1. No category

SampleApplications
Below you will find 5 differentemploymentapplicationsfor varioustypesof law
enforcementagenciesthroughoutNJ. Print andreview the applications.Altho,rgh
the applicationsdiffer, eachagencyaskssimilar questions.It would be highly
advisablein the spirit of practiceand futurepreparationto fully completethe first
application.In the applicationsthat follow, filI out anynew questionsthat you did
not answerin the first application.
By conductingthis "trial" process,you will learnthe lengthof time requiredto
completethis process.It is not uncommonto require8 - 12 hours,especiallyif you
haveto hunt for the information.
Hopefully,throughhavingthis "template"filed away in your records,when the
time arrivesfor you to completean official application,you will not be takenby
surpriseandthe informationwill be readilyavailable.
Additionally,review andpreparethe includeddocumentsthat you will haveto
supplywith an applicationin the book titled, "How To BecomeA NJ Police
Officer Or StateTrooper".You may find that you havemisplacedmany of them.It
is alsoadvisableto rnakemultiple copiesof eachdocument,clip themtogether,
and file them for the future.
GoodLuck!
POSITION
SOCIAL SECURITYNO.
BOROUGHOF I
POLICEDEPARTMENT
APPLICATION
FOR EMPLOYMENT
PzuNTNAME
LAST
FIRST
MIDDLE
MAILING ADDRESS Number& Streetor R.D Number
City or Town
County
State
Zip Code
-- Readeveryquestioncarefully.Answer every question
INSTRUCTIONS
leave no question unanswered-- if questiondoes not apply to you,
so state: DNA. A candidatewill be rejectedwho has intentionally
madea
falsestatementof a materialfact or practiced,or attemptedto practice,any
deceptionor fraud in this application,
in any examination,
or in securing
eligibility
for appointment.This candidate
preparethisform.
will personally
All entries,except the signature.must be printed legibly in BLOCK
LETTERS. Entriesmust be made in eitherblue or black ink. tf space
availablefor answeringany questionis insufficient,
use the continuation
pages includedand precedeeachanswerwiththe numberof the question
beinqanswered.
AN EQUAL OPPORTUNITYEMPLOYER
White (Male)
White (Female)
Black (Male)
Black (Female)
Hispanic (Male)
ATTACH
Hispanic (Female)
PHOTO
Asian (Male)
HERE
Asian (Female)
American Indian (Male)
American Indian (Female)
PersonalData
1. Whatis your full name?
Middle Name
First Name
Last Name
2. Give any other namesyou have usedor beenknown by, and attacha statement,giving reasons(if
none, so state)
3. Where were you born?
ZipCode
State/Countrv
City/Town
4. Birth Certificate
Number
Weight
6 . Social SecuritvNumber:
7 . Do you wear contact lensesor glasses?Yes or No
8 . Home TelephoneNumber:
Country
Sex
Age
5. Date of Birth
Height
Zip Code
City/Town
Hair
Eyes
StateIssued:
Citrzenship
9. Are you a native born or naturalized cittzen?
Native Born
Naturalized
If you areof foreignbirth, or area naturalizedcitizen,fill in the following:
Countrvof birth
Port of place of departurefor the United States
Date
prane,
How were you transported into the United States?(Ship,
rrain,etc.)
Name of transportconveyanceand or companyyou arrived on
Portor placeof entryinto the UnitedStates
Date
lf a naturalizedcitizen, name and addressof personwho sponseredyou on arrival
First addressafter arival
How did you obtain citizenship?
PetitionNumber
State
Court
Date
CertificateNumber
SocialStatus
1 0 .Are you single,married,separated,divorced,widowed, or widowered?
n. Give following informationregardingmarriageor marriages.List numberof times married:
When
Where
By Whom
Wifes MaidenName
or HusbandsName
12.lf separated,
statereason
1 3 .If separatedor divorced, what is the presentaddressof that person?
1 4 .How many times were you legally or voluntarily separated?
1 5 .Were you ever divorced or had a marriageannulled?
How many times
1 6 .If ever separated,annulled,or divorced,indicatewhich below, and fill in requiredinformation:
Separated,
Annulled,
Divorced (Indicate)
By Whom
Where Issued
(Court and State)
OffendingPartyas
Decreedby Law
17. Where you ever the parent of any children, whether alive or deceased?Yes or No
18.List below every child born to you:
Name
Date of
Birth
Placeof Birth
With WhomandWhereDoes
ChildReside
19.Are you now supportingall children born to you, including adopted,and stepchildren?
If no, statefull details
20.Have you ever beeninvolved as a plaintiff or defendantin a paternityproceeding?
If yes, statefull details
2l.If single,list name,etc., (of at leastone) girlfriend/boyfriend,pastor present:
Name (Relationship)
Full Dateof Birth
Fulf Address (lnclude ZipCode)
SocialSecurity
Number
Name (Relationship)
tull Date oI tsrrth
Nameof Business/Employer
Occupation and Work Phone No.
Home PhoneNo.
Nameof Business/Employer Occupationand Work PhoneNo.
Home PhoneNo.
Full Address(lncludeZip Code)
Social Security
Number
22. Fantily information - Father,mother, brothers/sisters,spouse,stepfather/stepmother:
Name (Relationship)
Full Dateof Birth
Fuff Address(lncludeZip Code)
soclal secunty
Number
Name (Relationship)
Full Date of Birth
Occupation and Work PhoneNo.
Home PhoneNo.
Occupation and Work PhoneNo.
Home PhoneNo.
Full Address(lncludeZip Code)
Social Security
Number
Name (Relationship)
Full Date of Birth
Name of Business/Emolover
Name of BusinesslEmployer
Full Address(lncludeZip Code)
Socral Secunty
Number
Name of BusinesslEmployer
Occupation and Work PhoneNo.
Home PhoneNo.
Name (Relationship)
Full Date of Birth
Full Address(lnclude ZipCode)
Social Security
Number
Name (Relationship)
Full Date of Birth
SocialSecurity
Number
soclal secunty
Number
Nameof Business/Employer
Occupationand Work PhoneNo.
Home PhoneNo.
Name of Business/Employer
Occupation and Work PhoneNo.
Home PhoneNo.
Occupationand Work PhoneNo.
Home PhoneNo.
Occupation and Work PhoneNo
Home PhoneNo.
Full Address(lncludeZip Code)
soclal secunty
Number
Name (Relationship)
Full Date of Birth
Home PhoneNo.
Fufl Address (lnclude Zip Code)
Name (Relationship)
Full Date ol tslrth
Occupation and Work PhoneNo.
Full Address(lncludeZip Code)
Name (Relationship)
Full Date of Birth
Name of Brlsiness/Employer
Name of Business/Employer
Full Address(lncludeZip Code)
Social Security
Number
Name of Business/Employer
23. List namesof threefriends and or associates
otherthan vouchers:
Name (Relationship)
Full Date of Birth
F u l l A d d r e s s( l n c l u d eZ i p C o d e )
SocialSecurity
Number
Name (Relationship)
Full Date of Birth
Occupationand Work PhoneNo.
Home PhoneNo.
Occupation and Work Phone No.
Home PhoneNo.
Occupation and Work PhoneNo.
Home PhoneNo.
Full Address(lncludeZip Code)
Social Security
Number
Name (Relationship)
Full Date of Birth
Nameof Business/Emolover
Name of Business/Emnlover
Full Address (lnclude Zip Code)
Soclal Secunty
Number
Name of Business/Employer
List namesof membersof the I
Acquaintedwith:
Name
Police Departmentwhich you are socially or personally
Address(if known) or Department
BadgeNo.
Social/Personal
BadgeNo.
Relationship
List namesof any relativesin the law enforcementfield:
Name
Address(if known) or Department
Residence
24.Wheredo you now reside?
PhoneNo.
Number & Street
County
City
State
25. How long have you residedthere?
Floor No.
(Check)
ApartmentNo._
North
Zip Code
With whomdo you reside?
Front
South
Rear
West
26.rf you live with someone
otherthanspouseor parentslist:
Name
Date of Birth
Occupation
Social Security Number
27.In chronologicalorder (startingwith most recent),stateeachand everyplace in which you have
residedsincebirth.
From
Mo.
Year
To
Mo.
Year
Address(Street,Apt., City, State,Zip Code)
or voted(if none,so sfifly;
28.List all placeswhereyou registered
County
County
Year
State
State
Year
Education
29.List chronologically(mostrecentfirst) all schools,collegesandtrainingcoursesyou haveattended:
Exact Address
Zip Code
To
From
Month
Month
Year
Year
Day or Evening
Exact Address
Last Grade or Term
Zip Code
To
From
Month
Month
Year
Year
Day or Evening
Exact Address
Last Grade or Term
Zip Code
To
From
Month
Month
Year
Ye ar
Day or Evening
Exact Address
School
Last Grade or Term
Zip Code
To
From
Month
Year
Month
Year
Day or [:vening
Exact Address
School
L.astGrade or Term
Zip Code
To
From
Month
Year
Month
Year
Day or Evening
Exact Address
Last Grade or Term
Zip Code
To
From
Month
Year
Month
Year
Day or Evening
30. What collegedegree(s)or professionallicense(s)do you possess?
Majoring in
Total credits achievedtoward degree
31. Other than englishwhat language(s)do you:
Speak
Understand
Gradepoint average(cummulative)
LastGradeor Term
32-List anyproblemswith school(absenteeism,
tardiness,
poorgrades,otherdisciplineproblems)includecollege.
Date
School
Problem
33. It is understood
that I will immediatelyhaveforwardedtranscriptsfrom all collegesattended
to:
. All necessary
feesmust be
fonvardedto thqcollegeby the applicant.
Mititary Service
34. Have you ever servedin an active military organizationof the United States? Yes orNo
35. Have you ever servedin a military organrzattonofany foreign government?Yes or No
If yes, give details
36. Give branchof service
Military Specialty
37. Rank held
ServiceSerialNumber
38' How manyperiodsof activemilitary servicehaveyou had(drafts,enlistments
or recallsto service)?
39. How many dischargesor separationsfrom the servicewere given to you?
40. Give period or periodsof active service:
From
To
From
To
From
To
From
To
41. List all medalsand decorationsawardedyou as a memberof the armedforces:
42. What type of discharge(s)or separation(s)
(hororable,dishonorable,honorableconditions)
Be exact.
43. Has your dischargeor separationnotice ever beencorrectedor changed?Yes or No
44. What was the nature of the change? Changedfrom
to
45. were you evercourtmartialed,tried on charges,
or wereyou the subjectofa summarycourt,deck
court, captain'smast,companypunishment,or any other disciplinaryaction?
Yes or No
Numberof times
If yes, give detailsof chargesand dispositions
46. Are you now or wereyou everan activeor inactivememberofthe ReserveForces(anybranch)of
theUnitedStates,any foreigngovernment,
or theNationalGuardofany state?
If yes, statewhich - activeor inactive
Yes or No
Branch
Regiment
Unit
Address
Rank
From
To
SelectiveService
47. SelectiveServiceNumber
Last Classification
Employment
48. Present
Employer:
Name/Company
Date hired
Number & Street
Ciry/Town
Statelzip
phone No
Supervisor
Duties
49. Are you now engagedin any businessas an owner (activeor silent),partner,stockholder,or
corporatemember?
Yes or No
If yes,give details
50. Hasyour nameeverbeensubmittedor usedasa trustee,officer,or in any capacity,or any laboror
trade union, organrzationor affiliate? Yes or No
If yes,give details
51. Using the chart on the following pagelist chronologically most recentdatesfirst, eachand every
placeyou were previouslyemployed: Omit none. Give correct, full addresses.Give datesof
idlenessbetweenperiod of employmentin propersequence.(includeall part-timeemployment.)
From
MolYr
To
Mo
Yr
Name. Address and PhoneNumber of
Employer (lnclude Zip Codesand Area Codes)
Occupation
Immediate
Supervisor
Reasonfor
Leaving
52. Were you ever dischargedor askedto resignfrom employment?Yes or No
How many times?
