Employment Application Step 1 of 13 0% A. Application Identification Part 2Information provided in this section is used for identification purposes only.Name* First Middle Last Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Secondary PhoneEmail* C. Employment HistoryHave you ever taken a civil service exam?* Yes No Agency Date MM slash DD slash YYYY Position on List Status Agency Date MM slash DD slash YYYY Position on List Status Agency Date MM slash DD slash YYYY Position on List Status Are you now on any eligibility list?* Yes No If yes, explain Were you ever placed on a civil service list and not hired?* Yes No If yes, explain Were you ever rejected for any service position?* Yes No If yes, explain Have you ever been a law enforcement officer or held a similar position?* Yes No Position Dates Location Position Dates Location Were you ever discharged or forced to resign because of misconduct or unsatisfactory service or while under investigation?* Yes No If yes, explain Are you now, or have you ever been, engaged in any business as an owner, partner, or corporate member?* Yes No If yes, explain 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob Title Supervisor Name of a Coworker 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob Title Supervisor Name of a Coworker 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob Title Supervisor Name of a Coworker 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob Title Supervisor Name of a Coworker 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob Title Supervisor Name of a Coworker Duties Reason for Leaving INDICATE BY NUMBER(S) ANY OF THE ABOVE EMPLOYERS WHOM YOU DO NOT WISH FOR US TO CONTACT. D. Special Qualifications & SkillsList any special licenses you hold (such as Paramedic, Pilot, Radio Operator, Scuba, etc...).Show licensing authority, original dates of issue, and date of expiration. List any specialized machinery or equipment that you can operate. Are you fluent in a foreign language?*SelectYesNoWhich Language? Reading AbilitySelectExcellentGoodFairSpeaking AbilitySelectExcellentGoodFairUnderstanding AbilitySelectExcellentGoodFairWriting AbilitySelectExcellentGoodFairWhich Language? Reading AbilitySelectExcellentGoodFairSpeaking AbilitySelectExcellentGoodFairUnderstanding AbilitySelectExcellentGoodFairWriting AbilitySelectExcellentGoodFairPlease use the space below to state why you want to work as a police officer and why you wish to work in Fairview Heights. You should also state the special talents that you feel you would bring to the position.* E. ReferencesList five persons who you know well enough to provide current information about you. Do not list relatives or former employers.1.Name* First Last Years Known*Please enter a number from 0 to 99.Home Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Business Phone*Business Address* Street Address City State / Province / Region ZIP / Postal Code 2.Name* First Last Years Known*Please enter a number from 0 to 99.Home Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Business Phone*Business Address* Street Address City State / Province / Region ZIP / Postal Code 3.Name* First Last Years Known*Please enter a number from 0 to 99.Home Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Business Phone*Business Address* Street Address City State / Province / Region ZIP / Postal Code 4.Name* First Last Years Known*Please enter a number from 0 to 99.Home Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Business Phone*Business Address* Street Address City State / Province / Region ZIP / Postal Code 5.Name* First Last Years Known*Please enter a number from 0 to 99.Home Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Business Phone*Business Address* Street Address City State / Province / Region ZIP / Postal Code F. MEMBERSHIP IN ORGANIZATIONS(Past and/or Present)Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliations Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliations Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliations Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY G. TATTOOSDo you have any tattoos? Yes No If yes, list location(s) on your body.H. PERSONAL DECLARATIONSHave you ever made an application for employment with this or any other municipality? Yes No If yes, give municipality, date(s), and status of applicationHave you ever used or currently use marijuana, cocaine, or any other illegal substances? Yes No Have you ever abused or currently abuse prescription drugs? Yes No Have you ever abused or currently abuse alcohol? Yes No Are there any incidents in your life or details not mentioned herein which may influence this department's evaluation of your suitability for employment as a police officer? Yes No If yes, explain I. BACKGROUND INFORMATIONInformation provided in the following sections will only be used for background checks if you are offered a position and will not affect your status as an applicant in any manner.Name First Last Date of Birth MM slash DD slash YYYY Driver's License Number Gender Race(s) Height Weight Eye Color Hair Color Place of birth: (City, County, State) List every member of your immediate family who is still living; include father, mother, sisters, & brothers.NameRelationshipAddressOccupation Are you: Single Married Separated Widowed Divorced Civil Union Are you living with your spouse/civil partner? Yes No If