EMPLOYMENT APPLICATION
Police OfficerApplication for the position of:
Directions:
1. Read and sign the Data Practices Advisory that immediately follows this page.
2. When completing this form, please print clearly and give complete and accurate information. This includes but is not limited to data practices releases, school transcripts, area codes and zip codes. If you do not, you may be removed from further consideration. USE ONLY BLACK INK.
3. If you find that there is not enough space to answer a specific question, provide as much information as space permits. Continue your response on additional sheets of paper if necessary. Include the number of the question and maintain the same format as on the background investigation form.
4. A set of releases is contained at the end of the form. Please complete the proper release form as indicated in the background investigation form.
You may need to copy extra releases. Therefore, complete the background investigation form first and then determine the type and number of releases you will need.
5. If a question does not apply to you, please write N/A (not applicable).
6. Include any requested documents.
7. Be sure to sign each of the release forms, the signature page, and the autobiography with an original signature.
8. You must return a hard copy of the completed background investigation packet either on or prior to November 10, 2016. Packets may be mailed to:
Sergeant Tim Tomasek
Marshall Police Dept.
611 W. Main St.
Marshall, MN 56258
9. If you have any questions, please call the Marshall Police Department Background Investigations Office.
DATA PRACTICES ADVISORY
READ THIS ADVISORY BEFORE COMPLETING THIS FORM:
The Minnesota Government Data Practices Act requires you to be informed that the following information, which you have been asked to provide on the attached form is considered private data:
1. Your full name. Any and all previous names by which you are known, regardless of whether or not they were your legal names.
2. Your date of birth.
3. Your race.
4. Your sex.
The purpose and intended use of this data is to conduct the background inquiries which under the POST Board’s Rules, Minn. Rules pt. 6700.0700, the agency is required to conduct before you can be licensed as a peace officer and/or appointed as a peace officer in this agency. The specific use for each category of data is described below:
1. To conduct a thorough and complete criminal history and felony background check, all names by which an applicant is or has been, known must be listed.
2. In order to access driver’s license data, date of birth must be supplied.
3. In order to complete, and send for evaluation fingerprint cards as required by state statute, the race and sex of the person fingerprinted must be entered on the fingerprint card.
4. In order to access criminal history data, date of birth, race and sex must be supplied.
5. A complete criminal history and felony background check, driver’s license check, and fingerprint evaluation are required minimum selection standards for peace officers in Minnesota, pursuant to Minn. Rules pt. 6700.0700. These checks are conducted to determine whether there are any job-related factors which affect your suitability for employment.
This data will be used solely for the above-mentioned purposes. This data will not be made available to the hiring authority. The data will be forwarded to the background investigator for completion of the criminal history inquiries as required under Minn. Rules pt. 6700.0700. Information gained by use of previous names, date of birth, or race, will be forwarded to the hiring authority without reference to date of birth, age, or race. You are not legally required to provide the requested information. However, if you do not, the agency will be unable to conduct the required background inquiries and will not be able to consider you for appointment as a peace officer. The information obtained by use of protected class data will be available to you and those in the appointing authority who have a bona fide need for the data. The data may also be used for other purposes necessary for the administration of law, rule or ordinance but will be disseminated only as required by law. If you are certified as eligible for appointment to a position or are considered a finalist, your name becomes public.
I have read and understand the information stated above.
Applicant’s Signature Date
Background Investigator’s Reference Sheet
This is used as a quick reference sheet and some questions may be duplicated.
1. Name:
(Last) (First) (Middle)
Nicknames:
Have you ever changed your name? Yes No
If yes, list other name(s) used:2. Current Address:
(Apt.) / (Number) / (Street)(City) / (State) / (Zip)
Home Phone: / ( )
Business: / ( )
E-mail Address:
3. / Current Employer:
Address:
(Number) (Street)
(City) / (State) / (Zip)Phone: / ( )
Position:
From: / To:
(Month/Date/Year) / (Month/Date/Year)
APPLICANT INFORMATION
4. What is your full name?
(Last) (First) (Middle)
5. Give any other names you have used or have been known by. (If none, state none)
6. Are you a citizen of the United States? (POST requirement)
Yes No
If yes, provide a copy of your birth certificate or other documentation that proves citizenship.
7. Are you currently licensed as a peace officer in Minnesota?
Yes No
If yes, please provide a copy of your license and current renewal card. Complete the following information:
Current status of your peace officers license:
Valid-Active Status Valid-Inactive Status
Lapsed Surrendered
Suspended Revoked
License Number:Date Originally Issued:
Expiration Date:
If no, please provide the following information if licensed elsewhere:
Name of state where licensed: / License #:Expiration Date:
8. Have you ever had any disciplinary action against your license?
Yes No
9. Academic Component of Professional Peace Officer Program completed at:
(Complete a Type I release for each academy and or school)
(School) (Degree)
(From: Month/Year) (To: Month/Year)
()(Number) (Street) (Phone #)
(City) / (State) / (Zip)10. Are you “eligible for a license?”
Yes No
If yes, when does your eligibility expire?(Please provide a photocopy of POST Board eligibility letter)
11. Skills Component of Professional Peace Officer Education completed at:
(Complete a Type I release for this school)
(School) (Degree)
(From: Month/Year) (To: Month/Year)
()(Number) (Street) (Phone #)
(City) / (State) / (Zip)Date completed Skill Component:
Date of passing Peace Officer Licensing Examination:
12. Have you participated in an internship with a police department(s)?
(Complete Type I release for this department(s)
Yes No
If yes, please list departments below:
(Department) (Internship Dates) (Supervisor’s Name)
( )(Number) (Street) (Phone #)
(City) / (State) / (Zip)13. If you were trained out of state, please complete the following:
(Complete a Type I release for each academy and/or school)
(Name of training program)
( )(Number) (Street) (Phone #)
(City) / (State) / (Zip)Date of completion:
Length of Course:
Date of certification:
Date of passing the Minnesota POST Reciprocity Exam:
RESIDENCY
14. In chronological order, list each and every place you have lived, beginning with your present address. Include all addresses while in school and the military. (Make photocopies of this page if you need additional space.)