Give detailsof dischargeor forcedresignations(include
employer'sfull address,phonenumber,dateof occurance,supervisorsname,and the reasonfor the
discharge)
53. Were you ever subjectedto disciplinaryactionin connectionwith any employment?
lf yes,givedetails
Yesor No
54.Haveyou,yorrrspouse,or any corporationor partnership
of whichhe/shewasan offrcer,director,or
partner,everpossessed
a licenseor permit(excludingdriver'slicenseor leamer'spermit)issuedby
any governmentalagency? Yes or No
If yes,give details
Has any such licenseor permit ever beenrevoked,cancelledor suspended?Yes or No
Iffes, give details
55. Haveyou eversponsored,
vouchedfor, servedascharacter
witnessfor, or madeany
recommendations
for or conceminganypersonor premisesto anymunicipal,stateor federalagency
in connectionwith the issuance,
revocation,or suspension
ofany licenseor permitor for anyother
reason?Yes or No
If yes,give details
56. Have you ever receivedunemploymentinsuranceor other federal,stateor local benefitsor
assistance?Yes or No
Kind
Local office
Address
Give periods:
From
From
To
From
To
To
From
To
Have you ever receivedany allowanceto which you were not entitled? Yes or No
If yes,explain
57. Have you made application with any other police organization?Yes or No
when, where and the presentstatusof that application
l0
If yes. list
58. Have you ever been rejectedby anotherpolice departmentfor employment? Yes or No
If yes, list when, where and why
59.Wereyou evera memberof a social,labor,or fratemalorganization?Yesor No _
list beloweverysuchorganization.
If yes,
To
From
Mol"'
MolYt
Name& Full Addressof Organization
Type of Organization
General
60. Have you ever petitioned for bankruptcy? Yes or No
wageassignment,
lien,or judgmentpendingagainstyou? Yes
61. Haveyou any loan,debt,gamishee,
If yes,givedetails
or No
Type: Loan, credit card,
garnishee,judgment, etc.
W i t h w h o m : N a m e F u l l A d d r e s s& P h o n e
When
Original
Present
Monthly
Number includingareecode
lncurred
Amount
Amount
Peyments
62. Are you a co-maker on an outstandingloan? Yes or No
63. Have you ever beenbonded? Yes or No
Amount
of Arreers
If yes, give details
With respectto eachtime bonded,state
detailsbelow:
Reason
By Whom - Name, Addressand PhoneNumber
64.Have vou ever beenrefuseda bond? Yes or No
Date
lf yes, by whom
65. Wereyou or your spouseeversummoned
or subpoenaed
to courtin a civil actionor proceeding
in
this stateor elsewhere.
or couldsucha possibiliwensueasa resultofa recentoccurrence
or
ll
Indicatebelow everT civil action or proceedingin which
transaction? Yes or No
you or your spousewere a party and also the contingentpossibilitiesas describedabove.
Action or Proceedins
Date
As Plaintiff, Defendant,
Petioner,Respondentor Witness
CourtDisposition
Etc.
ArrestsoSummonseso
66. Have you ever beenarrestedfor or chargedwith JuvenileDelinquency?Yes or No
If yes, insertinformationbelow:
Date
Age
Violation
Actual Charge
Location
Charge
Court Disposition
PoliceAgency
ReducedTo
of Sentence
Concerned
or otherwiserequiredto testiff beforeany
requested
subpoenaed,
67. Have you ever been summoned,
municipal,state,or federalagency,committeeor other investigativebody? Yes or No
If yes,give details:
68. Have you everreceiveda summonsfor any violationof the fish and gamelaws? Yes or No
If yes, insertinformation below.
Date Age
Violation
ActualCharge
Location
Charge
ReducedTo
CourtDisposition PoliceAgency
of Sentence
Concerned
69. Have you ever beenarrestedfor, or chargedwith, a violation of the disorderlypersonsact or city
If yes, insertinformationbelow.
ordinance?Yes or No
Date
Age
Violation
Actual Charge
Location
Charge
ReducedTo
t2
CourtDisposition PoliceAgency
of Sentence
Concerned
70. Have you everbeenarested,indicted,or convictedfor any violation of the criminal law? Yes or No _
Have you ever had any criminal record expunged? Yes or No
answerto either question is yes, insert information below:
Date Age
Violation
ActualCharge
Charge
Reduced
To
Location
If the
CourtDisposition
of Sentence
71. Have you ever beenheld as a materialwitness? Yes or No
PoliceAgency
Concerned
If yes, insertinformation
below.
Date Age
Reason
Location
Disposition
PoliceAgency
Concerned
72. Haveyou everbeenheldasa suspicious
personor investigated
by any law enforcement
or private
securityagencyfor any reason?Yes or No
Date Age
Reason
If yes, insertinformationbelow.
Location
Disposition
73.Have you ever beenfingerprinted? (Excludeonly presentapplicationwith the
Department)? Yes or No
When
If yes,fill in the following:
Where
Purpose
l3
PoliceAgency
Concerned
Police
SubversiveAffiliations
or other
74.Are you now, or haveyou everbeen,a memberof anyCommunist,Communist-front,
subversiveorgarizztion,association,movement,or group,which advocatesthe overthrowof our
constitutionalform of govemment,or which seeksto alter the form of govemmentof the United
or unlanfirl means?Yesor No
Statesby unconstitutional
with anyofthe organizations
or groups
75. Are you now, or haveyou everbeen,affiliatedor associated
describedin question74? Yes or No with, any individuals,includingrelatives,
with, or haveyou everassociated
76.Are you now associating
who you know or havereasonto believeare,or havebeen,membersofany organizationor groups
describedin question74? Yesor No
or issuedby anyorganization
77. Haveyou eversignedor solicitedothersto signanypetitionsponsored
or groupdescribedin question74,or anypetitionwhichhasasits purposethe iadingofany person,
or groupsdescribedin question74? Yes
causeor programcornectedin anyway with organizations
or No
78. Haveyou everparticipatedin any of thefollowingactivities:
affair,forum,
demonstration,
a. Attendanceor participationin anyparade,picketline,delegation,
or groupdescribedin question74? Yes
or organizedby anyorganization
or project,sponsered
or No
or
b. Paymentor collectionor any money,dues,contributions,or donationsto any organrz:ttion
groupdescribedin question74? Yes or No
c. Saleor distributionof an,vwritten or printedmatterprepared.reproduced,or publishedby any
groupor organizationdescribedin question74 , or any of it's agents?Yes or No
or publishedby
or subscribedto any publicationor periodicalprepared,reproduced.
d. Purchased
any group or organnationdescribedin question74 or any or it's agents?Yes or No
explain
79.lfyour answeris YES to any of the abovequestions,,
t4
Motor VehicleHistory
80. Have you ever receiveda summonsfor violation of the Motor Vehicle Laws in this or any other
If Yes.insertinformationbelow.
state?Yesor No
Date Age
Violation
Location
Actual Charge
Charge
ReducedTo
CourtDisposition
of Sentence
PoliceAgency
Concerned
81.Wasyour Motor VehicleRegistrationCertificate,Driver'sor othervehicleoperator'slicenseever
revoked? Yes or No
Suspended?Yes or No
Whichlicense?
'dlhy?
When?
Where?
Certificateor Driver's Licenseever
82.If answerto previousquestionis "Yes", wassuchRegistration
Where?
When?
restored?Yesor No
83. Have you ever beeninvolved in a motor vehicleaccidenteitheras a registeredowner or operator
If Yes. state
which resultedin any personalinjury or propertydamage?Yes or No
details
84. If you possessany of the following, completethe informationbelow:
Date
Issued Expires
Date
Item
Number
State
PlateNumber
Year/MakeModel/Color
PlateNumber
Year/MakeModel/Color
MotorVehicle
Driver'sLicense
Number
Restriction
Code
Operator'sLicense
Number
Explain
Motor Vehicle
Registration
SecondMotor
Vehicle Registration
Anv Other Vehicle
l5
85.Did you everpossess
a chauffeur'sor commercialdriver'slicense(CDL) or operator'slicenseissued
by any stateother than New Jersey? Yes or No
lf yes, give stateand number
Other Information
86. Haveyou everpossessed
any pistol,firearmpermit,firearmsID card,firearmsdealerlicensein this
state,any other state/federal?Yes or No
Permit Number
FirearmsDealer'sLicenseNumber
IssuingAgency
87. Have you ever usedany illegal drugs? Yes or No
If yes, statedetails
88.Haveyou everpreviouslytakenan examinationfor appointment
to the
Yes or No
PoliceDepartment?
If yes, list date(s)of written examination
Has a backgroundinvestigationever beenconductedon you by the
PoliceDepartment?Yes
or No
89.Do you haveany knowledgeor informationin additionto that specificallycalledfor in thepreceding
questionswhich is or which may be relevant,directlyor indirectly,in connectionwith an
investigationofyour eligibility andqualificationsfor thepositionofPolice Officerin the
PoliceDepartment,
includingbut not limitedto, knowledgeor informationconcemingyour
character,
temperance,
habits,education,subversive
activities,family,association,
criminalrecords,
trafic violations.residenceor otherwise?Yes or No
l6
If yes,give details
Vouchers
POLICEDEPARTMENTOR
(NOT TOBE SWORNMEMBERSOF THE
ANY OTHER PERSONLISTED IN THISAPPLICATION)
Uponcompletionof this form, the applicantmustobtainthreereputablecitizens(no relatives)who will
vouchfor thehonesty,reputationandability ofthe applicant.
The vouchershouldreadcarefully all statementsmadeby the applicantBefore Signing. Then,the
voucherportion of the form shouldbe comPletedbYthe voucherandsignatureafixed'
I, the undersigned,declarelhat I am over eighteenyearc of age,that I havepersonally known the
applicantfor at leost oneyea\ that I have read the whole of theforegoing application and believeall
the statementsherein to be true, I am not related in any way to the applicanl I will, upon rcquest,
givefurther facts concerning the applicant asI may possess.
ALL INFORMATION WILL BE TREATED AS CONFIDENTIAL
VOUCHERONE
(PleasePrint)
Name
AreaCode& PhoneNo.
Address.
Business
Address
City, State,Zip Code
Occupation
PhoneNo. (Area Code)
How long haveyou personallyknown the applicant?
Date of Birth
Is applicantof good characterand reputation?
SocialSecuriryNumber
Signature& Date
VOUCHERTWO
( P l e a s cP r i n t )
Name
BusinessAddress.Area Code& PhoneNo.
Address
City, State,Zip Code
Occupation
PhoneNo. (Area Code)
How long have you personallyknown the applicant?
Date of Birth
Is applicantof good characterand reputation?
SocialSecurity Number
Signature& Date
VOUCHER THREE
(PleasePrint)
Name
BusinessAddress.Area Code & PhoneNo.
Address
City, State,Zip Code
Occupation
PhoneNo. (Area Code)
How long have you personallyknown the applicant?
Date of Birth
Is applicantof good characterand reputation?
Social Security Number
Signature& Date
t7
Certification
I certifr that all ofthe the statementsmadein this applicationaretrue, completeandcorrectto the best
of
of my knowledgeand belief, and aremadein goodfaith. I am awarethat any misrepresentation
from the selectionprocess.Further,I
informationsupliedby me will resultin my disqualification
Police Departmentto verifr any andall informationcontainedhereinandto review
authorizethe
my employment,education,financial andcriminal history, military, disciplinary andother recordsand
information from any sourceasnotedin the dult executedAuthority andReleaseForm.
andasreetheconditionsimposedherein.
I havereadthis CertificationandI understand
Signature:
Date:
(Sign in Ink)
(Print Name)
Stateof:
County of:
beforeme this
Swornto andsubscribed
l9
Day of
(Print Name and Title)
Signature (Sign in Ink)
NotaryPublic,my Commission
Expires:
DO NOT WRITE BELOW THIS LINE
Signatureof applicantmadein presence
of investigator
Date
Signatureof InvestigatingOfficer
l8
ContinuationPage
l9
ContinuationPage
20
I}OROU(;II OI.
