Employment Application To complete this form on your mobile device, scan QR code below with your cell phone camera. "*" indicates required fields Step 1 of 5 0% Preliminary QuestionsDo you have any convictions for felony offenses?* Yes No Do you have any tattoos on your hands, neck, or head?* Yes No What is your current age?* under 20 20 - 34 35 - 44 over 44 At this time, you do not qualify to apply with the Fairview Heights and Collinsville Police Departments for the position of police officer. Have you ever served in the United States Armed Forces?* Yes No Have you ever served in the United States Armed Forces?* Yes No Have you served for 24 months of honorable active duty in the US Armed Forces; or, have you served at least 180 days of active duty in the US Armed Forces in combat duty recognized by the Department of Defense?* Yes No Have you served for 24 months of honorable active duty in the US Armed Forces; or, have you served at least 180 days of active duty in the US Armed Forces in combat duty recognized by the Department of Defense?* Yes No Do you possess an associate's degree in a criminal justice related field; a bachelor's degree in any field; or, possess at a minimum, 64 credit hours towards the attainment of a bachelor's degree at an accedited college or university?* Yes No At this time, you do not qualify to apply with the Fairview Heights and Collinsville Police Departments for the position of police officer. A. Application IdentificationInformation 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 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* Social Security Number*xxx-xx-xxxx Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you a U.S. Citizen?* Yes No Which are you?* Native Born Naturalized Please give details of naturalization Are you authorized to work in the United States on an unrestricted basis?* Yes No B. Educational HistoryHigh School Name, City, & State* Graduate?* Yes No High School Name, City, & State Graduate? Yes No High School Name, City, & State Graduate? Yes No College/University Name, City, & State Major/Minor Degree Received, if any College/University Name, City, & State Major/Minor Degree Received, if any College/University Name, City, & State Major/Minor Degree Received, if any List other schools attended (trade, vocational, business, etc...).Give name and dates attended, course of study, certificate, and any other pertinent information.Were you ever suspended or expelled from any school?* Yes No If yes, explain List other formal education beyond high school you may have, including special training courses:List any special licenses or certificates you hold or have held: 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* Δ