no, explainGive the following information regarding your marriage/marriages/civil unions:Date MM slash DD slash YYYY Where Spouse Maiden Name (if applicable) Date MM slash DD slash YYYY Where Spouse Maiden Name (if applicable) Date MM slash DD slash YYYY Where Spouse Maiden Name (if applicable) If a marriage to which you were a party was ever dissolved, fill out the following:Separated To Whom Was Action Granted? Divorced To Whom Was Action Granted? Annulled To Whom Was Action Granted? Are you paying alimony? Yes No If yes, explain If divorced, list the name(s) of your previous spouse(s) and where he/she reside(s)List below every child born to you or adopted by you, and stepchildren:NameDate of BirthPlace of BirthWhere does child live and with whom? Are you now supporting all children born to you, adopted by you, and stepchildren? Yes No If no, please explain fullyHave you ever been named as the natural father in a paternity proceeding? Yes No If yes, please explain fullyAre you obligated to the State to pay child support, and if so, are you delinquent on any obligations to the State for unpaid child supports? Yes No If yes, please explain J. FINANCIAL HISTORYSource of IncomeWhat is your present salary or wages? Do you have income from any source other than your principal occupation? Yes No If yes, how much? How often? The source? Do you own any real estate? Yes No Value? Location: Do you own any bonds, government or other? Yes No Value? Do you own any corporate stock? Yes No Value? Do you have a bank account? Yes No Savings Average Balance: Name and address of BankChecking Average Balance: Name and Address of Bank K. FINANCIAL OBLIGATIONSGive names and addresses of the individuals, companies, or others to whom you are indebted, and the extent of your debt. Include rent, mortgages, vehicle payments, charge accounts, credit cards, loans, child support payments and other debts and payments. Include account numbers were applicable. Use extra sheet if necessary.ListTypeName and Address of CreditorReason for debt or item purchasedAccount NumberTotal BalanceMonthly Payment L. MILITARY RECORDHave you served in the U.S. Armed Forces? Yes No Date of Service: From Date of Service: To Branch of Service Unit Designation Military Service Record Highest Rank Held Type of Discharge and Rank at Discharge Date and location of entrance to active duty Date and location of discharge Period(s) of active service:FromTo List all draft classifications you have had (i.e.,1-A, etc...)If you are not a veteran, list the following:Local Board Number Address Are you now, or were you ever, a member of any branch of the U.S. Reserve Forces? Yes No If yes, Active Inactive Branch Unit Rank Address From To Are you now, or were you ever, a member of the National Guard? Yes No If yes, what state? Regiment Unit Rank Type of Discharge From To Were you ever disciplined while in the Military Service? (include court martial, captain's masts, company punishments in active service, reserve unit, or National Guard) Yes No ChargeAgencyDateDisposition Are you registered with the Selective Service? Yes No If no, please explain: M. RESIDENCEList ALL addresses where you have lived during the past ten years, beginning with the present address. List date by month and year. Attach extra page if necessary.FromToAddress With whom do you live at your current address?Full NameRelationships N. CRIMINAL HISTORYHave you ever been placed on probation? Yes No If yes, please explainHave you ever been required to pay a fine in excess of $25 Yes No If yes, please explainHave you ever been reported as missing person or runaway? Yes No If yes, please explainHave you ever been the victim of a crime? Yes No If yes, please explainHave you ever been fingerprinted by a police agency other than for an arrest? Yes No Are there any warrants, traffic or otherwise, now pending against you? Yes No If yes, please explainHave you ever been arrested, detained by police, or summoned into court for anything other than a traffic violation? Yes No If yes, complete the following:Offense ChargePolice Agency, City and StateDateDisposition of Case Have you ever been convicted of a felony or misdemeanor? Yes No O. TRAFFIC RECORDCan you operate an automobile?* Yes No Do you possess a valid operator's license from any state in the U.S.?* Yes No If yes, date of expiration Driver's License NumberStateHave you ever been refused an operator's or chauffeur's license in any other state?* Yes No If yes, please explainHave you ever had an operator's or chauffeur's license in any other state?* Yes No Has your driver's license ever been suspended or revoked?* Yes No If yes, give dates, location, and reasons below:Has your license ever been placed on probation?* Yes No If yes, please explainList, to the best of your memory, all traffic citations you have received (excluding parking tickets).Month and YearChargeCity and StateDisposition In a brief narrative, describe any traffic accidents in which you have been involved, giving approximate dates and locations:** I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the statements and answers to questions I have provided in this application. I am fully aware that any such willful misrepresentation, omissions, or falsifications may be grounds for immediate rejection or termination of employment.Full Name* First Middle Last Today's Date* MM slash DD slash YYYY Signature* Δ