, NEI!'JI'RSIiT'
O F F I C E O T C H I E F O I . -P O I , I C E
SELECTIVE
PROBATIONDEPARTMENTS,
TO ALL COUR.TS,
SERVICEBOARDS,HOSPITAL,AND OTF{ERNSTITUTIONSAND
AGENCIES,WITFIOUTEXCEPTION:
, arnmaliing applicationfor
As a resuit,an investigationin beingconductedto determinemy eligibility. Therefore,you
areauthorizedto releaseto thr
any and all
PoliceDepartmentor its representative
information,documentaryor otherwise,pertainingto me that they require.
A photostaticcopy of this authorizationwill be consideredas effectiveand valid as the original.
DATE:
SIGNATURE:
WITNESS:
End Of An Application
Next Page,
BeginsAnother
APPLICATTON TNSTRUCTIONS
PLEASE READ CAREFTJLLY
Beforeconsideringany individualfor law enforcement
employmentwith the Ner,v
,, certaininformationis requiredto be disclosedby the applicant.
The applicatio,.must be completedand submittedwith all questions
answeredand with copiesof "Pertinentl)ocumentation"on
The informationthat you provideis subjectto verificationthroughinterviews
via public and otherrecordspertainingto
with personsiisted,as well as conf,trmation
yor-rrfile.
for obtainingcorrectaddresses,
whereindicatedin the
You areresponsible
applicationform, as well as any otherinforrnationlistedby you.
An accurateand completeapplicationwill help expeditethe investigationprocess,
and your completedcooperationis essentialto the successful
outcomeof the
investigation.
Shouldyou at any time havequestionsregardingyour application,you shouldfeel
Law Enforcementor the "CaseInvestigator"
freeto contact
, Chief
you.
who will be assignedto
You will be requiredto deliveryour completedapplication,in person,on
, between10:00amand 1:00prnat th'
WARNING
ANY OMISSIONS, FALSIFICATIONS OR INTENTIONAL FAILURES TO
DISCLOSE MANDATORY INFORMATION BY YOU, WILL RESULT IN YOUR
REMOVAL FROM FURTHtrR EMPLOYMENT CONSIDERATION.
FAILURE TO PROVIDE COPIES OF PERTINEI\T DOCUMENTATION WILL
FROM
RESULT IN YOUR REMOVAL
FURTHER EMPLOYMENT
CONSIDERATION.
LOplesreqLllreo
(rf ArrLtLAuLl,)
l.
SocialSecurityCard
2.
Birth Certificate(includelegalnamechange)
3.
W-2 for 2002 and 2003 (State& Federal)
4.
Tax Returns(State& Federal)for 2002and 2003. Telefile worksheetsare
acceptablefor StateTax Returns
5.
Marriagecertificateor divorcedecree
6.
Unemploymentrecords
7.
New JerseyDriversLicense
8.
Vehicle Registration(s)A copy of eachvehicleregisteredto you must be
provided
9.
Motor Vehicle InsuranceCard(s)
10.
Copy of Motor VehicleAccidentReports(if applicable)
1l.
DD-214 (Military DischargePapers)
12.
High Schooldiplomaor GED certifications
13.
Collegedegreeand transcript(if applicable)
14.
Judgements,
Liens, andExpungementOrder and othercourt actions(i.e.
RestrainingOrders in NJ and other states)
15.
Landlord affidavit, a propertydeed/taxreceipt or rental agreement.(If
properly is not listed in your namepleasesubmit a written statementfrom
the person(s)with whom you resideand their relationshipto you.
16.
Two (2) ReleaseAuthorizationForms
17.
One (i) FirearmRestrictionForm
18.
Any documentsthat you feel would be benefitto the investigator(i.e.
specializedtraining,awards,citations)
TF{E FOLLOWING DOCTIMENTS WILL BE OPTAINED BY THE INVESTIGATOR:
l.
2.
3.
4.
New JerseyCriminal History Check
FederalCriminal History Check
New Jersey(DIvfV) Drivers History Abstract
CreditProfile
IMPOI{IANT
will result in the
Failure to answerany question listed in this application completcly and uuthfirlly
neccessary'
revocation ofyour eligibitry for emplofment' Anach additional pagesas
place a photograph that was tatr<enwithin dre past yezr.
Name:
Rcviscd5.00
PE,RSONALDATA
TO BE FILLED IN COMPLETELY
1. Nam e:
Middle tnidat
First
Last
2. Address:
3. Date ot birth:
Mondr/DayYar
)
Placeof birth:-
-
4. Social SecuriryNumber:
Sex:
Alias:
Veight:
5. Height:
Race:
Eye Color:
6. Hair Color:-
g. Scars,Marks, Tltoos (for identification PurPosesonly):
'
9. N.l. Drivers License#t
one):
10. U.S Citizen(check
$
l*
O no
RESIDE.NCE,
11. Address:
12. How long have you residedtfiere?
13. \fifi
whom do you reside?
14. Home Telepirone#
Work Telephonc #
15. If you reside with someone other than sPouse or Parent , [ist:
Namc
Social SccuritY #
Ro'iscd 5.00
Datc of Birdr
Occupation
Addrcss o[ Employcr
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I 8. DISCIPLINARY ACTIONS:
for improper
Have you sver been disciplin.d bJ any employer, educational or military establishment
conduct? (check one) Cl Yo il tto
If yes,explain:
or any written or verbal
19. Have you ever received any lessthan satisfactory performancc notices
tto
,.pri-"r,ds in any currenr or previous emptoymenc (chcck one) il yo fJ
lFyo, explain:
jurisdiction for a position in law cnforccment, induding shcriffs officcr'
20. Have you wer applicd in any'iitles
and Sccurity Positions? (indude D.O.P examsthat were taken)
C,o.re'ctio.rspo.iti^on., police
\/
(checkotte)fl ycs I no
If yes,supply the following information:
a. Date ofapplicadon
c. Dirpo.itiin (Hired./Denied)
Rcviscd5.00
b' Positionappliedfor
d' Rcasonfor Denial
ARRESTHISTORY
'DETAINING", 'HOLDING"'
-21. For thc purposesof this question, the word aRREST" indudes any
agency-of a
orlThI{N'G INTO CUSTODY, by'POLICE oranyother'lA'w'ENFORCEMENT"
in tlis or any other
p...oo i., ord.. ,o answcrfor dre allegcdperformanceof any othcr'oFFENSE",
state,or foreigncountrY.
Thcword.CFIARGE"includesany.INDICTMENT",.coMPt^AINT",.sUMMoNs",
or othcr noticc of thc allged commission of any IOFFENSE" in this or any other
"INFORMAilON.,
state or foreign countrY.
Thc word'OFFENSE", includesall'HIGH MISDEMEANORS"''FEi'ONIES"'
.MISDEMEANORS", .DISORDERLY PERSONSOFFENSF.S",OTANY.CRIMINAL STAI'TJTE"'
This appliesto the
1i.J i. N* 1.ocy Codc 2C. This indudes any and all ]uvcnile" violationscriminal statuics in any other statcof forcign country aswdl'
wi*r any felony'.crime'
22. Havc you cver beenarrcstedor charged,EVEN IF NOT CONVICTED'
(including traffic violations) in
^isd.-."rro., disordcrly personso6*", o. ",,y otlrer offense,
fl yo 0 tto
&c. (checkonc)
N.* J..r.y o.
"o1*h.."
Ifyes, cxplain, completc the following tablc, and list whcthcr ercpungedor not?
22.(A) lf answer is yes,completethe followingtable:
Natureof
Chargeof Anest
Namcof Agenqor CounInvolved
wi*r Datc
o[C-asc
Disposition
your disclosure.
NOTE: you wi[[ be requiredto supply fie propcr court documentation widr
I{cviscd 5.00
by *y kgislativc, Grand J.try, or other official
23.Haveyou sverbecn calledto testify before , or investigated
criminal activicy-fl yo f] tto
investigative body whcn that body is cngagedin thc investig"tion of
Datc
Natu re of Inves tig-etio n
NemcofAgcncy
and/orowned'byyou andyour sPouse'
24. Complete-thefollowingublc{orali motor vehidescurrentlyregistered
Ycer
Makc
rnd Modd
Uccnsc Numbcr
and Satc
Rcgistered Ovrnc(s)
Expiration of
Registration
any other jurisdiction by completing
25. List all moter vehiclc &iver licrnses issuedro you by *ris statc or
thc following:
Detc
Issuod
Rcviscd 5.00
Liccnsc Numbcr
Typc ofUccosc
Jurisdictio n Issuing Liccnsc
F-pintion
Datc
26. Have you cverhad any license,perrrit, or vehicleregistrationdenied,suspendcd,
or revokedby agy,
agency,including thc Division of l:ish & \?ildlile, in New Jerseyor any other State.
O y-X
"o
Ifyes, plcasecompletethe following table:
Tlpc of Uccnsc Pcrmit, Ccnificacc
Datc oJ-l)cnial,
Susp.'rrsion
Rcason(s)Dcnial, Suspcruion'
27. List all motor vehicle moving violations, parking violations, and Division oFFish 6a \Tildlfe violations
tlat you have bcen issueda summons for. (Include D.!7.I. Offenses) [1 (check if no violations)
Datc
Summons Issued
Violation
Ag"n.y
l s s u i n gS u m m o n s
Name and Addrcssof Municipd Court
28. Did you grad.uatefrom High School,or possessa G.E.D. Cenificate?
Month/Year
-
Higest Grade Complcted
29. Name and location oF High Scliool's attendcd, (.iqF and state)
VU/
Il.cviscd5.00
l0
re-
Hr*
r/-
.O .ro
30. College:
Drtcs
Ancndcd
Gceduatcd
Dcgrcc/Major
Namc undAddrcs of C.ollcgc
Numbcr
of Crcdits
31. Graduate school or [,aw school:
Datcs
Amcnded
i
'
'
Graduatcd
Degree/Major
Name end M&css of C,ollcgc
Number
oICredics
32. O&cr schools or training (ie trede, vocation, armed forces,or busincss),plcascgive namc and location,
i.duding city, statc, and zip codc oFschools actended, subjects stu&ed, nurnber of class hours of
irutruction, ccrtificaccs and any otler pertincnt data:
Rcviscd5.00
1l
MILITARY
33. Have you cvcr scrvedin any militarygrgar\iytiqn of the United Sates or becnan active mcmber of tle
.o.*. fo..esof theUnitedStat*?fr ra{
""
If yes, thcn provide the information below:
Branch of service and highest rank held
Periods of :-ctive service:
To:
Frop
To:
Frorru
To:
From:
Periods of active servicc:
To:
From:
34.'Whar qfpe of dischargeor separationfrom military servicedid you receive?
deck, captains mast,
35. !?'cre you cver court ma.nialed,tried on charges,or thc subject ofa sumnury court
in
the
military
service?
while
action
company punishment, or rle subjeo of eny other disciplinary
If yes, give details of the charges and their disposidon:
Rcviscd 5.00
t2
SERVICE,
SE.LE,CTTVE,
36. How many selectiveserviceclassificationsha.,eyou had?
37 . Have you registeredwith the selectiveservice
- F y.t f] .,o
lFno, state reason:
2a
(olo-i.'o
J(r.-rJvruv(lvv
S o ^ r iv - l-w
vvl
#r ,
Local Board:
Address:
Rcviscd 5.00
l3
SOCIALSTAIUS
All applicantsmust givecompleteinformationconcerningthcir rcletives.If you havcbeenmarried more
,-1"t oi L, gr.,,.th. ,e{u.sted information conccrning eachspouse. If you havc s!? Pefnts, -legalguardians
o. o,h.., *f,o havc rearedyou insteadofparena, thc rcqucstcd information should bc furnishcd concctning
them, aswell asyo* ,..1 irt nt. If you are engagedto be married or contcmplating marriage in thc future,
comolcte information must be includcd regardingyou future spousc- Also, list all mcmbersof your
household, including thosc who arc not rclated to you'
39. Marital Starus,
f,fi Singte
f, M"tti.d
Datc of Marrage
Your Maiden Na-me
fl widowed
il Di.rorced il sepa.ated Placeof Divorce
(no initials), and maiden narne' date of
39(A). Give complete narne of spouseinduding rniddle narne,
bifth, social s.c*iry number and complete ad&ess.
