Application for hualapai police department icon

Application for hualapai police department


APPLICATION FOR HUALAPAI POLICE DEPARTMENT

Peach Springs, AZ

(Rev. 4-17-09)


All questions must be answered. It is mandatory that all spaces requiring written explanations be completed. If not applicable, write DNA. If more space is required attach a blank sheet. Use black ink; do not type. Any false, misleading, or incomplete information will be grounds to disqualify you from employment with the Hualapai Police Department. The following documents must accompany this application when it is turned in:

  • A copy of your high school diploma or G.E.D. certificate

  • A copy of any post high school academic degrees or certificates

  • A copy of your birth certificate or naturalization papers

  • A copy of your DD-214 (military discharge papers) if applicable

  • A copy of your current driver’s license and social security card

  • A copy of your Marriage License/Certificate

  • A copy of your Divorce Decrees

  • A copy of your Bankruptcy Order of Discharge



^ POSITION APPLYING FOR ___________________________________________________________


Tribal Affiliation _____________________________________ Enrollment No. ___________________


  1. Full Name _____________________________________________________________________




  1. Mailing Address ________________________________________________________________




  1. E-mail Address ________________________________________________________________




  1. Date and Place of Birth __________________________________________________________




  1. Social Security Number __________________________________________________________




  1. Other Names Used For example: maiden name, names by a former marriage, alias(es), or




  1. nickname(s) ___________________________________________________________________




  1. Height ______ Weight ______ Hair Color ______ Eye Color________ (circle one) M F




  1. Telephone Numbers (Day)_____________________ (Night) ____________________________




  1. Where You Have Lived List places where you have lived, beginning with the most recent and working back 10 years. All periods must be accounted for in your list. Be sure to list actual physical location; do not use a post office box as an address.


A. Dates lived at this address (mo/yr to mo/yr) ____________________________________


Street Address ______________________ City _______________State___ Zip _____________


B. Dates lived at this address (mo/yr to mo/yr) ____________________________________


Street Address ______________________ City _______________ State ___ Zip ____________


C. Dates lived at this address (mo/yr to mo/yr) ____________________________________


Street Address ______________________ City ________________ State ___ Zip ___________


11. ^ Where You Went to School List the school(s) you have attended, beyond junior high school


A. Name of High School _____________________________________________________


Address ______________________________________________________________________


Diploma/Other _________________________ Mo/Yr Awarded _________________________


B. Name of College/University ________________________________________________


Address ______________________________________________________________________


Degree/Diploma/Other __________________________________________________________


C. Name of Trade School _____________________________________________________


Address ______________________________________________________________________


Degree/Diploma/Other _________________________Mo/Yr Awarded ____________________


12. ^ Your Certification Status Are you currently certified in any state or the federal government as a

peace officer/police officer? List state/agency and date of certification _____________________


_____________________________________________________________________________


  1. Your Certification Status Have you ever been denied peace officer/police officer certification status or have your status revoked or suspended? If so, explain __________________________


_____________________________________________________________________________


14. Your Previous Applications List all law enforcement agencies applied for in the past three years.


_____________________________________________________________________________


  1. Your Employment Activities List your employment activities beginning with the present and working back 15 years. List all work and all periods of unemployment.




    1. Employer__________________________ Your Position/Title ________________________


Employer’s Address ____________________________________ State ____ Zip ____________


Supervisor’s Name _____________________________ Tele No _________________________


Dates Employed (mo/yr to mo/yr) __________________________________________________


Reason for Leaving _____________________________________________________________


  1. Employer __________________________ Your Position/Title _______________________


Employer’s Address ______________________________________ State ___ Zip __________


Supervisor’s Name ______________________________ Tele No ________________________


Dates Employed (mo/yr to mo/yr) _________________________________________________


Reason for Leaving _____________________________________________________________


  1. Employer __________________________ Your Position/Title _______________________


Employer’s Address ______________________________________State _____ Zip _________


Supervisor’s Name ______________________________ Tele No ________________________


Dates Employed (mo/yr to mo/yr) _________________________________________________


Reason for Leaving _____________________________________________________________


16. ^ Your Employment Record In the past 15 years, have you ever been fired from a job, quit a job after being told you’d be fired, left a job by mutual agreement following allegations of misconduct, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reasons under unfavorable circumstances?


Specify Reason _______________________________________________ Mo/Yr ___________


Employer’s Name and Address ____________________________________________________


_____________________________________________________________________________


17. ^ People Who Know You Well List three people who know you well. They should be friends, peers, colleagues, etc., whose combined association with you covers the last 10 years. Do not list your spouse, former spouses, or other relatives. Try not to list anyone who is listed elsewhere on this form.


  1. Name______________________________________ Dates Known (mo/yr) ____________


Home or Work Address ____________________________ Tele No ______________________



  1. Name______________________________________ Dates Known (mo/yr) ____________


Home or Work Address ____________________________ Tele No _____________________


  1. Name _______________________________________ Tele No _____________________


Home or Work Address _____________________________ Tele No _____________________


18. Your Marital Status


Circle One: Never Been Married Married Separated Divorced Widowed


Current Spouse Full Name _______________________________________________________


Date of Birth________ Place of Birth _________________ Soc Sec No ___________________


19. Your Military Record If other than an honorable discharge, explain


Branch of Service __________________________ Yr/Mo to Yr/Mo ______________________


Type of Discharge __________________________________ Yr/Mo _____________________

20. ^ Your Police Record Do not include anything that happened before your 16th birthday. Have you ever been arrested for, charged with, or convicted of any offense(s)?


