizen, but I was NOT born in the U.S. I am not a U.S. citizen.

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Section 18: Where You Have Lived Provide a detailed entry for each place you have lived in the last 7 years starting with the oldest. All periods must be accounted for in your list. Include all school or temporary addresses. Indicate the actual physical location of your residence. Do not use a post office box as an address. Be sure to specify your location as closely as possible. For example, list your barracks number or home port.


From (Month/Year): To (Month/Year): House # and Street Address:




City: State: Zip Code: C. Dates of Activity



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D. Dates of Activity



Section 19: Social Networking Information List any Internet social networking sites, Apps, Internet chat rooms, instant messaging (IM) services, video messaging, or Internet forums that you currently use, or that you have used in the past. Include online dating, gaming, or blogging sites and services. Indicate whether those accounts are active or inactive by checking the active or inactive box next to each account description. Also include the account name or number, username, or email address associated with each account.

1. Website or Service Active Inactive

Username/Account #


Username/Account #


Username/Account #


Username/Account #


Username/Account #

If any of these accounts have been terminated for terms of service (TOS) violations, provide a full explanation as an

attachment to this application.

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Section 20: People Who Know You Well

List three people who know you well and who live in the United States. They should be good friends, peers, colleagues, college roommates, etc, whose combined association with you covers the last 7 years. Do not list your spouse, former spouses or other relatives. Explain how you were acquainted with this person. Dates Known


Name: Home or Work Address

Street:


Work Number: Home Number:

Cell Number:

Explain:

Dates Known



Street:


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Cell Number:

Explain:

Dates Known



Street:



Cell Number:

Explain:

Section 22: Other States or Countries Where You Have Lived List foreign countries or states other than Indiana where you have lived regardless if they have been mentioned elsewhere in this application. List the timeframe you lived at each place.

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WHERE YOU HAVE LIVED - SUPPLEMENT

Dates of Activity

From (Month/Year): To (Month/Year): Street Address

House # and Street:

City: State:

Zip Code:

Explain:

WHERE YOU HAVE LIVED - SUPPLEMENT Dates of Activity

From (Month/Year): To (Month/Year): Street Address

House # and Street:

City: State:

Zip Code:

Explain:

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EMPLOYMENT ACTIVITIES - SUPPLEMENT

Dates of Activity


Employer Name:








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