40. List below every child born to you:
Name
Date-of Bifth
Placeof Binh
Where and widr Whom does child reside
41. Are you supponingany ctrildrcn,born to you, adoprcdby you, or stcpchildrcnby marriagc? fl yes o no
If yes, give name and eges:
Rcviscd5.00
t4
pmcceding?fl y'
42. Have you cverbeeninvolvedaseit}lera'Ptainti{F or'Defendent' in a Patemity
X"o
Ifyes, give fi.rll details:
43.Ifsingle, list na-meof any persons you are prescntly seeing.
Name
DOB/SS#
Address
Occupxti..
Phone
and spouse(maiden name)'
44. Givethe name of your father, mother (maiden name), sisters,brothers,
(Include step-parentsand family; if deceased,pleaseindicate)
Name
Address
Relationship
Occupation
Phone
other dran references'
45. List the names of at least three (3) peopte, who are friends or associates,
Name
DOB/SS#
Address
Occupation
Pllone
with, who are
46. Lisr thc names oF any police officer that you personally or socially are acquainted
employed widrin fie Stateof New Jersey'
Name
Ag"t.y
Home
Ra*
Address
Rcviscd 5.00
l5
Phone
Ycars Known
FINANCIAL HISTORY
for:
47. What is the presenr amount of yearly income or wages
Your Spouse $
Yourself $
occupation?
4g. Do you earn add.itional income from any source, besidesyotrr present
il yo fl
tto
If yes, list source and amount earned:
49. Do you owrl real estate?
F Yo E tto
If yes, give the location and value of said ProPergn
.Bank
name, or that you have legal
Accounts", and'Safery Deposit Boxcs', tlat are cither in your
50. List all
accessto:
NameorBank
H;i
)ffiT$:::H'
51 . Havc you ever been bonded?
E yo f, tto
Ifyes, list below each time you were bonded:
rcason
by whom
reason
by whom
rcason
by whom
Rcviscd 5.00
16
t::iH;..
52. H*eyou
-\
sver been refi'rseda bond?
E yo d to
If yes, list bY whom:
loan from a goverrlment or private agency?
53. Havc yotr c1/erreceived a student
If yes, give details:
loan?
54- Did,you default on a stud'ent
I
yo ffi to
If yes, give details:
loan?
55. Areyou a co-signer on an ouatand'ing
& yo B tto
If yes, give details:
Rcviscd 5.00
r7
El yo 4 oo
>.:
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57. Areyou up.to dateon all payments?
E y"s El no
If no, pleasegive details:
58. Have you cver been adjudicaqcd a bankrupt, or filed a petition for any rFpe of banlauprry
or insolvency?
E yo K to
If yes, provide the following details:
Date
Fited
Dockct
Number
Name and Ad&css
of C-oun
Name and Address
of Filing P*ry
59. Are all tax payments to be made by you current? ff yo W rro
If no, pleaseexplain:
a
Rcviscd5.00
l9
Name of
Tiustee
OTHERINFORMAIION
or owri annpistol, firearms,frearms l.D. card,or firearmsdealerslicense,in this stateor
60. Do you possess
ff Yo Ef tto
any other state?
Ifyes, pleaselist type and issuingagencyalongwith completedescriptionof fireerms:
61. Do you use or havc you sver used i["g"] drugs or narcotics?
Fy*
ffitto
If yes, give full details and amounts:
62. Do you have any knowledge or information inaddition to that specifrcally called for in r}re preceeding
questions *rat is or may be relevant, direcdy or indirecdy in connection with an investigation oF
your eligibility and fitness for this position, including but not limited to, knowledge or information
.o.,-.^irrg yo.r. character,for exemple: rcmpcrencc, habia, employment, education, subvcrsive
activities, family, associatcs,criminal records,traffic violations, residence,or etc'?
Give dctails:
I certi$ r.[1atthe information on rhis application is complcte and accuratc,to rhe best of my knowledge. I
understand that any omissions,falsificationsor intentional hilurcs to discloseman&tory information could
resuft in my rcmoval ftom furthcr cmploymcnt considcration or if employed, bc just causefor tcrmination.
Datc
Signa
I{cviscd 5.00
20
End Of An Application
Next Pag€,
BeginsAnother
L1
POSIIIOI.I
CITYOF
POTICEDEPARTM-ENT
APPLIC IONFOP::I.MPTOYMENT
PRINI' NANltl
lvlAlUNG ADt)llllSS
Nrrrnber& Streel or R.D- nurnber
Courrty
Slate
7-ip CcrJe
HOMETEL-LPI
I()T{I:I'IO
INSTRUCTIONS - Read every qlrestioncarefully.Answer every question leave no qtlestion unanswere(l -- if question does not apply to you, so
state: DNA. A candidatewill be reiecledwlto has ir-rtentionally
made a falsestatement of a materialfact or practicecl,
or atterrrpted
to practice,any deceptionor fraud
in tllis applicatiott,itr allv exalttittatic-rn,
or irr sectrrirrg
eligibilityfor appointment.
This cancliclate
persottally
will
ltreparetlris fonrr. All errtries,except tlre siglature,
must be printecl legibly in BI-OCK l-E'l-fERS. l:ntries rnust be rrradein either
blue or black ink. If spaceavailablefor arrswerirrc{
any questionis insufficient,
use
the continttationpagesinclrrdecl
arrcllrrecedeeach answerwitlr tfte number of tfte
questionbeing answered.Applications rrot frrlly cornpleted or illegible will
be catrse for rejection.
N N F ,()tINI, 0I' I' ()II Il IN I I I' IIMI} I,OY E R
C I T Y OF
PCLICE DEFARTIV1ENT
r
il r' .L 1
F
ir\/
- t Y
l t r a ql v tLr ' /
v r - l
I
THE FOLLOWING ADDIT ON}T DOCUMENTS'AFE RSQUIRED A}ID I4UST BE SUBMITTED
BOOKLET
WITI-I THE AP P LICATIObI FOR EMPLOYNTENT
Photostacic certi.Eied
or coliege transcript
l.
A
5.
6.
1.
.]
9.
10.
photosta;ic
VJLJfU:
only )
Photostatic
copy of
coov
qaltr.tirre
avrYr ln v . Fv :
u
. -c^d-r-- - r v^rtur \
v
vr--i.^-
I
a6Ff
Prof essionai
i Fi-rf
of
copy of
Fnr-:n nn2l4
hlgh school diplorna or cer--if ica:e
fFonl iFs
nrcvinttq
cert if icate/naturalrz
birth
Serrri.-c
6/nirrnrr.a
Reoiq,i-rat:on
rni l:tarv
ation
C . a - J '( n a I c s
oersonnel
docu-rnentation
hcfTpon
L8 and
26
dor-:-oc<
Cer'tif icaLes,/Cerciiications
License
Dri'rers
Securicy
Caro
Sociai
Credit
check liis tsry (Inf orrraticn
D"p arcE en L )
Certified
to
ani
New Jersey drivers
to
be s en& to
licenqe abstract
(Certified
the
within
P ol i c e
the last nonth)
W l r i t e( M a l e )
W l r i l e( F e r n a l e )f l
lJlacl<(Male) fl
Black(Female) tl
(Male) n
I Iisparric
l-lispan
ic (Fernale) n
Asiarr(Male) n
n
Asian ([:emale) f
AmericarrIncliarr(Male) n
A r r r e r i c a lrrrr r l i a r(rF e n r a l e )t ]
PersonalData
I
LastName
First Name
Middle Name
2 . Give any other namesyou have used or been known by, and attach a statement,giving reasons
(if none, so state)
3 . Where were you born? -
-c-ffi-"",r--.=-.:'
4 . Birth Certificate
Number
Cily fown
State
5 Date of Birth
Age
Month
Height
Day
Year
Weight
Eyes -=-€
6 . SocialSecurityNo.:
7 . Do you wear contact lensesor glasses?\'es or Nq
7A.
Zip Code
State issued:
.__
__
County
itizenshi gr
n
I'ialrr1.1l1,*''l
f * ' l ; l t i r ' 'l t] 'o t l r
A r e v r ) 1 a t l r a l i r . ' rI' r 1 , 1 1r1, 1 t t ; t l t t l l l i z r ) ( i r i t i T t ' t t ' t
n
r
r
,
r
'
i
r
r
l
l
,
r
q
(
)
l
f
r
i
r
r
l
l
r
e
f
i
l
l
t
i
l
i
z
r
l
t
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.
i
t
l
t
a
t
t
t
t
a
l
i
z
t
'
,
1
I
'
i
r
t
l
r
a
l
r
,
If v9u alr, c,f lorr:ic;rr
C o u r r t r v, r f b i rl l r
tllales
P o r t o r l r l a c e, r f r l e r l r a t l t t tf oc t t l r e L J r r i l e S
Itatt,
P c - r rot r p l a c r :o f p t t t t v i r t t o l l r e L J r t i t e tSl t a t e s
IJate
' l r a i np t c
)
H o w w p r ? v ( ) l l t r a l r s p o r t e cilr r l o t l r r : I l r r i t e s S t a t e s ' /( S l r i 1I ,' l n r r r '
N a n t e o f l t a r r s l . r o r(l, ( ) n v e v a n c pa t r t l T ' r , rc ( ) l t l l ) a t l vv ( ) l t ; r t r i v e t l o l l
()t) artir"'al
I f a l r a t u r a l i z e ccl i l i z e t t . t ) a r t ) ea l t c l a c l r l r e s st l f l l e r s o t l t v l r o s l ) ( ) n s o r e c lV O t l
Firstaddressafterarrival - --.How did you obtairrcitizetrsltipi)
PetitiortNtttttlrer
-,'-l-----,---
-*
-- -_---
( l o r t rI
l)al.
C c ' r l i I i r : a l eN
' tttrrlrer
State
Social Status
9 A r e y o u s i n g l e . l r r a r r i e d ,s e p a r a l e r l ,c l i v o r c e c l ,u , i d o w e d o r w i d o w e r e d ?
. ist number of times rnarried:
1 0 G i v e f o l l o w i r r gi l r f o r r n a t i o r r e g a r d i r r gt r t a r r i a g eo r t t t a r r i a g e s L
Wife's MartlertName
o r H u s b a r r d 'N
s ame
1 1 . If separated, state reasotl
1 2 . I f s e p a r a t e do r d i v o r c e d , w l t a t i s t l r e p r e s e l t t a d d r e s so f t l r a t p e r s o n ?
1 3 . How many tirneswere you legallyor voluntarilyseparated?How many times?