Offense ___________________________ Disposition ________________________________


Mo/Yr ___________ Law Enforcement Authority or Court _____________________________


  1. ^ Your Driving History List driver’s or chauffeur’s licenses: State issued, type, number & expiration date. Also list all traffic citations you have received since 16 YOA. Begin with the most recent and include all citations that may be been dismissed. If applicable, explain revocation or suspension. ________________________________________________________


_____________________________________________________________________________


22. Illegal Drugs Since the age of 16 or in the last 15 years, whichever is shorter, have you illegally used any controlled substance, for example, marijuana, cocaine, crack cocaine, hashish, heroin, meth, LSD, PCP, etc, or prescription drugs? If yes, identify the controlled substance(s) and/or prescription drugs used and the number of times each was used.


Controlled Substances/Prescription Drug Used _______________________________________


Mo/Yr to Mo/Yr__________________ Number of times used ___________________________


23. ^ Your Financial Record In the past 10 years, have you filed for bankruptcy, been declared bankrupt, been subject to a tax lien, or had a legal judgment rendered against you for a debt?


Type of Action _________________________________________ Mo/Yr _________________


Name/Address of Court/Agency ___________________________________________________


Address of Court/Agency ________________________________________________________


24. ^ Your Use of Alcohol In the last 10 years has your use of alcohol beverages (such as liquor, beer, wine) resulted in any alcohol-related treatment or counseling (such as for alcohol abuse or alcoholism)? If you answered “yes”, provide the date(s) of treatment and the name and address of the counselor below.


Mo/Yr to Mo/Yr ____________ Name of Doctor or Counselor __________________________


Name/Address _________________________________________________________________


  1. ^ Your Medical Record In the last 10 years, have you consulted with a mental health professional (psychiatrist, psychologist, counselor, etc.) or have you consulted another health care provider about a mental health related condition? Note: you do not have to answer “yes” if you were only involved in marital, grief, or family counseling not related to violence by you. If you answered “yes”, provide the dates of treatment and the name and address of the therapist or doctor below.


Mo/Yr to Mo/Yr______________ Name of Doctor or Counselor _________________________


Name/Address _________________________________________________________________


^ Certification That My Answers Are True

My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that any false answers may result in my being automatically rejected for employment consideration.


________________________________________________ ___________________________

Signature (Sign in ink) Date


^ HUALAPAI POLICE DEPARTMENT

Peach Springs, Arizona


AUTHORIZATION FOR RELEASE OF INFORMATION


(Carefully read this authorization to release information about you, then sign and date it in ink.)


I authorize any investigator or other duly accredited representative of the Hualapai Police Department conducting my background investigation, to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishment establishments, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history record information, and financial and credit information. I authorize the Hualapai Police Department to use information obtained about me to determine my suitability or eligibility for employment.


I understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, a separate specific release will be needed, and I may be contacted for such a release at a later date. Where separate release is requested for information relating to mental health treatment or counseling, the release will contain a list of the specific questions, relevant to the job description, which the doctor or therapist will be asked.


I authorize any investigator or other duly accredited representative of the Hualapai Police Department to request criminal record information about me from criminal justice agencies for the purpose of determining my suitability or eligibility for employment.


I authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator or other duly accredited representative of the Hualapai Police Department regardless of any previous agreement to the contrary


Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for one year from the date signed or upon the termination of my employment with the Hualapai Police Department, whichever is sooner.


Signature (Sign in Ink) _________________________________ Date Signed ____________________


Full Name (Type or Print Legibly) _______________________________________________________


Social Security Number _________________________ Tele No _______________________________


Current Address ______________________________________________________________________


^ HUALAPAI POLICE DEPARTMENT

Peach Springs, Arizona


AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION


Carefully read this authorization to release information about you, then sign and date it in ink.


Instructions for Completing this Release


This is a release for the investigator or other duly accredited representative of the Hualapai Police Department to ask your health practitioner(s) the three questions below concerning you medical/mental health consultations. Your signature will allow the practitioner(s) to answer only these questions.


I am seeking employment with the Hualapai Police Department, which requires certain medical/mental/physical fitness requirements. As part of the background investigation process, I hereby authorize the investigator or other duly accredited representative of the Hualapai Police Department conducting my background investigation, to obtain the following information relating to my medical/mental health consultations:


Does the person under investigation have a condition or treatment that could impair his/her judgment or reliability to serve as a police officer?


If so, please describe the nature of the condition and the extent and duration of the impairment or treatment.


What is the prognosis?


I understand the information released pursuant to this release is for use by the Hualapai Police Department to determine my suitability or eligibility for employment, and it may not be redisclosed.


Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for one year from the date signed or upon my termination of employment with the Hualapai Police Department, whichever is sooner.


Signature (Sign in Ink) ________________________________ Date Signed ______________________


Full Name (Type or Print Legibly) _______________________________________________________


Social Security Number _______________________ Tele No _________________________________


Current Address ______________________________________________________________________







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