NOTICE: The following additional documents must be attached to this application
1. A copy of birth certificate
2. A copy of high school diploma or approved G.E.D.
3. A copy of military discharge(s)
All questions must be answered. Applications which are not complete will not be considered.
I understand that the submission of this application for sponsorship to a law enforcement academy does not constitute an appllcation for employment or appointment with the sponsor-law enforcement agency. Moreover, I understand this law enforcement agency is under no obligation to sponsor me as a candidale for any law enforcement training program.
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Other: List all other names you have used including circumstances and time periods you used them. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Resume {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Background Information
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Place of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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County of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Country of Birth (if not United States) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Height {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If naturalized, please provide date, place and number. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Passport Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Education/Training
School {binding ItemNumber}
Name of School {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Location of School {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Degree Received {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Major {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Number of Years Completed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe any awards, honors, citations, positions held in school organizations, and any other special recognition you received while attending school: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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List the languages you speak, read or write. Indicate if you are fluent, good or fair. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Indicate any law enforcement education/training {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe any special abilities, interests, and hobbies includang the degree of proficiency: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lndicate any special skills you possess and equipment you can use which may be related to law enforcement work. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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List all employment including summer & part time. Account for all unemployment periods.
Employment History
Employer {binding ItemNumber}
Name of Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date Worked From {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date Worked To {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Title or Position {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Supervisor Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Reason for leaving {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you answered YES to any of the three questions above, please provide details. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, please provide name of agency and date of application or service. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, please provide name & address of business, corporation or organization & describe your relationship/position. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Residences
Residence {binding ItemNumber}
Date From {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date To {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Arrest History/Court Data
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Provide details for each response for the three questions above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you answered yes, give date, place orcourt, case number, names of involved parties, nature of action, and final disposition. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you answered YES to the two previous questions, please provide details. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Driving History
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License No. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Expiration Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Restrictions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, please provide state(s), name used, and approximate dates license(s) was/were held {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lf yes, please provide complete details lncluding why license was revoked. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lf yes, please provide complete details. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Military History
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If yes, your Selective Service Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Classification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of Classifacation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Branch of Service {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Highest Rank {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Serial Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Duty Dates - Please list the date from and the date to: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date and type of discharge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lf yes state the branch of service, name and location of your unit and whether you attend drills, meetings, or camps: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If YES, please provide date, place, nature of offense and action taken: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, please spcify countries and dates {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Organization Membership
List all clubs, societies of which you are a former or present member. Include name, city, state, and position held & describe activity. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you answered yes to the two previous questions please answer the next two questions.
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If you answered YES to any question in this section, please explain including name of organization and location. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Personal References: Give three references (not relatives, former or present employers, fellow employees, or school teachers) who are responsible adults of reputable standing in their communitites, such as proprety owners, business or professional men or women who have know you well for the past five (5) years. lf retired, give former occupation.
References
Reference {binding ItemNumber}
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Employee History
THE INFORMATION CONTAINED HEREIN MAY BE CONFIDENTIAL AND NOT AVAILABLE FOR PUBLIC INSPECTION.
Applicant's Current Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Applicants Social Security Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spouse's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spouse's Address (If Different) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Former Spouse's Name and Address (If Any) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Former Spouse's Name and Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please provide name and address of next of kin or other person to be contacted in case of an emergency: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please provide the name and address of your personal or family physician to be contacted in case of an emergency: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Drug History
The information contained herein MAY BE a confidential medical record under the Americans with Disabilities Act if the applicant is a rehabilitated drug or alcohol abuser or under section 119.071(4()b) whether the medical information, if disclosed, would identify the applicant.
If yes, please complete the following: (Drug taken, how long, last time experimented with or used) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lf yes, please complete the following: (Drug, circumstances, number of times illegally obtained/possesed/supplied/sold, and first and last time illegally obtained/possesed/supplied/sold) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lf yes, provide details, including drug, date, and circumstances {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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lf yes, provide details. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I understand that the "Applicants Certification" applies in all respects to the responses provided in this "Confidential Employee History" and "Drug History."
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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