1 4 . Were you ever divorced or had a nrarriage anntrlled? Yes or Nq
information:
in
required
fill
and
1 5 . If ever separatecl,annultecJ,or divorcecl, indicate which below,
Offending Party as
Separated.Annulled
_f)ivorced llnliqq]-e-l
Reason
9v-wl:gtn-
1 6 . W e r e y o u e v e r t h e p a r e n t o f a n y c h i l d r e r r ,w l t e t l t e r a l i v e o r d e c e a s e d ?Y e s o r ' N o
17. List below every child born to you:
Whom and Where
Child Reside
Yes or No adopted,and stepchildren?
borrr to you, irrcludirtg
a ll chilclrerr
1 8 Are you notv sttpPc-rtling
lf no, statefull details
1 9 . H a v e y o u e v e r b e e r t i r t v o l v e d a s a p l a i r r t i f fo r d e f e l r d a n ti n a p a t e r n i t y p r o c e e d i n g ?Y e s o r N q If ves. state fLrlldetails
-
|
2 0 l f s i n g l el,i s tr r a r r ) (. ' .t r ( , r I a l l r - , a sol l r ( ' )r l i r l f t i c l r t l . , / l r r ir,,'rrfr1r l .1 r ; l c tr ) l l ) t ( , q ( ) n t
\,iame (Relationshrp!
ff
$
t
Name'(Relationship)
Full Date
of Birth
f
( . ) c c r r p a t i o r ra r r r l L V o r k P h o r r e N o
2 I . F a m i l yi n f o r m a t i o n- I r a t l r e rr,rrotlr€l. sislers,/trrotl
rers,slx)lJSe,
step[atlter
/ slepnrotlrer:
Name (Relatronshirr)
I r r l l A d d r e s s ( l n c l r r r l pZ i n ( . ' , i e )
+{---I ' l a m e o f B u s i r r e s s iE m n l o v e r
I Occurration arrd Wnrk Pl'rne
tl
_ -.1_k
l.{,r
I
llorne Plrone No
I
|
Name (Relationshrp)
S o c i a lS e c u r i t vN u m b e r
Name (Relatronship)
Ft'll Address {lprlrrrL' 7rn {'r.rlp)
Narneof Busirress,'Ernpl,ryer
F r r l lA d d r e s s ( l r r c h r d e
Zip Code)
N a m e o f B u s i n e s sE, r n r r l o v r " r
Full Address (lnclude Zio Codel
Social Sectrritv Numlter
Name of Brrsinessi'Ernployer
F u l l A d d r e s s ( l n c l u d eZ i p C o d e )
Full Date
o{ Birth
Social Security Numtrcr
Name (Relationship)
Full Date
of Birth
Name ol Business/Employer
Occupation and Work Phone No
Fulf Address (lnclude 7,:p Codel
Social Securitv Number
Name of Business,/Employer
O c c u p a t i o na r r d W o r l
F u l l A d d r e s s ( l n c l u d eZ i p C o d e )
N a m e o f B u s i n e s sF, '- r r r p l o y e r
O c c u p a t i o r ar n < l W o r k P h o n e N o
{
_ , _ _ * _ _
+ _ j
'22
, l l l ( l ( ) t ; l ( . q ( li(a t l c s r r t l t r ' l t l r ; r r r\ ' ( ) l t (l t , ' t s
L - i s tn a r . ( "
l,r"
\
r,,,
,t,
1 . ,1 ,
I
{
',
I 1 1 , , , , , 1, ' l r , r , | . . 1 , ,
I rrll [ ),rtc
,r{ Rrrtlr
I
L-!'---.'-.-. --:-:-:--:-:-
Nam,,
\
Ijull l)ar.
/
of []rrtlr
tr"r*
-
1_l
I
ltllice DeJrt-tvlriclrvou are sociallyor personallyacquainteclwith:
List namesof rllerlll)ersof the
A t l c l r e s(si f k l r o r v l r o) r D e p a r h n e r r t
Barlqe No
Social/Persorral
;
1
List namesof anv relativesin tlre law enforcementfield:
SocialP
,/crsonal
Address{if known) or f)epartrnenr
N;rrrrt'
Residence
Phone No.
23. Where do you l)ow reside?
Nunrber & Street
Area
State
County
City
t73Jl
With whom do you reside)
No.
Apartment
Give Floor No.
--Rear fJ
(Check) North t.j South tl East n West fl Front I
25. If vou residewith someoneother than spouseor parentslist:
2 4 . How long have you rEsidedthere?
:
g -
(Nanre)
' -
(Dte oi Birtlt)
(Occupation)
(SocialSecurityNo )
2 6 . I n c h r o n o l o g i c a lo r ( l e r ( s t a r t i n gw i t h r n o s t r e c e n t ) , s t a t ee a c h a n d e v e r y p l a c e i n w h i c h y o u h a v e r e s i d e d
sincebirth.
. p t . . C i t y , S t a t e .Z i p C o d e t
l \ - d d r e s s ( S t r e e tA
27
L i s t a l l p l a c . e s\ \ ' l ) c r t ,L , ( ) l rl r , t l i s l ( , r r ,n( lf 1 , 1 1 1 1( ,i f1r1r 6 r r r , .s 3 s l ; r l r , )
Ccrurrtv
5talc
( o111111
Year
"/
' - d - . -
-_l
Education
28. Listchronologicallv
(rrrost
recetrl
datesfirst)allsclrools,
colleges
arxJtrairring
cornses
vorrlraveatterrcled:
Sclrool
[ - x a c tA r l r l r e s s
From
------^r-_-,'j
Month
Year
Nlorrrlr
Vear
I)av or Everrirrq
't-..-- Exact Acldress
[:t om
^
Zip Code
'l'o
-
--------._-M ont h
Y ear
,_..-___
l rl o rrtl r
Year
Sclrool
From
I-astGrade or Ternr
Zip Code
Dav or F.r'ening
Last Grade or Terrrr
[',xaclAclrlress
Zip Code
J'o
Month
Year
l v l o r rt l r
Year
School
From
[)ay or Everrilrq
Last Grade or Ternr
[-xactAdr:lress
Zip Code
To
Month
Year
Month
Year
School
From
Day or Everring
ExactAdclress
Last Grade or Ternr
Zip Code
l-o
Month
Year
Morrth
year
Day or Everring
Last Grade or Term
29. wh^at-collegedegree(s) or professionallicense(s)clo vou possess?
Majoring in
Grade point average (cumulative)
Total credits achieved toward degree
3 0 . O t h e r t h a n E n g l i s hw h a t l a n g u a g e ( s )d o y o u :
Speak
Understand
31' List any problemswith school (absenteeisnr,
tardiness,poor grades,other disciplineproblems)- include
colleoe.
al
'fi
RI
.{I
/ )( )
.)L
1,.,
I t i S L r r r r l r , r s t, ,1, ll l r t I r y i l l i r p p t ( , r l i ; r l r ,l lty; i r . , , , { , , 1 \ \ ' i r r rlli,.,ur tl , - r ' r i l r tfst o n t , r l l , , ' l l t ' t i , " , ; r l l c t t r l c t l
l ) 1 n at r n e r r t
ti
fltr
il
.tr
dl
'I
(Properfeo ,rit,stbe [orwarrletlto tlre collegetlre applic:arrt)
Ill
{
.I
I
l
$
Military Service
fl
il
{
States?\'es ortNJ_r--of tlre LJrritecl
33. Have you ever sg!'c'l jn an aclivernililaryorgalrizaliotr
Yes or@:--of alry foreiqngoverltrnenl?
34. Have you evel servptlirr a rnililarvorqarrizaliorr
a
ra
F
:r
.u
Y
IT
d
{
,{
*
,t,:l
lf yes, give r.lelails
il
4
$1l
3 5 . G i v e b r a n c l r t - l [ s e rv i c e
a
M i l i t a r yS p e c i a l i l v
S c r v i r : e S e ri a l N t t t r r l l e r
36. Rank ltelcl
v e r v i r : rl ,) a v e y ( ) r rl r a c l ( c l r a f t se, l t l i s t t r r e n tosr r e c a l l st o s e r v i c e ) ?
3 7 . H o w l l t a l ) y ' e r i . c l s 6 [ a c t i v er r r i l i t a r s
38. Give periodor periorlsor actives e tv r c e .
J'o
From
l'o
Frr-rttt
l'o
.From
39. List all medalsancltlecoratiotrs
l-o
;.-,,,;",:::11",
of the armed forces
frolrt llte setvice w e t e g i v e t r t o Y o u ?
4 0 . H o w m a n y d i s c l r a r g e so r separati<.rns
) separationls)(trortorable,d i s l r o n o r a b l e .h o n o r a b l ec o n d i t i o n s )
4 I . W h a t t y p e o f d i s c l r a r g e ( sor
Be exact.
42. Has your discharge or separation notice ever beert corrected or cltanged? Yes or no
to
43. What was tlre nature of tlre change? Charrged from
44. Wereyou evercourt rnartialed,trieclott cltarges,or were you the subjectof a summary court, deck court,
captain'srnast,c o r n p a n y p u n i s h n t e n t ,o r a n Y o t h e r disciplinary action?
Yes or no
N u r n b e ro f t i n r e s
If yes, give detailsof charges ancl diipositions
45. Are you now or were you ever an activeor inactivernentberof the ReserveForces(anybranch)of the United
S t a t e s ,a n y f o r e i g n g o v e r n m e n t , o r t t r e N a t i o n a l G u a r d o f a n y s t a t e ?
/, \
If yes, state which - active or inactive
Yes or@:
Branch
Address
Regitrretrt
[':rottt
Rank
Unit
To
Selective Service
46. SelectiveServiceNurrrlcr
I-.asC
l lassification
Employment
47. PresentEmplover:
-fi.ffifi",l"
Datehired
*
iqi-il;E Sr,:""r
_ Supervisor
-f,"rt6---ffitFh"*ffi
Duties
49. Are you now engagedirt arty lrusiness
as an owner (acliveor silerrt),partner,stocklroider,
or corporate
member?
Yes or @
I f y e s . 5 ; i v ec l e t a i l s
4 9 . H a sy o u r n a m ee v e rbeensubmittedor usedas a trustee.officer.O T i r r a r r y c a p a c i t y ,o r a n y l a b o r o r t r a d e
u n i o n , o r g a n i z a t i oor
n affiliate?Yes or Ncr
If yes, give cletails
50. List belowchronologicallymost recentdatesfirst, each and everyplaceyou were previously
employed.
omit none. Give correct,full addresses.Give datesof idleness
betweenperiodof employmentin proper
sequence.(lncludeall part-timeemployment.
)
From
N a m e , A d d r e s s ,a n d P h o n e N u m b e r o f E m p l o y e r
( l n c l u d eZ i p C o d e sa n d A r e a C o d e s )
lmmediate
Supervisor
Yes orq@
to resiqttfrottt ernploynretrt?
or asl<ecl
51. Were you ever clisclrargecl
below:
Give detailsof dischargeor forceclresignations
How manv times?
Ernployer'sAddress
(includeZip Code)
Employer
Area Code &
Plrone Number
Name
Supervisor's
Reason for
Discharge
52. Were you ever subjectedto disciplinaryactiort in connectionwith any emploYment?
lf yes, give rletails
Yes or @) -_'_---
53. Have you, your spouse,or any corporationor partnerslripof which he/she wasan officer,director,or partner,
a licenseor permit (excludingdriver'slicenseor learner'spermit)issuedby any governmental
everpossessed
agency?Yes
"t@+
If yes, give details
H a s a n y s u c h l i c e n s eo r p e r m i t e v e r b e e n r e v o k e c l ,c a n c e l l e do r s u s p e n d e d ?Y e s o t @
If yes, give details
5 4 . H a v e y o u e v e r s p o r r s o r e , l v. c ' t t t : l r e rf lo t . s t ' t r , , c ral s c l r a r a c l t , t t , i l t r e c sf o r ' . , r r r r r a r l ea n g r t , r : o r r r r e r r d a t i rosr
l q e r r c vi r r c o n r r e c t l o nw i t t r t l r e
f o r o r c o n c e r n i r r ga n y l ) e l s o n o r p r e n l i s e sl ( ) a n v n ) u l r i c i p a l s. l a l e o r f e t l e r . r a
o f a n t ' l i c e n s eo r p e r r r r i to r f o r a r r y o t l r e r r e a s o r r ?
i s s u a n c e ,r e v o c a t i o n .r r r s r r s p e t t s i o n
/-\
>\
lf ves. givc details-----
\Y$o.@)-
",'"':'::r'
il:'T:llT:l:"
i::i|'':,i;1"'1
ll"'ii
i:T* "'^tnil
5 5 . H a v e you ev
or@
@
Givep e r i o d 5 :
o r a s s i s t a n c?e
'l'c-r
----'l'o
'l'o
I:rotrr
'J'o
l:ronr
H a v e y o u e v e r r e c e i v e cal r r y a l k r w a n c el o r v l r i r ; l ry o r r w e r e l r o t e r r t i t l e d ? @ o r @
From
From
If g€s, explain
witlr arryotlrerpoliceorganizatiorr?
56. Have you made appliclIir-rr
Gd or,@
(Where)
( P r e s e n tS t a t r r s )
57 . Have you ever been reiectedby anotherpoliceclepartment
for employmerrt@
(When)
or@
(whv)
(Where)
sa.
lf yes, list below every such organization.
Address(includezip code
General
59.
