It is the policy of the West Miami Police Department to establish a drug free icon

It is the policy of the West Miami Police Department to establish a drug free


CITY OF WEST MIAMI POLICE DEPARTMENT

901 SW 62nd AVENUE

WEST MIAMI, FLORIDA 33144


Phone (305) 266-0530 Fax (305) 266-0970


Police Applicant Drug Policy


It is the policy of the West Miami Police Department to establish a drug free

workplace in accordance with State and National efforts. Drug use or abuse by

applicants will be cause of disqualification from employment consideration, except in

very limited cases. All applicants will be polygraphed. If you do not meet the below

criteria, do not apply.


1. NO marijuana use within the last 5 years.

2. NO marijuana use past the age of 21 years.

3. NO chronic marijuana usage during any period of time.

4. NO illicit cocaine use.

5. NO illicit heroin, opium or derivative use.

6. NO use of crack, ice, speed, hash, LSD, qualudes, rohypnol, or any other illicit

drugs.

^ 7. NO sale, possession, distribution, delivery, trafficking or conspiracy involving illicit

drugs, except as required by law enforcement duties.

8. NO abuse of, or fraud involving prescription drugs.

9. NO conviction of any alcohol related offense within the last 5 years, nor more than

once in entire lifetime.

^ 10. NO current or past addiction to alcohol, unless in successful and continuous

treatment and remission for past 10 years.




to keep kids off drugs


^ CITY OF WEST MIAMI POLICE DEPARTMENT

MIAMI-DADE COUNTY, FLORIDA


LAW ENFORCEMENT

EMPLOYMENT APPLICATION


The West Miami Police Department is in Equal Employment Opportunity Employer. We consider applicants for all positions without regards to race, color, natural origin, sex, age, handicap, marital status, religion or any other legally protected status.


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 G.E.D. or Florida Police Standards Certificate.

  3. A copy of military discharge(s) – All DD 214’s issued.

  4. A copy of current driver’s license.

  5. A copy of social security card.










^ POSITION APPLYING FOR:


□ Police Officer □ Community Service Aide


□ Reserve or Auxiliary Officer □ Communications




Application must be printed legibly in black ink. All questions must be answered. Applications

which are not complete will not be considered. If space provided is not sufficient for complete

answers or you wish to furnish additional information, attach sheets of the same size as this

application, and number answers to correspond with questions. You must attach a color, portrait

style photograph of yourself to the front of this application.


^ PERSONAL HISTORY

1. Last Name____________________________First____________________________MI_____


Home Address ________________________________________________________________

Home Phone _________________________________Cell Phone _______________________


2. Other: List all other names you have used including circumstances and time periods you used them. (For example: Maiden name, former name(s), or nickname(s).


Name

Circumstance

Dates From

Mo./ Yr.

Dates To

Mo./ Yr.


















































1


3. Date and Place of Birth: _______________/______________/____________/_____________________

DOB City State Country (if not the US)


4. Are you a United States citizen? □ Yes □ No


5. Social Security Number: _________-_______-________


6. Marital Status: □ Married □ Divorced □ Separated □ Widowed □ Never Married


7. Do you have or have you ever applied for a passport? □ Yes □ No Passport No. _________________


8. Height: __________ Weight: _________ Eye Color: ____________ Hair Color: _____________

^ EDUCATION / TRAINING

1.

High School

Name/Address

Dates Attended

From To

Years Completed

Did You Graduate?

Type of Diploma










































































2.

College/University

Name / Address

Dates Attended

From To

Credit Hours

Qtr. Sem.

Did You Graduate?

Type of Degree










































































































*Attach diploma or official transcript from last institution of higher education attended.


Major____________________________________ Minor _______________________________


3. Other Schools (Trade, Vocational, Business or Military):


Name / Address



Dates Attended

From To

Credit Hours Earned


Area

of Study


Did You Graduate?

