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1. As either a juvenile or as an adult have you ever committed an offense where you could have been/or were arrested? *

Yes

No

If yes, provide the charge(s), date(s), and disposition(s) of offense.

2. Have you ever petitioned any court to seal or expunge a criminal or juvenile record?*

Yes

No

If yes, provide a detailed explanation with date(s).

3. Have you ever had a Civil Protection Order or No Contact Order served or issued against you?*

Yes

No

If yes, provide a detailed explanation with date(s).

4. Have you ever been involved in or arrested for any of the following:*

If yes, provide a detailed explanation with date(s).

5. Have you ever stolen anything or been the subject of an investigation dealing with the theft of anything? *

Yes

No

If yes, what was taken, what was the value, and when did this occur?

6. Have you ever purchased an item(s) that you knew or suspected was stolen? *

Yes

No

If yes, list item, quantity, value, and date of purchase.

7. Have you ever had a criminal warrant or a traffic warrant issued for your arrest? *

Yes

No

If yes, provide the charge, the date the warrant was issued, and date it was cleared.

8. Do you reside or associate with anyone (family or friends) who is or has been involved in, charged with, or convicted of a misdemeanor or felony? *

Yes

No

If yes, provide a detailed explanation.

9. Have you ever been placed on probation or parole? *

Yes

No

If yes, when, where, and for what offense?

10. Have you ever failed a polygraph examination? *

Yes

No

If yes, provide the location(s), dates(s), and reason(s).

11. Have you ever falsified:*

an Insurance Claim
an Income Tax Return
None of the Above

If yes, provide a detailed explanation with date(s).

12. Have you ever fraudulently misused a credit card or forged a check? *

Yes

No

If yes, provide a detailed explanation with date(s).

13. Have you ever collected unemployment, disability, or welfare benefits that you were not entitled to? *

Yes

No

If yes, provide a detail explanation with dates(s).

14. Have you ever, or are you currently involved in a civil lawsuit?*

Yes

No

If yes, provide a detailed explanation with date(s).

15. Has there ever been any situation in which you have been involved which may be incompatible with the duties of a certified police officer? *

Yes

No

If yes, provide a detailed explanation with date(s).

16. Has your driver's license ever been:*

If yes, provide a detailed explanation with date(s).

17. Have you ever been refused a driver’s license by any state?*

Yes

No

If yes, provide the state(s) name, date(s) and the circumstances.

18. Do you drink alcohol?*

Yes

No

If yes, how much and how frequent?

24. Have you ever had a drug or alcohol-related accident?*

Yes

No

If yes, provide a detailed explanation with date(s).

25. Have you ever been convicted or pled guilty to driving while under the influence of alcohol or drugs, or to lesser charges following a D.U.I. arrest? *

Yes

No

If yes, list the date of the arrest, the law enforcement agency involved, and the final disposition?

26. Have you or your spouse ever:*

Defaulted on a loan, debt, or obligation in the past five years?
Had your wages attached or garnished?
Been refused credit?
Had any collection or repossession action taken against you?
Filed a petition for bankruptcy?
Had a check bounce or returned for insufficient funds?
None of the Above

If yes, provide a detailed explanation with date(s).

Bankruptcy Discharge Records

if applicable

27. Do you have any issues or problems losing your temper or with anger management?*

Yes

No

If yes, provide an explanation.

28. Have you ever been involved in any domestic violence? *

Yes

No

If yes, provide a detailed explanation with date(s).

29. Have you ever ______________________ sexual battery, abuse, or harassment?*

If yes, provide a detailed explanation with date(s).

30. Do you have any issues or problems with honesty, reliability, integrity or moral character?*

Yes

No

If yes, provide an explanation.

31. Have you ever perjured yourself in a court of law?*

Yes

No

If yes, provide a detailed explanation with date(s).

32. Would you object to taking a polygraph screening?*

Yes

No

If yes, provide your objection.

33. Have you purposely omitted any information from your employment application? *

Yes

No

If yes, provide an explanation.

34. Have you ever worked for any law enforcement agency in any capacity? *

Yes

No

If yes, list the agency name, dates, job title, and status.

If yes, list the type of certificate, agency name, state, highest level attained, and date awarded.

36. Has any supervisor ever reprimanded you for being late or absent? *

Yes

No

If yes, provide a detailed explanation.

37. Has any supervisor ever reprimanded you for misconduct or not doing your job properly?*

Yes

No

If yes, provide a detailed explanation.

38. Have you ever been terminated during the probationary period from any employment?*

Yes

No

If yes, provide a detailed explanation.

39. Have you ever been suspended, fired, or asked to resign from any employment?*

Yes

No

If yes, provide a detailed explanation.

40. Have you ever quit a job without giving proper notice?*

Yes

No

If yes, provide a detailed explanation.

41. Have you ever been rejected for employment for any reason by any law enforcement agency? *

Yes

No

If yes, provide the agency name and reason.

42. Would contacting your current employer during the background investigation present a problem for you?*

Yes

No

If yes, provide an explanation.

43. Are you able to lift one hundred pounds?*

Yes
No

44. Have you ever attempted to enlist in any branch of the United States Armed Forces?*

Yes
No

This includes the Reserves, National Guard, or Coast Guard.

If yes, list which branch and the date you attempted enlistment.

45. Have you ever served in any branch of the United States Armed Forces? *

Yes
No

This includes the Reserves, National Guard, or Coast Guard.

If yes, list which branch, dates of services, highest rank held, and job title.

47. If you served in the military, were you

deployed in a combat zone?
in a military police position?

Provide details

48. As a member of the military have you ever been*

If yes, provide a detailed explanation with date(s).

49. Have you ever been convicted of a misdemeanor for any use or attempted use of physical force or threatened use of force against any individual with whom you were in a domestic relationship?*

Yes
No
Not Sure

This include a spouse, ex-spouse, cohabitant, parent, or child.

If yes, provide a detailed explanation with dates.

50. Have you obtained any form of legal relief or judicial finding of factual innocence from this conviction?*

Yes
No
N/A

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