60.
Haveyou everpetitionecl
for bankruptcy?
@rr@
Haveyou everhasa financialjudgrnentor garnishment
placeclr-rpon
you?@ot
If yes, explain
60A. List all activeloans,liensor debtswhichvou are responsiblefor:
TYPE: Loan, credit card,
garnishee,judgment, etc.
With Whom
Name, Address and Zip Code
Area Code &
Phone Number
@
A l.-,
{l i
Are
V r ) l l r - rr . , , t r t i l l ( t ' r ( ) l ) ; u l
( ) u l s l ; r r ( l i nl ( i) a r r / ' r ' { '(s) r t ' i i i i r/ t / U
l f y e s . ! J i v r , 'r l c l a i l s
I l,^,
62
H a v e v ( ) L r e v c f l [ ' c e l t l , t , l t , l ( ' r l '\r' 'p s , , r t . i i , D / V - U
W i t l r t ' e s p e c . l l , r e r r r l t l i n r p l r o r r < l l ' r ls. l n l r :r l e t a i l sl l e , t o t v :
. t l r l r e s sa t r r l Z i p C o d e
[ ] v W l r o r r r [ ' l a r r r pA
Ilpas..rn
6 3 . H a v e v o t r c v e r b c ' e r rr e f t r s r : ral f r . r r c l ' /Y e s o r ( 9
--/\ L:
Area C-ocle
a n d P l r o r r eN o
If ves. bv wltonr
64
to cdurt in a civil actionor proceedingin this
ever srnllltilne(lor subpoerraed
Were you or your sl)ot-lse
or transaction?
as
a
result
of a recentoccurrence
elservhere.
or
coukl
srrt:lt
a
ensue
stateor
trossibilitv
Yes or nr,r
r11
irrwlriclrv()u (,r vour spouseweresuntnronedor subpoenaecl.
Indicatebelorveveryr:ivil.rction()r proceedir
possibilities
above.
party
as described
arrdalso llre r:orttittgent
or in wlrich vou or your sl)ouserverea
C r , u r tD i s p o s i t i o n
Arrests,Summonses,Etc.
V", or@-A/Qwith JuvenileDelinquency?
65. Haveyou ever beenarrestedfor or chargecl
If ves.insertinformalionbelow:
Charge
R e d u c e dT o
Location
Court Disposition
of Senlence
PoliceAgency
Concerned
to testifvbeforeany municipal,
requested
6 6 . Haveyou ever beensumnroned,subpoenaed,
or otherwiselequired
bodv?I
state.or fecleralagencv.committeeor other investigative
If yes. give details:
67. Have y o u e v e r r e c e i v e d a s L l n ) r n o n sf o r a n y v i o l a t i o no f t h e f i s h a n d g a m e s l a w s ?
If yes, i n s e r t i n f o r t n a t i o nb e l o w .
PoliceAgency
Concerned
l0
68.
Have yo{ever leerr arresledfcrr.or clralged',vitlr.a violati<;rrof llre clisorderlyl)ersonsact or Cily ordinartce'?
lf yes, irrseltitrforttraliotrlrelow.
Yas o(NoL\oLrr Age
al Tirne
I
rt,ti.n Agencv
Concerned
for arryviolatiotro[ ilte crintinallaw? IVO
irrclictecl,
or convit:tecl
69. Haveyou everbeerrarrestecl.
Have vou ever,haclatty (ilirlritralrecorclexJlr.rtrgecl?
lrelclw.
If ves. ittsertitrfortttatiorr
- -l:..!!lT"'t!ql----
69A. Have VS ever been a defendant or a plaintiff irr any dotnesticviolertceincident?
--=-,If yes, insert inforntation below.
Yes or@)
70. Have gglever been held as a materialwihess?
If yes,insertinformationbelow.
Yesor@:
personor investigated
or privatesecurity
by anylaw enforcement
71. Haveyou a.lerbeenheldasa suspicioug
If yes,insertinformationbelow.
YesorQj--agencyfor anyreason?
Disposition
72. Have vou everbenn fingerprinted?(Excludeonly presentapplicationwith
GEorNo
If yes, fill in the following:
Address and Zip Code
)
s
SubversiveAffiliations
$
ll )rrl or oilrer subversive{
'1 .t
oI atty clrrttttttttttislc'tnttttltllsl
/ . ) Are yolr rr,r*,..r lrat,r'v.rr evcl llcett. . ttteltttlet
l:l:
3lJ:1ff'l'i:::
,::'ilitlit,lilff::rJiH:l*ilt;]i;;31*l'
il,,tutlt;l:,,?::lTil:ll
;;"";l;;i..;i';";",',Y.,.''(.Q-- t't()- -.,f
74
- *o,:']'"*"':"$
organizatio"
anvofrlre
$'itlr
,t ass.ciarerl
alfiliaterl
ffi#,l:,:i?,;; 1il".1.;ff:l'/irr'
7 5 A r e y o u t l o t v a s s ( ) c i a t i l l g w i t l t . o r l t a v r , v ( ' t l e v € I a s s r r c i a l e r l w o{
i t | rairv
. a r rorsatrizatiorr
y i r r t | i v i d u aor
l s groups
. r n c | u ddescrib
inqle|ativ
,'.=,,:ff'Tlllfi:i',b,"hi;ir:l.,;'::i;;;"T"i""'l*''L'""
76
il
[ffiu;m]fl";,'":ill:';}:1,"j1;;:',,il:i'ii'l{iJl:'::il
s or llroups clescribeditl clttesliott
witlr or 'oatrizatioll
or program colllF.cted ,,t u"y tuou
YesorQg)
77
ii
rvu/
ii
o.pr,,l
{orum
1"";d:H,".""'jT:,',':,X':,ill',,l:ililX,::'fJlJ,1ffii:j:::ll,:il:,,::
,1lair
H::61trU''*lnuatteorsanizatio'"'u"",'..:.:'..'.'r:":,:,::",
.,"
-i
b.Pavrnentorcollectionolallvtrlorleyr]L11scorrtribrrtiotls'ordonalioltslt'at'-orgatlizatio
. g:il':i"$ffffi1'il:l;Jil:lY:;'1,::,*xil,?tiilli,ti,
anv
bv
sr':
p",[rr,:fi;k';ii:1'Ellil''*
, ?::J'?::ii:,1*?i:J"l?:;';;;,r,i1..,""'",
or any of its agents/ Yes orQgr'_/!:\l-.' ..n".'-.'olr c|escribeditt cluestitltr73
..
l
xplain
explain
q
u e s t i o l l s .e
queslions'
t 8 l{ your answer is YES to arry o[ tlre al'-:ove
Motor Vehicle HistorY
7 9 Have you ever receivecla surnlr)olls.fgLliolatiort
) 'es)or
( E x c l u d eo v e r t i r n ep a r k i n g v i o l a t i o n s Q
No
in this or anY other state
Motor
informationbelow.
:fllrr: ff$:I",k::;
Court DisPosition
i Your Age
i ar Time
Driver's orrother vehicle operato
e g i s t r a t i o rcertificate,
t
V e h i c l e R egistratiorr
80
When?
Yes otSJ - L/ C
Suspendecl?
Wlrere?
l2
Whichlicense?
Police AgencY :f
Concerned 'l
licenseever revoked
J I I f a n s w e l l o I ) l r , \ r i ' ) l r(sl l . , s l i 1 | ni s
yes or No ____
'\'r's
. r v l s s r r l r I l e g i s t r a l i o n( ( ' t l i { i (a l { ' , r t l ) t i r . , , 'st I i c c t t s r ' c v e rt e s l o t c r l ?
LVlrr:rc.1
Wlr.r,,
i 2 H a v e y o u e v e r b e e l ) i t r v r . r l v eidl t a n t o t o r v e h i c l ea c c i d e r r te i t l t e r a s a r e g i s t e r e tol w l t e r o r o p e r a t o r w l ) i c l t
resulted in any personal iniury or property darnage?
If ves. state details
'telow:
l f y o u p o s s e s sa n y o f t l r e f o l l o w i n g , c o u r l ) l e l et l r e i r r f o r l l l a t i o t b
-s-!q!n
Y e a r/ M a f r p \ l o r l e l / C l o l o r
Motor Vehicle
Registralion
Irr
A t-l
Nlorlel/Color
Second Motor
Vehicle Registratiorr
Motor Vehicle
f)river'sLicense
I
r
r''
1_1,!-l-
Operator'sLicense
Any Other Vehicle
licenseissuedby any
oper
driver'slicense(CDL) or operator's
or cornrnercial
a clrauffeur's
Did you everpossess
,-\
l, L^
stateother than New Jersey?Yes orQlg)JVll If yes, give staleancl nurnber
Other Information
lD card, firearrnsdealerlicensein
85 Have you ever possessedany pist{-{{earm permi_t,.firearms
this state, any other state/fedpral?Vg/or No .{-r-:+
Firearms Dealer's License Number
Permit Number
IssuingAgency
86. Haveyou everusedany illegaldrugs?Yes
"@IO
If Yes,state cletails.
87. Have you everpreviouslytakenan examinationbr appoinbnentto the
FoliceDeparbnent?
It yes, list date(s) of written examination _-
waseverconductedon you by the NewJerseyStatePolice.
investigation
fl (CheckBox)If a background
88. Do you haveany knowledgeor informationin additionto that specificallycalledfor in the preceding
queslionslghichis or whichmaybe relevanl direcllyor indirecdy,in connectionwilh an investigation
of lnur
eligibilityand qualificationsfor the positionof FoliceOfficerin the
FoliceDeparbnenf including
habib,educaton
but not limitedto, knowledgeor inbrmationconcemingyour character,temperance,
criminalrecords,traffic violations,residenceor otherwise.
subve$lveagtivities,family , association,
ff yes,givedehilsYeso(Nj-MQ-
l3
f,
d
ilI
Vouchers
T
I-lS]fDlN TLISAPPLlOlTlONl
I'EIISON
OIrll,lj I II P.DORANI'O11J[ll
(NOTTOBESWORN
M1:MB6HS
il
t l t r e e r e l t u t a t r l ec i t t z e t t s( t t o r e l a l i v e s )w h o u ' i l l v c ' r r c h {
U p o n c o . ' l e t i o r r o f l l r i s f o r r n . l l r e a p p l i r - a n rl r r r r sol t r t a i t t
il
f o r t h e h o n e s t y . I e p u l a t i o l l a r r d a b i l i t y' r [ t l r e a p p l i c a n t
Before Signirrg l-lrerr' tlre voucherl
a
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The voucher
affixetl
p o r t i o n o f t h e { o r t t r s l r o r t l , l r e c r : n t p l e l e rl ' v l l t e v o t t c l t e ra r r r l s i q t t a t u r e
il
+*ir-,f,
l'theundersigtted,decllrelhcdlantotlereighleenyeursoJuge,thatl|nuepersonallgknonn,th"''||,,,::
o! llrcloreg<tittgopplicationondbelieueall the statenrcntsfl
irl t, i""tt ori"y"nr, lhot I llrrvet'eodthe wlnle
thereinto be true. I artr ttol reloled in ony looy to tlrc oltplicanl'
$
cottcerningtlrc oltltlictnt,trsI nloy possess'
I will, uponretluest,givelurllrcr .fat:lls
il
fl
nl.t.lNl:ollMAti0t'lwlt.t.llE'tltl:n'l[l) ns cc)NFll)l]NTlnL
fln
voucrlERoNh
il
{lleasoPlirrt)
Name -
AddressAtea Cor]e& PhoneNo
[Jusiness
Address
-
-
City. State. Zip Code
Occupation
li
:;$
,il
-l
PhoneNo.{AreaCode)-llowlonglraveyoupersonatlyknownapplicant?--fi
characterand reputation?--.'-ll
n-r- ^{ Ri,rh
- Is applicant of good
-
Social Security Nunrber --
.,1
Signattrre
::I
. voucl.lEltTwo
d
(Please
Print)
Name-
AreaCode& PhoneNo'
Address'
Business
-
--$
-
Address
_--
{i
---Occupation
t
-----Jl
known applicant?