BLE #, or Degree or Certificate





















































































2

4. Describe any awards, honors, citations, positions held in school organizations, and any other

Special recognition you received while attending school:

_________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________


5. Indicate any foreign language you can Speak: _________________________________________

Read: __________________________________________

Write: __________________________________________


6. Indicate any specialized law enforcement education/training not listed on page 2:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


7. Did you receive a certificate * for this training? □ Yes □ No Certificate No. _______________

* Attach a copy

8. Describe any special abilities, interests, and hobbies including the degree of proficiency:

_________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


9. Indicate any type of special license such as pilot, radio operator, etc., showing licensing authority,

where the license was first issued, and date current license expires (except vehicle operator’s license):

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


10. Indicate any special skills you possess and equipment you can use which may be related to law

enforcement work. (For example: two-way radio communications, breathalyzer, speed detection

equipment and/or firearms):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


11. A) Typing Speed___________


12. Have you used computers in your prior or current positions? □ Yes □ No

If yes, list programs/software used:

______________________________________________________________________________

______________________________________________________________________________


13. Are you willing to work Nights? □ Yes □ No

Weekends? □ Yes □ No

Holidays? □ Yes □ No

Shift Work? □ Yes □ No


3



^ EMPLOYMENT HISTORY



  1. List chronologically all employment beginning with present employment, including summer and part-time

employment while attending school. All time must be accounted for. If unemployed for a period, set forth dates

of unemployment.


Name/Address/Phone No. of Employer

*Please include zip code*

Dates Worked

Mo. / Yr.

From To

Annual

Salary

Title

or

Position

Name

of

Supervisor

Reason

for

Leaving

________________________________

________________________________

________________________________
















________________________________

________________________________

________________________________
















________________________________

________________________________

________________________________
















________________________________

________________________________

________________________________
















________________________________

________________________________

________________________________

















2. Have you ever been dismissed or asked to resign from any job or employer? □ Yes □ No


a. Have you had any disciplinary action taken against you from any employer? □ Yes □ No


3. Have you resigned, or left a job by mutual agreement following allegations of misconduct or unsatisfactory job

performance ? □ Yes □ No *If yes to questions #2 or #3, provide details on page 13.

4. If you were previously employed by a law enforcement agency, were you ever the subject of an internal affairs

investigation? ______ Yes ______ No * If yes, provide details on page 13.


5. Have you ever applied to any law enforcement agency for employment which is not listed above as an employer?

□ Yes □ No *If yes, provide the name of all agencies and date of employment application for employment.

__________________________________________________________________________________


6. Do you own a business, or are you a partner or corporate officer in any business or organization not listed previously

as a current or former employer? □ Yes □ No If yes, provide name and address or business, corporation or

organization and describe your relationship or position.

__________________________________________________________________________________


4

RESIDENCES

Actual places of residences for past 10 years – list chronologically all addresses, including residences while at school and in military. For college on campus residences, give dormitory name, city and state. If residences in military service cannot be shown as street address, indicate complete military unit designation and location by city and state. If post office box, give location of post office.

Dates

Mo. / Yr.

From To


Apt. No.



Street Address



City



County



State































































































































































































^ ARREST HISTORY / COURT DATA

1. Have you ever been arrested, charged or received a notice or summons to appear for any criminal violation?

□ Yes □ No

Date

City, County & State Location &Police Department Name

Police

Case No.

Charge(s)

Court Location

Disposition






































2. To your knowledge, has any member of your family ever been arrested for other than traffic violations? □Yes □ No

If yes to questions # 1 or 2, list all such matters even if not formally charged, or no court appearances, or found not

guilty, or nolo contendre to any charge for which adjudication was withheld, or matter settled by payment of fine or

forfeiture of collateral. (Include your juvenile records and any sealed or expunged records, if any.)


