Fairview Heights Police
Board of Fire & Police Commissioners

David Bandy • Brenda McNeil • Lea Kwapis • Andrew Channer
10027 Bunkum Road Fairview Heights, IL 62208 | 618-489-2150 | Fax: 618-489-2159

ACCELERATED ENTRY APPLICATION FOR EMPLOYMENT

Step 1 of 6

A. Application Identification
Information provided in this section is used for identification purposes only.
Name*
First Middle Last
List any other names or aliases you have used or been known by (include maiden name, if applicable).
Address*
Street Address City State ZIP Code
Primary Phone*
Email*
Social Security Number*
xxx-xx-xxxx
Date of Birth*
Are you a U.S. Citizen?*
- Yes
- No
If yes*
- Native Born
- Naturalized
If "naturalized," give particulars
Are you authorized to work in the United States on an unrestricted basis?*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No

C. Employment History
Beginning with your present or most recent job, list all employment since the age of 18, including part time, temporary, or seasonal employment. Include all periods of unemployment.
1.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Phone
Job Title
Duties
Reason for Leaving
2.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Phone
Job Title
Duties
Reason for Leaving
3.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Phone
Job Title
Duties
Reason for Leaving
4.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Phone
Job Title
Duties
Reason for Leaving
5.
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Phone
Job Title
Duties
Reason for Leaving
INDICATE BY NUMBER(S) ANY OF THE ABOVE EMPLOYERS WHOM YOU DO NOT WISH FOR US TO CONTACT.

AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS
*
I do hereby authorize a review of all records concerning myself to any duly authorized agent of the Fairview Heights Police Department, whether the said records are of a public, private or confidential nature, including, but not limited to, applicant background information. I authorize you to furnish the Fairview Heights, Illinois Police Department with any and all information that you have concerning my: work record, salary, attendance, reputation, medical records, criminal history, credit history, loan history, driving history, and military service records. Information of a confidential or privileged nature may be included. Your reply will be used to assist the Fairview Heights Police Department in determining my qualifications and fitness for the position I am seeking with the department. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the Fairview Heights Police Department. I understand that all materials pertaining to this background investigation become the property of the Fairview Heights Police Department and will not be returned to me. I hereby release you and your organization from any and all liability or damages which may result from furnishing the information requested. I further release the Fairview Heights Police Department, and its agents, from any and all liability which may be incurred or as a result from the collection of such information. I further understand that in the event my application is disapproved; the sources of confidential information cannot be revealed to me.
Applicant's Electronic Signature*
First Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Subscribed and sworn before me this day of*
(Today's Date)
MM slash DD slash YYYY
Signature*

Fairview Heights Police
Board of Fire & Police Commissioners

ACCELERATED ENTRY APPLICATION FOR EMPLOYMENT

Step 1 of 6

A. Application Identification

B. Educational History

C. Employment History

1.

2.

3.

4.

5.

D. Special Qualifications & Skills

AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS

Fairview Heights PoliceBoard of Fire & Police Commissioners

ACCELERATED ENTRY APPLICATION FOR EMPLOYMENT

Step 1 of 6

A. Application Identification

B. Educational History

C. Employment History

1.

2.

3.

4.

5.

D. Special Qualifications & Skills

AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS

Fairview Heights Police
Board of Fire & Police Commissioners