How long have you personalfy
ls applicantof good characterand reputationt'il
Sisnature -Zi!i
City. State.Zip Code
phoneNo. (AreaCode)
Dateof Birth-,
SocialSecurityNumber,.--
THREE
voucHER
ii
(Please
Printl
#
.u
Name--BusinessAddress,.AreaCode&PhoneNo.-{
AddressCity. Stat€,Zip Codephone
(Area Code)
Code)
PhoneNo. (Area
Date of Birth
Social Security Nurnber -
occupation
applicant?---known applicant?
personaltyknown
have you personalty
How long have
How
=--
.l
ls applicant ol good character and rePutationt ------il
Signature
LII
ib;i;tji
CEti-I'II:ICAI'ION
are lrue, cotttplete atr<lcottect kr tlre best of my
I certify that all of tlre slatenrenlsrrrade irt llris ag4rlir:aliorr
good
of infunnation supplied
faitlr.
I
awate
that atty tttispresentation
atn
knowledgeand belief, arrclare rnade irr
Folice to
fronr tlre seleclionprocess Furtlter,I autlrorizetlre
by me will resultin my disqualificatiort
education,financialand criminal
verifyany and all inbnnatiotrconlainedlrereirrarrdlo reviewrrtyeu4rloytttettt,
fronr
atty
soltrce
as trotedin lhe duly executed
history,military,disciplinalyarrrlotherrecorls arrdinformation
Authorityand ReleaseFornr.
ir
,li
I
n n ( l I r r n ( l e t s l a l l (al n t l a e t e et c lt l r e c o n d i t i o n si t I ) l ) o s e (l rl e t e i t r
I l r a v e r e a dt h i sC e r t i f i c a t i o a
Date:
Sicllralrrrp:
( S i q r irr r I r r k )
( [ ) r i r r tN a r r r p )
State
County of:
S w o r n t o a n d s u b s c r i b e ttl r e f o r e n ) p l l r i s
lq
(Print Nanre arrd
'l'itle)
Signature(Signin Ink)
Notary Public,my Comnrissiort
Expires:
DO NOT WNTM BELOWTIIIS UNE
Signature oI applicant made ilr presence of investigator
Date
S i q n a t u r eo f I n v e s t i g a t i r rOqf f i c e r
I l-r
.l
. i
\
End Of An Application
Next Pag€,
BeginsAnother
tt
D.
POLICE DEPARTMEI{T
PRE-EVIPL OWTE NT BAC KG ROUND INVEST TC
ATION INFORMATION
\Varning:
type-rvri
in-If rnyreque't.o
a'tloo-, noreppry
.'.t"1;':''J:::j",:-"1]li:Ti:ji:11]*_d
to;
N/A-' Initirr rhebottom orateryp";-.;;;;;#hand
appl i cati onm ust be
siders,r" il;;?:,?,fj::indicete
prge-
bv entering
Photograph
(Trkcn wrrhrni:sr srx nronrhsj
1. ) ame:
L a s r\ a m e :
Drre of Birth:
First Name:
lliddle Name
S o c i a lS e c u r i r v) 0 .
\lhere Issued:
C u r r e n rO c c u p a r i o n :
r hl l-v) 1
-2.. - G
v r; '' -, '.e. i . ?! ^n,:"- / vn L
r . ^n r. l. T
. ^n^evcJ , r, -. '-^ r ' Jr l-3 ' , ' € U S e i O f b g g n l g l O W n
t
Jv ,r' v1 ' :{ irrr\ i. i
!:LLdU^i
" r t : t r - 1 . , t1i
gcs1g's1vtr A
r l ,rv. ^r io
L- r
-",i
:i,lng
3. Curent Aiiress:
iry
Fror,r:
F{omePhone:[__)
,Vlonrh Y:ar
WorkPhone:(_J
4. Placo
ef Binh:
lry or I owrl
S
.
Aoe'
\ \ v .
Sex:
F{eight:
ounory
Weight:
6 . S c a r s& T a t t o o s .
-1-
Eye Color
FIairColor:
fg3SOnS:
7. Do you wearcontactlensesor glasses?
W}at kind:
CITIZENSHIP
8. Are ;roua nariveborn or nafurajized
cirizen?
Nativeborn:
If ;.,euareof forei_s binh, or 're a naruraiizede i r i z . n
Counrrrof binh:
v . \ . & e . l t
Pon or olaceof cieoarn-rre
to ihe unirec
fill ;-
r I r I
l l l
Narurali zed:
the lbllorving:
Sta[es:
-F
FoinroiEnry inro rheUnjredStares:
rl0rv wereyou ti'ansported
to ihe unired
Ta'c,-
Strtes?
-
Nar-aeof tians.cortconver,'xr:ce
anc,or company.
l/our.nl.ed,on:
ai:::3n. rlne
P6rr;
t1 if'
P -v r. .jr f^ :v .n^ a
^
:r'ou
,.]nrarn
l i l d : c c : - - : s ' . ) i : e : S O I t ' . ' , ' : : OS D C i : S C : 3 C
cltlz:nsiijo.r (Gir-e delaiis)
--.
n rU,/ :, . r^| h
. / L ^ .
Dare:
: f
Coun:
Statg:
C:ri
vY'
.:-
ilr-.ro nr..'r ho-.
!'r'vsLv
algalllJ\rl
-
ihe n:osi recent'ail pflor plac--soiresicence rvirhin
F-^-'
rhe lasi 20 vears:
To:
StreetA Cd,ress:
Apt. Number:
Count.u:
St a t e :
./ l r-l, I
/\f1 0.
a^y
\,\J\-t\,.
lVith Wiorn did you residerhere:
l F r F r - l -
.r-!l-
L Iq,i>
PRE-EltPLoYivtENT
BACKGRoUNDII\nTESTIGATIoN
rNFozuvtATIoN
From:
To:
S treet .{ddress:
Apt. Number:
Cit.z:
County:
Stare:_
Zip Cod,e:
State:
Zio Cod,e:
lirirh Whorndid ,vouresidethere:
Frorn.
To:
Sire:rAdCress:
Counnr:
Wirh Whorn ciiC.vouresiCerhere:
Frorn :
To:
SireerAC&ess:
Apr.Nurnber:
CounF"':
Stare:
Zip Code:
v!'irhWtorn ciiCI'ou residerhere:
Fron:.
Act. \ un:ber:
I
t f ' t '
Counn;:
S ;L as r rv .a '
7in
v
4_LU
C
,^A-.
W (Jt_lg.
Ii ''o't i:;ec :t ccidlticnc! i'ocstions.inseft inform.ationon ihose rzsiiencescn a nov
shee!anc dttcch
d,t:|J enc ci :i!.!sforTn-
i0'
If -'uou
resiCewith or ha''ze
resid,eC,
with someoneotherihan a spousecr parentsiisr eachbeiow
pro'zidinqthe requireCinformationand indicateat whrchresidencethis
occurred:
Name:
Pl.nne.t'
A
r l v l r v . \
Daceof Binh:
\
,
n
Occupation:
R.elationship:
S o c . S e c .#
P l a c eo i e m p i o y r n e n r :
Curre:rraCCress:
l F i F r - l -
!1r..i-
r-.J-ai->
Name:
Date of Birth:
Occupation:
Phone:(
)_
Soc.Sec.#. (if available)
Curent.{ddress.
a
Narae:
Dareof Binh:
Phone:L_J_
-E--
Occuparion:
Soc.Sec.#. (if avaiiable)
CurrentAdciress:
1 1 . Lisi ail piaces'',vhere
you reg:srereC
[o voie: (If none,so state.)
Cirv
Counw
ii ne.,'eriegjstered.
State
Year
nor'l
SOCIAL STATT.S
l2
A.re','ouSingie?_, Ilarried?
Divorced?
Dare:
R g
Date:
. Selarateci?
wid,oweCor riiciower?
Date:
Date:
t i . ProviCeihe follorvinginforn:ationregarCingmardageor mariages:
Numberof timesrnarneC?
_,
l4'
!!?rere?
Were)/oue'ierdivorcedor hada rnariage annuiled?
F{orvmany times?
\!ftere?
l - l F r - l -
rri-1,
r- J.dl
>
t 5. Wereyou everlegallyor voluntarilyseparated?
How manytimes?
When?
l6'
If secaratec,
annullecor divorced,providethe presenracdress
o{the spouse(s)from
whornvou weresepareted,
annulledor divorced.
Narne:
Ph
nn.'/
r a v t l v .
\
A
AdCress:
Name:
F
hr ^ nv r n
.'' 1
I
.v.\_/
\
AiCress.
L:
If secar:iei.aniulieccrCii'orceC.
incic:te,vnicnbeiorv'and
prov'iCe
he iar: of each
ac:ion.:l:eCour ai:i Staierr:'vilcn ihe ac:ioncccuir'-d.ihe cr:siCingiuc.'e.cheaarrr
r : - l r i : a r i n:sh e i c : i o n a n d t h e a c : i o n a w a r d e d o v t , h ec o u n .
l - . F r - l -
F
18. Spouse:
Name:
Dateof B irth:
NIaiCenName:
Occupation:
Place of Emp lo-rrrnenr:
Addressif differenrrhanapplicanr:
19. lVereyou ever theparenrof a ciulCeithernaruraior by legaladoprion?
?0. List beiow every chilcieitherborn to you or legallyadopredand inciudestep-cluldren:
Nanne
Ser
DaieandPlaceof Binh
vlt,ereanci',viur,vhon:ccesihisithesechijci(ren)reside?
t i,
\\
21'- Flaveyou ever beeninvolvecies a plaintitf
or a defenCanr
_in
a pareririry
proceeCing?
if "Yes."starein full detailthe date,Iocation,party involvedand
theoutcomeof rheaction.
Iniciais
22'
Ifnever married'rist oneor morepersonswith whomyou
frequentrysociaiized,duringtherast
thre,
years'provideinformarionasto age,address,
occupation,phonenumberifrcrorvn,
and
durarion
of
friendship.
^ ^ ^ ^i ri/,' r !I,.r tr vr t::o
F rq m
cr l r. r-LrrrVrl i, n n l---- IF r rd h
L.rLr,
!
,-'lf11PF'
\,fnrt.o-
-ylUt-iCl.
Brothers,Sisiers:If dece3seC
inCicatesarne.
Living]
Adcress:
Phone:_(___)
!Iother:
L n'ine?
Phone.(___)
(1.^tr^..,^-.
uUw gLlrllt L,lll.
{ir:ss:
B i'other,'sisier:
Cccuratlon:
: r Jr l : - q t '
b e e l
v g g .
D i. n tt..
l . t u r 1 v . \
t'
Scouse's;;rr.ic.n
n
BrotlielSister:
? i-?'' P'
tlr'^:,...,rr,nr,,'
r
v v g g u l r V l l .
accress:
Phone:( ,
!Iarned?'
Brorhen'sister:
i - t ! t
)D OU S eS i nal den name:
Occuoation:
adciress:
P h o n e :__)
(
llamed?
B rother,"S
ister:
d
) 0 0 u s e s m a r o e nn a r T t e :
Occucation:
aCcress:
Ph
..n
v rn
. ve
. \' /
r
\, t
B rothe:'/Sisrer:
ivlarieC?
Spouse's
rnaidenname:
Occupation:
InitiaLs
address:
Phone:( )
z1
lvlarried?
_ Spouse'smaidennarne:
Lisi namesof threeciosefnendsancor associates
orherthanreferences:
Nan::e.
Age:_
P[one:(__J
Full Address:
Occuoation'
Durationof rssociation:
.\*aii:e:
{
op'
Dhnrto./
l' .t\./tl\,.
\
t
I
Fuii Adciress:
Cccupation:
Durationo f :ssociarion:
\-a;:ie:
l,te'
Dl.,r^o-i
\
Fuil Adcress:
Occurarion:
l-i.
P : o ' " ' : i : i i T : : l q ; 3 r - 3 n c 3' 's, r_, . iltvhh o m y . o uD e : s o n : l l . , , . r is: o c ; l j i , . , c r ; r o t e s s i o n a i l l , ,
acquainied:
)iane:
lh^to.,'
l,;.'