Date

Family Member Name & Relationship to You

Charge(s)

City & State

Court Location

Disposition

































5


2. Have you or your spouse ever been a plaintiff or defendant in a court action? □ Yes □ No

Provide details________________________________________________________________________________


3. Have you ever been detained by any law enforcement officer for investigative purpose or to your knowledge have

you ever been the subject or a suspect in any criminal investigation? □ Yes □ No

Provide details________________________________________________________________________________


4. Have you ever been fingerprinted for any reason (arrest, job application, military, etc.)? □ Yes □ No

Provide details _______________________________________________________________________________



^ DRIVING HISTORY


1. Are you a licensed Florida automobile operator or chauffer? □ Yes □ No

License No. ___________________________ Date of Expiration: ______________Restrictions: _______________


2. Do you hold or have you ever held an operators or chauffeur license in another state? □ Yes □ No If yes,

provide state(s), name used and approximate dates license(s) was/were held.

______________________________________________________________________________________________

3. Have you ever been denied issuance or have you ever had a license suspended or revoked? □ Yes □ No

If yes, provide complete details including why license was revoked.

_____________________________________________________________________________________________

4. Have you ever received a ticket or been charged with a traffic violation (excluding parking tickets)? □ Yes □ No


Date

Location & Police Department

Charge(s)

Court Location

Disposition






























































5. List all vehicles you currently own, either singly, jointly or in a company or corporation name:



Year

Make & Model

Color

Tag Number

Vehicle Identification No.

































6

^ MILITARY HISTORY

1. Have you ever served on active duty in the Armed Forces of the United States? □ Yes □ No

**If National Guard or Reserve list Basic Recruit Training active duty periods**


Branch of Service: ____________________________________ Highest Rank: ____________________________


Serial #: ________________Duty Dates: From _______ To: ________From: _________To: _______

From _______ To: ________From: _________To: _______


2. Date and type of discharge:______________________________________________________________________


3. Are you now or have you ever been a member of a reserve or the National Guard? □ Yes □ No


4. If yes, state the branch of service, name and location of your unit and whether you attend drills, meetings, or camps:

_____________________________________________________________________________________________


_____________________________________________________________________________________________


_____________________________________________________________________________________________


5. Was any type of disciplinary action taken against you in the service? □ Yes □ No If yes, please provide:

Date: ___________________ Place:_______________________________________________________________


Nature of Offense: _____________________________________________________________________________


Action Taken: _________________________________________________________________________________


_____________________________________________________________________________________________


6. Have you ever served in the Armed Forces of a foreign country? □ Yes □ No

If yes, please specify countries and dates.

_____________________________________________________________________________________________


_____________________________________________________________________________________________


_____________________________________________________________________________________________


7. Are you designated as disabled because of any military service? □ Yes □ No


7


8. ^ VETERANS’ PREFERENCE: Check the appropriate block if you are claiming veterans’ preference.

Documentation substantiating your claim must be furnished at the time of application.


□ 1. A veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement,

or pension under public laws administered by the U.S. Veterans Administration and the Department of Defense, or


□ 2. The spouse of a veteran who cannot qualify for employment because of total and permanent disability, or the spouse

of a veteran missing in action, captured, or forcibly detained by a foreign power, or


□ 3. A veteran of any war who has served on active duty for 181 consecutive days or more, or who has served 180

consecutive days or more since January 31, 1955 and who was honorably discharged from the Armed Forces of the

United States of America if any part of such active duty was performed during a wartime era, excluding active duty for

training, or


□ 4. The un-remarried widow or widower of a veteran who died of a service-connected disability.


Have you claimed and been employed using veterans’ preference since October 1, 1987? □ Yes □ No

If yes, please give name of employer: _____________________________________________________________


NOTE: Under Florida law, preference in appointment shall be given first to those persons included in 1 and 2 above,

and second to those persons included in 3 and 4 above. If an applicant claiming veterans’ preference for a

vacant position is not selected for the vacant position, he/she may file a complaint with the Division

of Veterans’ Affairs, P.O. Box 1437, St. Petersburg, Florida 33731.


8

^ PERSONAL REFERENCES & ACQUAINTANCES


  1. References: List three references (not relatives, former or present employers, fellow employees, or school teachers) who are responsible adults of reputable standing in their communities, such as property owners, business or professional men/women/ who have known you well for the past five (5) years. If retired, give former occupation.