(From: Month/Year) (To: Month/Year)
()(Number) (Street) (Apt.) (Phone #)
(City) (County) (State) (Zip)
(From: Month/Year) (To: Month/Year)
()(Number) (Street) (Apt.) (Phone #)
(City) (County) (State) (Zip)
(From: Month/Year) (To: Month/Year)
()(Number) (Street) (Apt.) (Phone #)
(City) (County) (State) (Zip)
(From: Month/Year) (To: Month/Year)
()(Number) (Street) (Apt.) (Phone #)
(City) (County) (State) (Zip)
15. Please list the requested information for your spouse, (include maiden name if appropriate and note divorced if applicable) father, mother, brother and sisters (note deceased if applicable): Make photocopies of this page if additional space is needed.
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / ( ) / Work: / ( )(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / ( ) / Work: / ( )(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / ( ) / Work: / ( )(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name) (Relationship) (Occupation)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
16. List any peace officers you are acquainted with: (Make photocopies of this page if additional space is needed.)
(Name) (Department)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / ( ) / Work: / ( )(Phone #) (Phone #)
(Name) (Department)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / ( ) / Work: / ( )(Phone #) (Phone #)
(Name) (Department)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name) (Department)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
17. List the name of five friends and/or associates. Do not include former employers, schoolteachers or peace officers listed previously.
(Name)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / ( ) / Work: / ( )(Phone #) (Phone #)
(Name)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
(Name)
(Number) (Street) (Apt.)
(City) (County) (State) (Zip)
Home: / () / Work: / ()(Phone #) (Phone #)
EDUCATIONAL BACKGROUND
18. In chronological order, list all colleges and high schools you have attended, beginning with your most resent. (Complete Type I release form for each school, make photocopies of this page if more space is needed.)
()(Name of school) (Phone #)
(Major) (Degree)
(From: Month/Year) (To: Month/Year)
(Number) (Street) (City) (State) (Zip)
()(Name of school) (Phone #)
(Major) (Degree)
(From: Month/Year) (To: Month/Year)
(Number) (Street) (City) (State) (Zip)
()(Name of school) (Phone #)
(Major) (Degree)
(From: Month/Year) (To: Month/Year)
(Number) (Street) (City) (State) (Zip)
()(Name of school) (Phone #)
(Major) (Degree)
(From: Month/Year) (To: Month/Year)
(Number) (Street) (City) (State) (Zip)
19. List any disciplinary action taken against you by the college (s) and or high school(s) you attended: (Include school, dates, problem, brief explanation.)
20. List any awards or certificates you have received in college or high school:
(Include school, dates, award/certificate, brief explanation.)
21. Please immediately have transcripts from all skills, colleges(s) and high school(s) that you have attended forwarded to the following address:
Marshall Police Department
Background Investigations Unit
611 West Main Street
Marshall, MN 56258
(Proper fees must be paid to school (s) by the applicant.)
MILITARY AND SELECTIVE SERVICE
22. If you are a male and were born after 1960, have you registered with the Selective Services?
Yes No
If yes, provide Selective Service Number:If no, please explain why:
23. Upon registration for military service, have you ever been disqualified for Reasons other than medical?
Yes No
If yes, explain below:
24. Have you ever served as an ACTIVE member in a military organization of the United States? (Reserves or National Guard see question below)
Yes No
If yes, enclose a copy of your DD 214 and complete Standard Form 180, Request Pertaining to Military Records.
If yes, give details:
Give branch of service:Military specialty (MOS):
Rank held at time of discharge:
What was the highest rank you achieved:
Service serial number:
Name of commanding officer at time of discharge:
Give period or periods of active service:
From: / To:From: / To:
How many discharges or separations from the service were given to you?
Discharges: / Separations:Has your discharge or separation notice ever been corrected or changed?
Yes No
What was the nature of the change?
From:To:
Were you ever the subject of any military disciplinary action?
Yes No
If yes, give details of charges, agency concerned, dates and dispositions:
25. Are you now or were you ever an active or inactive member of the reserve forces (any branch) of the United Sates, or the National Guard of any state? (If yes, complete Standard Form 180, Request Pertaining to Military Records)
Yes No
If yes, state which, active or inactive:Branch:
Regiment:
Unit:
Rank:
Address:
From: / To:
26. List any awards or decorations you received while in the military.
27. Have you ever served in a military organization of any foreign government?
Yes No
If yes, give details:
EMPLOYMENT HISTORY
28. In chronological order, list below your past employment history. Being with your present employer and continue listing all places previously employed with (full time, part time, seasonal etc.) since the age of 18 years. OMIT NONE. Give the correct, and current information. Give dates of non-employment between periods of employment in proper sequence. Applicants are eligible only if it can be determined from their application that they meet minimum qualifications for the position. Indicate name under which you were employed if different than present name. (Complete Type I Release Form for each employer; make photocopies of next page if more space is needed)
()(Present Employer) (Phone #)
()(Immediate Supervisor) (Phone #)
(Number) (Street) (City) (County) (State) (Zip)
(From: Day/Month/Year) (To: Day/Month/Year)
(Position)
Duties and/or reason for leaving:()
(Present Employer) (Phone #)