BUTLER POLICE DEPARTMENT
APPLICATION FOR EMPLOYMENT
DATE: ______
EQUAL OPPURTUNITY EMPLOYEER. It is our policy to abide by all Federal and State laws prohibiting employment discrimination solely on the basis of a person’s race, color, creed, national origin, age, sex, marital status, or physical or mental disability, except where a reasonable, bona fide occupational qualification exists.
POSITION APPLIED FOR: ______SOC#: ______
NAME: ______DL#: ______STATE: ______
ADDRESS: ______CITY: ______
STATE: ______ZIP: ______EMAIL ADDRESS: ______
HOME PHONE: ______CELL PHONE: ______
CHECK THE FOLLOWING OPTIONS YOU WOULD CONSIDER: _____ FULL TIME _____ PART TIME
WHAT IS YOUR MINIMUM SALARY REQUIREMENT: ______DATE AVAILABLE FOR WORK: ______
DO YOU HAVE ANY OBJECTION TO US CONTACTING YOUR PRESENT EMPLOYEER: _____ YES _____ NO
IF YES EXPLAIN: ______
EDUCATION AND TRAINING:
SCHOOL NAMECITY AND STATEDEGREE/MAJORDEGREE RECEIVED
HIGH SCHOOL: ______() YES () NO
COLLEGE: ______() YES () NO
TRADE SCHOOL: ______() YES () NO
POLICE ACADEMY: ______() YES () NO
LIST ANY OTHER EDUCATION, TRAINING, SPECIAL SKILLS OR CERTIFICATES/LICENSES THAT YOU POSSESS RELATED TO THE JOB:
______
GENERAL INFORMATION (A YES/NO RESPONSE WILL NOT NECESSARILLY BAR YOU FROM EMPLOYMENT)
CAN YOU, AFTER EMPLOYMENT SUBMIT VERIFICATION OF YOU LEGAL RIGHT TO WORK PERMANENTLY IN THE UNITED STATES: () YES () NO
HAVE YOU EVER BEEN EMPLOYED BY THE TOWN OF BUTLER: () YES () NO IF YES, WHEN AND REASON FOR LEAVING: ______
HAVE YOU EVER BEEN TERMINATED FROM A JOB: () YES () NO IF YES, EXPLAIN: ______
LIST THREE INDIVIDUALS NOT RELATED TO YOU THAT YOU HAVE KNOWN FOR AT LEAST THREE YEARS
NAMEOCCUPATIONPHONEYEARS KNOWN
______
______
______
EMPLOYMENT HISTORY: (LIST ALL JOBS FOR THE LAST TEN YEARS, BEGINNING WITH THE MOST RECENT)
BUSINESS NAME: ______
ADDRESS: ______
DATES EMPLOYED FROM/TO: ______PHONE#: ______
MAY WE CONTACT: () YES () NO JOB TITLE: ______
REASON FOR LEAVING: ______
BUSINESS NAME: ______
ADDRESS: ______
DATES EMPLOYED FROM/TO: ______PHONE#: ______
MAY WE CONTACT: () YES () NO JOB TITLE: ______
REASON FOR LEAVING: ______
BUSINESS NAME: ______
ADDRESS: ______
DATES EMPLOYED FROM/TO: ______PHONE#: ______
MAY WE CONTACT: () YES () NO JOB TITLE: ______
REASON FOR LEAVING: ______
BUSINESS NAME: ______
ADDRESS: ______
DATES EMPLOYED FROM/TO: ______PHONE#: ______
MAY WE CONTACT: () YES () NO JOB TITLE: ______
REASON FOR LEAVING: ______
BUSINESS NAME: ______
ADDRESS: ______
DATES EMPLOYED FROM/TO: ______PHONE#: ______
MAY WE CONTACT: () YES () NO JOB TITLE: ______
REASON FOR LEAVING: ______
BUSINESS NAME: ______
ADDRESS: ______
DATES EMPLOYED FROM/TO: ______PHONE#: ______
MAY WE CONTACT: () YES () NO JOB TITLE: ______
REASON FOR LEAVING: ______
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
NAMEADDRESSPHONERELATIONSHIP
______
Briefly describe why you want to be a police officer:
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
AGREEMENT: (PLEASE READ THE FOLLOWING STATEMENT CAREFULLY)
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.
I authorize all persons listed above(and on accompanying resume, if any) to give The Butler Police Department any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and The Butler Police Department, from liability for any damage that may result from furnishing same to The Butler Police Department.
I understand and agree that I may be required to take a drug and alcohol screening test. I hereby give my voluntary consent for blood and/or a urine sample to be collected from me and submitted for testing. I also consent to the release of the test result to The Butler Police Department for its use. I understand that any positive drug or alcohol result may preclude my employment.
I understand that a preliminary background investigation will be performed upon the submittal of this application.
PRINT NAME: ______DATE: ______
SIGNATURE: ______