** Include Zip Codes**


_________________________________________

Last, First, Middle


____________________________________________

Years Known / Occupation

Home Address:______________________________

City & State: ________________________________

Home Phone: ( )____________________________

Buss. Address:_______________________________

City & State:________________________________

Buss. Phone: ( )____________________________


_________________________________________

Last, First, Middle


____________________________________________

Years Known / Occupation

Home Address:______________________________

City & State: ________________________________

Home Phone: ( )____________________________

Buss. Address:_______________________________

City & State:________________________________

Buss. Phone: ( )____________________________


_________________________________________

Last, First, Middle


____________________________________________

Years Known / Occupation

Home Address:______________________________

City & State: ________________________________

Home Phone: ( )____________________________

Buss. Address:_______________________________

City & State:________________________________

Buss. Phone: ( )____________________________


2. Social Acquaintances: Give three (3) social acquaintances in your own age group (including both sexes) who have

known you well for the past five (5) years.

** Include Zip Codes**



_________________________________________

Last, First, Middle


____________________________________________

Years Known / Occupation

Home Address:______________________________

City & State: ________________________________

Home Phone: ( )____________________________

Buss. Address:_______________________________

City & State:________________________________

Buss. Phone: ( )____________________________


_________________________________________

Last, First, Middle


____________________________________________

Years Known / Occupation

Home Address:______________________________

City & State: ________________________________

Home Phone: ( )____________________________

Buss. Address:_______________________________

City & State:________________________________

Buss. Phone: ( )____________________________


_________________________________________

Last, First, Middle


____________________________________________

Years Known / Occupation

Home Address:______________________________

City & State: ________________________________

Home Phone: ( )____________________________

Buss. Address:_______________________________

City & State:________________________________

Buss. Phone: ( )____________________________


3. Are you acquainted with any employee of the City of West Miami or the West Miami Police Department?

□ Yes □ No If so, what is your relationship to them? __________________________________________________________________________________________


9

^ ORGANIZATION MEMBERSHIP

1. List all clubs, societies, organizations and memberships of which you are, or have been a member:

Name

City & State

Dates

List position held & describe activity






































2. Are you now or have you ever been a member of any foreign or domestic organization, association, movement,

group or combination or persons which has adopted, or shows a policy of advocating or approving the commission

of acts of force or violence to deny other persons their rights under the constitution of the United States, or which

seeks to alter the form of government of the United States by unconstitutional means? □ Yes □ No


3. Have you ever made a financial or other material contribution to any organization of the type described in

question #2 above? □ Yes □ No


4. At the time of your membership, participation, or contribution, did you know of any unlawful aims of the

organization? □ Yes □ No


5. Did you intend to promote any unlawful aims of the organization? □ Yes □ No

If yes, to question #2, #3, #4, or #5, explain including name of organization and location.

__________________________________________________________________________________________


___________________________________________________________________________________________

^ BUSINESS INTERESTS & LICENSES

1. Do you or have you ever owned any stock or interest in any firm, partnership or corporation wholly or partly in

the sale or distribution of alcoholic beverages? □ Yes □ No

2. Are you now issued or have you ever been issued a license to engage in a business or profession? □ Yes □ No


3. Was license ever cancelled, suspended or revoked? □ Yes □ No

If yes to question #1, #2 or #3, please provide details including the type of license or certificate, the agency that

issued the license, effective date of license and license number.


___________________________________________________________________________________________


___________________________________________________________________________________________


___________________________________________________________________________________________


10

^ CREDIT DATA

1. Do you have any sources of income other than your salary or the salary of your spouse? □ Yes □ No

Specify each with an estimated annual amount.

_________________________________________________________________________________________


2. Are you or your spouse indebted to anyone? □ Yes □ No If yes, please list all debts over $500.00. Be sure

to include student loans and charge accounts. Also, list any debt where payment is past due, regardless of amount.



