Joint Application Step 1 of 15 0% A. Applicant 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Secondary PhoneEmail* Social Security Number*xxx-xx-xxxxAre you a U.S. Citizen?* Yes No If yes* Native Born Naturalized If "naturalized," give particularsAre you authorized to work in the United States on an unrestricted basis?* Yes No Have you ever been convicted of a felony?* Yes No B. Educational HistoryHigh School Name, City, & State*Graduate?* Yes No High School Name, City, & StateGraduate? Yes No High School Name, City, & StateGraduate? Yes No College/University Name, City, & StateMajor/MinorDegree Received, if anyCollege/University Name, City, & StateMajor/MinorDegree Received, if anyCollege/University Name, City, & StateMajor/MinorDegree Received, if anyList 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, explainList other formal education beyond high school you may have, including special training courses:List any special licenses or certificates you hold or have held: C. Employment HistoryHave you ever taken a civil service exam?* Yes No AgencyDate Date Format: MM slash DD slash YYYY Position on ListStatusAgencyDate Date Format: MM slash DD slash YYYY Position on ListStatusAgencyDate Date Format: MM slash DD slash YYYY Position on ListStatusAre you now on any eligibility list?* Yes No If yes, explainWere you ever placed on a civil service list and not hired?* Yes No If yes, explainWere you ever rejected for any service position?* Yes No If yes, explainHave you ever been a law enforcement officer or held a similar position?* Yes No PositionDatesLocationPositionDatesLocationWere you ever discharged or forced to resign because of misconduct or unsatisfactory service or while under investigation?* Yes No If yes, explainAre you now, or have you ever been, engaged in any business as an owner, partner, or corporate member?* Yes No If yes, explainBeginning 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.EmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob TitleSupervisorName of a CoworkerDutiesReason for Leaving2.EmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob TitleSupervisorName of a CoworkerDutiesReason for Leaving3.EmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob TitleSupervisorName of a CoworkerDutiesReason for Leaving4.EmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob TitleSupervisorName of a CoworkerDutiesReason for Leaving5.EmployerStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneJob TitleSupervisorName of a CoworkerDutiesReason for LeavingINDICATE 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 Collinsville, Fairview Heights, and/or O'Fallon. 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)NameAddress 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliationsDate From Date Format: MM slash DD slash YYYY Date To Date Format: MM slash DD slash YYYY NameAddress 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliationsDate From Date Format: MM slash DD slash YYYY Date To Date Format: MM slash DD slash YYYY NameAddress 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type (Social, Fraternal, Professional, etc...) Do not include religious or ethnic affiliationsDate From Date Format: MM slash DD slash YYYY Date To Date Format: MM slash DD slash YYYY G. TATTOOSDo you have any tattoos?YesNoIf yes, list location(s) on your body.H. PERSONAL DECLARATIONSHave you ever made an application for employment with this or any other municipality?YesNoIf yes, give municipality, date(s), and status of applicationHave you ever used or currently use marijuana, cocaine, or any other illegal substances?YesNoHave you ever abused or currently abuse prescription drugs?YesNoHave you ever abused or currently abuse alcohol?YesNoAre 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?YesNoIf 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.List every member of your immediate family who is still living; include father, mother, sisters, & brothers.NameRelationshipAddressOccupation Are you:SingleMarriedSeparatedWidowedDivorcedCivil UnionAre you living with your spouse/civil partner?YesNoIf no, explainGive the following information regarding your marriage/marriages/civil unions:Date Date Format: MM slash DD slash YYYY WhereSpouse Maiden Name (if applicable)Date Date Format: MM slash DD slash YYYY WhereSpouse Maiden Name (if applicable)Date Date Format: MM slash DD slash YYYY WhereSpouse Maiden Name (if applicable)If a marriage to which you were a party was ever dissolved, fill out the following:SeparatedTo Whom Was Action Granted?DivorcedTo Whom Was Action Granted?AnnulledTo Whom Was Action Granted?Are you paying alimony?YesNoIf yes, explainIf 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?YesNoIf no, please explain fullyHave you ever been named as the natural father in a paternity proceeding?YesNoIf 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?YesNoIf 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?YesNoIf yes, how much?How often?The source?Do you own any real estate?YesNoValue?Location:Do you own any bonds, government or other?YesNoValue?Do you own any corporate stock?YesNoValue?Do you have a bank account?YesNoSavings 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?YesNoDate of Service: FromDate of Service: ToBranch of ServiceUnit DesignationMilitary Service RecordHighest Rank HeldType of Discharge and Rank at DischargeDate and location of entrance to active dutyDate and location of dischargePeriod(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 NumberAddressAre you now, or were you ever, a member of any branch of the U.S. Reserve Forces?YesNoIf yes,ActiveInactiveBranchUnitRankAddressFromToAre you now, or were you ever, a member of the National Guard?YesNoIf yes, what state?RegimentUnitRankType of DischargeFromToWere you ever disciplined while in the Military Service? (include court martial, captain's masts, company punishments in active service, reserve unit, or National Guard)YesNoChargeAgencyDateDisposition Are you registered with the Selective Service?YesNoIf 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?YesNoIf yes, please explainHave you ever been required to pay a fine in excess of $25YesNoIf yes, please explainHave you ever been reported as missing person or runaway?YesNoIf yes, please explainHave you ever been the victim of a crime?YesNoIf yes, please explainHave you ever been fingerprinted by a police agency other than for an arrest?YesNoAre there any warrants, traffic or otherwise, now pending against you?YesNoIf yes, please explainHave you ever been arrested, detained by police, or summoned into court for anything other than a traffic violation?YesNoIf yes, complete the following:Offense ChargePolice Agency, City and StateDateDisposition of Case Have you ever been convicted of a felony or misdemeanor?YesNo O. TRAFFIC RECORDCan you operate an automobile?*YesNoDo you possess a valid operator's license from any state in the U.S.?*YesNoIf yes, date of expirationDriver's License NumberStateHave you ever been refused an operator's or chauffeur's license in any other state?*YesNoIf yes, please explainHave you ever had an operator's or chauffeur's license in any other state?*YesNoHas your driver's license ever been suspended or revoked?*YesNoIf yes, give dates, location, and reasons below:Has your license ever been placed on probation?*YesNoIf 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* Date Format: MM slash DD slash YYYY 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 Subscribed and sworn before me this day of*(Today's Date) Date Format: MM slash DD slash YYYY Signature*