Creditor

Address

Loan or Account Number

Amount Owed or

Account Balance












































































  1. Have you, your spouse, or a company controlled by you filed for bankruptcy? □ Yes □ No




  1. Declared bankrupt? □ Yes □ No


b. Had a legal judgment rendered against you for a debt? □ Yes □ No

If yes to any of these questions, please provide details.

____________________________________________________________________________________________


4. Have your accounts ever been placed in the hands of a collection agency? □ Yes □ No If yes, give details:

___________________________________________________________________________________________

___________________________________________________________________________________________


During your background investigation, you may be asked to provide a current credit report, along with a copy of

your last year’s Federal Income Tax Return. You should have these documents readily available.


11

^ APPLICANT’S CERTIFICATION

I understand that my appointment or employment will be contingent upon the results of a complete background

investigation. I am aware that my omission, falsification, misstatement or misrepresentation will be the basis for my

disqualification as an applicant or my dismissal from the West Miami Police Department. I agree to the conditions

and certify that all statements made by me on this application are true, correct and complete, to the best of my

knowledge. I further fully understand and consent to a polygraph examination concerning the veracity of my

responses to the information requested on this application or which is discovered as a result of the background

investigation, or any physical examination or drug test. I also understand that I will be fingerprinted. I understand

that this employment application shall become property of the West Miami Police Department and that it and the

information received in responses to the background examination are public records.


I also understand that I may be required to furnish the West Miami Police Department with a copy of my Income

Tax return for the year preceding this application and for each year during my employment or appointment. I

further understand and agree that my employment or appointment will be contingent upon the results of a complete

drug test and that I may be required to take drug tests during the term of my employment or appointment with West

Miami Police Department.


I understand that the use of drugs or alcohol is not permitted during work or duty time, whether paid or unpaid, in

the areas, including vehicles, where work is performed by employees or appointees. I understand that my continued

employment or appointment may be contingent upon the results of medical or psychological examinations that I

may be required to take during the term of my employment or appointment and the maintenance of personal

physical fitness, to the degree necessary, to perform satisfactorily the duties of my position or assignment with the

West Miami Police Department.


I understand the following types of information will be collected: employment and educational histories; medical,

military, insurance, credit and financial information; motor vehicle and police records; information about your

abilities, family, character, lifestyle, and organization memberships, and information about any current drug use via

drug testing. Information will be obtained by letter, by telephone and by personal interview with both primary and

secondary sources. This information is used as one element for appointment decisions. I authorize any of the

persons or organizations referenced in this application to furnish information, personal or otherwise, regarding my

ability and fitness for employment or appointment with the West Miami Police Department and I relieve all such

parties from any and all liability for any damage that might result from furnishing such information to the West

Miami Police Department .


I agree to conform and abide by the rules, regulations and orders of the West Miami Police Department and

acknowledge that these rules, regulations and orders may be changed, interpreted, withdrawn or added to by the

West Miami Police Department, at its discretion, at any time and without any prior notice to me. I understand that

failure to abide by the rules, regulations and orders of the West Miami Police Department may be grounds for my

termination of employment.


_______________________________ _______________________________ __________________

Applicant Name Printed Applicant Signature Date

_______________________________ _______________________________ __________________

Witness Name Printed Witness Signature (Required) Date


12

^ THIS PAGE HAS BEEN LEFT BLANK FOR YOUR USE TO PROVIDE ADDITIONAL INFORMATION. INDICATE PAGE NUMBER AND QUESTION NUMBER.

________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


________________________________________________________________________________________________


13


Name:__________________________________ Social Security No. ____________________________

^ CONFIDENTIAL EMPLOYEE HISTORY

THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL AND

WILL NOT BE MADE AVAILABLE FOR PUBLIC INSPECTION.


1. Applicant’s Current Address:


___________________________________________________________________________________________

House Number Street Name Apt. # City County State Zip Code


___________________________________________________________________________________________________

Mailing address if different from above.


_________________________ _________________________ _________________________

Home Telephone Number Cellular Telephone Number Work Telephone Number


2. Spouse’s Name, Social Security number, Address and cellular phone number.


__________________________________________________________________________________________________

Name Social Security #


_________________________________________________________________________________________________

Address Cellular Phone


3. Children’s Names and Ages:



Name / Social Security No.

Age

Address (if different)





























4. Former Spouse(s) Name and Address:



Name

Address














5. Are you now able to participate in defensive tactics, firearms or physical training, operation of a motor vehicle, or

otherwise perform the duties set forth in the job description or task analysis related to the position for which you

applied? □ Yes □ No


6. If a physical abilities test or examination is required for this position, would you be able to take this physical

test or examination? □ Yes □ No


8. Would you require any special accommodation(s) to take the physical abilities test or examination? If yes,

explain. □ Yes □ No ___________________________________________________________________


14


9. Do you now, or have you ever used, possessed, supplied, or sold any narcotics or controlled substance such as.

but not limited to, marijuana, cocaine, LSD, amphetamines, heroin, steroid or any drug of a similar nature?

□ Yes □ No


a. Drug: _________________________________________________________________________________

b. Circumstances: _________________________________________________________________________

c. Number of times used/possessed/supplied/sold:_________________________________________________


d. First time used/possessed/supplied/sold: ______________________________________________________


e. Last time used/possessed/supplied/sold:________________________________________________________


10. Do you currently use any narcotic or controlled substance, or have you used such a narcotic or controlled

substance within the last year? □ Yes □ No


11. Please provide name and address of next of kin or other person to be contacted in case of an emergency:


________________________________________________________________________________________

Name Address Phone No.


12. Please provide the name and address of your personal or family physician to be contacted in case of an

emergency:

_________________________________________________________________________________________

Name Address Phone No.


The following information is solely for the purpose of compliance with federal regulations (item 13 – 17):


13. Race/Ethnicity (Check only one)

W ( ) White, Non-Hispanic A person having origins in any of the original peoples of Europe, North America, or the Middle East.

B ( ) Black, Non-Hispanic A person having origins in any of the Black racial groups of Africa.

S ( ) Hispanic A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish Culture of origin

regardless of race.

A ( ) Asian or Pacific Islander A person having origins in any of the original peoples of the far East, Southeast Asia, the Indian Subcontinent,

or the Pacific Islands. This area includes, for example: China, Japan, Korea, The Phillipine Islands and Samoa.

I ( ) American Indian or A person having origins in any of the original peoples of North America, who maintain cultural identification

Alaskan Native through tribal affiliation or community recognition.


14. □ Male □ Female 15. Date of Birth: _____/ ______/______


16. Place of Birth: _________________________________

City, County, State


17. US Citizen: □ Yes □ No Native: : □ Yes □ No


Naturalized Certificate No. ________________________________

If derived, parent Certificate No. ____________________________


Date, Place, Court:__________________


15


NOTICE

If you need a question answered or further information on completing this application, contact:


City of West Miami Police Department

Employment Applications

901 SW 62 Avenue

West Miami, Florida 33144

(305) 266-0530

(305) 266-0970 Fax


^ FOR OFFICE USE ONLY


APPLICANT CONTACT ACTIVITY LOG


Date

By Whom

Description





















































































Test

Scores

Date





































FOR OFFICE USE ONLY

( ) Birth Certificate ( ) Drivers’s License ( ) References / Employers Complete

( ) High School Diploma ( ) FL Driver’s License Addresses and Phone Numbers

( ) Discharge – DD214 ( ) Notarized Authorization ( ) Citizenship Certification

( ) SS Card ( ) Complete Address/Phone No. ( ) Name Change







Download 207.47 Kb.
leave a comment
Date conversion24.10.2013
Size207.47 Kb.
TypeДокументы, Educational materials
Add document to your blog or website

Be the first user to rate this..
Your rate:
Place this button on your site:
docs.exdat.com

The database is protected by copyright ©exdat 2000-2017
При копировании материала укажите ссылку
send message
Documents

upload
Documents

Рейтинг@Mail.ru
наверх