\
j. .^Ll.r-.i
- ii-.
,
Fr' ll I ,j,irec r'
r e s l
v g J .
,1^^,r-.a.^-.
r-zLgg|Jd,LlUll.
t j u : t : c n o i i s s o c la t i c n :
\l''-o'
Full ACcress.
Cccucation:
Durarionoi associ
aricn:
\l
Nanie:
A se'
Dhnna.i
\
Full .{ddress:
O
r v. v^q '! , ^ e qr l it nv l nL .
v
D u r a t : o no i 3 s s o c : a i i o n :
IniEials
EDUCATIOiY
26. Listchronologically
(eariiest
datesfirstbeginning
at flrsrgrade) ail schools,
colleges
and
trr.rrungcoursesyou haveaftended:
Schooi:
From:
To:
ExactAd,dress.
GradeLeveisAltendeC:
School.
From:
To:
Exacl Adciress:
CraCesI' eveisAnend,eC:
Scilooi.
Fiorn:
Tc:
E.xaciAd,iress:
Cl-:c:s i J','eis-r.-:nc:c:
Schcci:
I I0 i:it:
I r.)'
F:rrct AdCress:
Grries:
College
o r T r e d eS c h o o l s
27. College,,Scnool:
\
Frorn:
To:
E.xactAdciress:
Full Time:_
PanTime:_
Degreeor CenifrcationReceived?
CollegeiScnool:
Degreeor Cenification
Soughr:
If nor.'ryhvnoi.
From.
To:
E;<act
Address:
Inic,iaLs
F u i lT i m e :
DP.;'teo
v v \ r v v
n.
V a
PartTime:
Degreeor CertificationSougfrt:
Cenifi cationR.ecei
ved?
If none,why not:
Colleee,/School:
From: .
To:
E.xactA.idress:
F u i lT i m e :
PenTirne:
Degreeor Cenitjcarion
Souehr:
Desr:e c"'
r Cenificrrion Receivei?
lI none. lvnv nol:
if De_e"es
not receiveC,how nnan-ucreCirshaveyou cornpleted?
I ra.nscrtDts of student records r\ust be provided when submining this e
Iicent orm.
23. Wiat pror-esslonal
iicense(s)
io yroupossess?
scealcl:
10. Ljsi an'rprobienis;''ou
hai wilie anenCingschool(absenreeism.
tarcii:ess,
poor eraies.oriier
i i < , ^i : r ri ^i ^t^' v:p n r n h i p - " : c ' t - - i t 1n i r r l a , - n i i e o a '
r : i v r q U V
V V f f V 5 v .
. e I v v . v ^ ^ . J ? /
Scnoo
I
T)aro
lJclv
,v -r r r ! I' (-t o td l
Problems
fnlcials
-t
1l
n aveyou everser"/ed
on activedury l 1 1
militarr organization
of rheUniteCSrates?
From:
To:
2n\/
lf ;ves.rvh:rorganizrrion?
TLr , . r r e
Jyw
i
a
u tF A
\ : i )eL rr -l \( l nl _- r<yup rr "Lnr aol v; rg. rU, ..).r .
\!hat was your n:iiiraii,zsoecialqr?:
)-.
Hrve !'ou e'ier ser.'ei in a R.eserret - r t l l r f T r / orqrnr:3trcn
or NarionalGuardUrur?
raa^
tt
t
Lq
I i v e s .w h a r o r q t n i z t r i o n ?
F
I rorn:
To:
I lvl]eoI dlscnarger e , - . i
t v v v a
tYtvo\ A
1. . 1
W]ratrvasvour miiirary speciair,,.?:
nrr
vr
-
,h:-pi c'n
-vav^\.^
onr,'eryrt'.,.rrro
vVri4.t.l].vlLL-
iv
Fron:
'* irce:'.vn3.t;;rctrnsisnces cld,itris iorei.=i
-{
To.
ser-,'rcs
cccurl ci,,'e c::aiis.
Dic iou rec:l';e:n;,'i:iei,aisor d,ecorations a menibercf che;rilicar; sen'ice'?
If ;res.wharwere thev?
b
35. Werei'ou eversubjectto a c o u n m a t i i a l i n o r r i r ; t n e r i n n c h a r o e s or rvereyou ihe subjectof a
r ^ r q q ^ ^ / ' ,
el!a-ma!-.'
Jur^_^rsl
arrrri4
vv
Lrr L.
A-ni.
\Jvvr..
-^,rt
uvur
s,
! a i v s
v i l
V r ^ a n s U J .
u a p ra rns m:.5I, cornD anl / :ui l l si uTl ent, or
^ a F l ^ . ' - l -
- ^ ^ .
an'/ other discipiinar/
rn': n n'
s v . l V l ^ .
[f yes, horv rn3nr/ tirnes?
If ,ves,give deraiisof charges,
agencyconcen:ted,
datesand
disoosirions:
Tn i r i :'l c
b - 5 - J
E } t P L O Y } I E N TH I S T O R Y
35. Present
Ernployer:
ciry:
Address:
Zip Code:
Dateliired:
Phone:
State:
Imrneciiere Suneryisor:
ebv
v
sH
Duties:
3i . -\e yrounow engageiin anyrbusinessas en owner(activeor siienr),part'rer,srociCoiCer,or
coitcratemember?
If izes,.givederaiis:
i , - q . H a s ; o u : t r t n e 3 ' , ' e rb e e ns u b n , : t i e co r u s e d : s 3 i r . r r t e 3 c. i i c e r . o r i n a n - "c- 3 D a c i : ; ,o f e n i '
iaboriraie union.orsani:eticncr aliiiate'l
ii ves.st'ie ii,eraiis.
IniE,ials
39. List below cluonologically,
earliestdatesfirst,eachand everyplaceyou werepreviously
employedsincetheageof i6. OIIIT NO|YE. Give correc!,lull addressesGive datesof
periodof empio,vment
(Lncludeall part-time
idlenessbetrveen
in propersequence.
employment.)
TO
F RO NI
Mo.
. 1n
Ye:r
Mo.
of Ennployer
Name& AtJCress
Werg'u'cui','er iisclar:eC,,-rfrsked :o :esienror, :n;ic''r:::entl
,^
Were'/ou eversubjectec
,u
f f r r \o- J .,
-v
If ves. ho',r,'ianv
r n
)ule:.-lsor s KilISon
Date
FEo ior el
lj'
ReesonFor Lerving
beiovi
Ci','ei::ails oiiischar?eor iorcesresis'tetioirs
iin.es?
.A
? lI
kanrcClate
Supervrsor
Ye:r
.J,-^;^1,-^-
ul5uiplLl,rcll
r ontt^./
d,Lrrull
i-
.L -v rl !r -n- F
-ntinr'.t
v!LlvlI
lll
,' rY-l 'Li :f lh (r rnl l\/,v/ p r y t n J n r r r n r - n l ?
v.lIvl\J,vrlrvrrL.
n r rYr o / - t l i i S .
_iI
v
Enclo,zer
\J\-r
Daie
( r r n e : - , ' i s o r 'R
! eason
!
u v v
in
! t 1 5 9
i r i :'l
q
A1
H,avevou or your spouse,or any corporationor parinership
of which you or she was an
officer,director,or panner,everpossessed
a license
or permit(e.rcludingdriver'sIicense
and Iearner's
perrnit)issuedby any governmentaiagencyr?
+J.
4,!
If Yes, give derails:
lia're '/ou or '/our sDouse,
everDossesseC
a pror-:ssionai
or occuDaricnai
iicense,peIT.iror
ceniicatron?
If ;res,grve details:-
Has anv'licensecr pe=:ii, inclucrnginl'er's lice:secr ieln:er'scen:it. issuecby'ur,uciqi,
si3i: -'; .e'je:al:g:nc','i','er Deei,:e:lirl
taiiii3rsnip
lo ',ou.'c-: j;Lrusi. ci;c 3t','corf,ori.tcn or
of '*i-uch'/'ou or ycur spouse was xn ciicer, d^iiecior, or pa-nner'l
i . r . . is u c i l i c e : s e o r : e l : i t
lias
s ' . ' 3 :o e 3 : l t 3 ' . ' c k : c .c r : c e i : d o r s u s : e n i : c ?
Eivecetaiis:
A<
Have vou et/ersponsored.
vouchedfor, serredasl charecier
wiinessfor, or maie iny
recorrlrnendations
for or concemingan;;personor prenisesio an)/municipai,siateor
fieCerai
agenc'iin connection,vith
the issuanc3,
rei'ocation,
orsi]spension
of anv licenseor
pennitor for anl/otherretson?
Ir l ,i Jv ew Jct 5or i vv ew 's r! !ps , t i i s .
Tnir'ia'lq
i . . -
9 5 s - s
46'
17
Flaveyou ever receivedunemploymentinsuranceor other
federal,stateor local benefitsor .
assistance?
If yes,give detailsas to whgx,from whom,what
kind, and for how long-
Fiave1/'ou
3v'erreceil'ecany pubiicassistance
to whichyou werenot enrirlei?
rqrvv
svn
'.\iJ
19.
!v
Yv
If yes,
_
la. - l r . : , . 1 . l1, .
Ha v e y o u e v e r O e e rtreJivev \cv te
qLv
ri ivrv
J y rnnr[er
L r l w r }D
iLe:ar:nenr
iL--<.Li.ia:uiiL
J \ oi
J r i \i,cl
v
s
i ri r pmnl
g i . l . l u I Uo'
- v 1nrenr.)
119i11_,
j,\Jl
give fuil detaiisas to when,whereand wh./:
Irr.J-LJ.d.:>
_
.r'C5.
I Fwec
11
50'
Are you culTentiyon an employmentlist, or haveyou taken
anytestsfor potential
employment
any othei'larvenforcemenr
agency?_lf
yes,what agency?when?
"rrith
Werevou everor areyou a rnernberof a labor,or fratenai
orsanizarion?
beiorveverysuchn r o r n
v .
FR.Cfvl
!1o.
If yes,Iisr
izr rinrt
- g . a ^ ! $ s l v
l I .
Nane of Crgan::ac:on
Adciress
Ye:r
bev'erages?
FIN.{\CIAI,
You must include a TRIV'or similar
ry-'pefnancial report witlt this completedform in
addirion to providing the
fotlowing f nancial information.
51. F{avevou eve:-fiiec for ban-h".rptc;r,
had a debrgamish.menr
or wage2 q q t g n r r r P n l
5 v v ^ : - g a l v l t l
irrriornenr held
^ v l a L
t l v l u
againstyou or currentlypendingagainst;rou.)
r'\r
V l
if yes,give details:
Ini. ciaLs
FIavevou e!'er ceiauitei on a loan.hadpropenyoirny kind repossessed?
giveCetaiis:
If ,v"es,
C u r r e r t o u t s t a n d i n gd e b t :
-1": '---\ rt
- l .
/
/ -
i ^ L
Dace i Cn qinai
i-
r t F
Y v { r !
(
9 .
- . n ! . 1
- v . \
- v { . - d g
P:esent
I
\.f^-.L i., I
-vtL,rl.l,Lr1i-/
I
lncured i fu:ou:lr
.l-nount
P
o r r ' rr 'I r. irv-^-, rl ,iL l
t {-'
i
I
.f-mcunr
PastDue
'l
56. F{avevou everrecei','ed
a siudentloan frorne govenLrnental
or privateagenc'l?
r -.,i
IrlJ.
l. .i -'l
uJ.q,..l->
i f yes.
g i v ed e t a i i s :
57. Did you e'ierdefauiton such loan or areyou in oorvs1 in the pag in arr.eers
rnoretha' three
rnonthson ihe scheduieci
repa-vments?
if yes,gived,eraiis:
iE. iJe;,'ou 3 co-irlakeronarl outstancingloan?_
t9
H3.','e','0u
.','e:been;c.nc:i?
if y-es,giv'ed,eraiis:
If ','es.g'"'ecci::rtie::ietails';,'iihr3sDeciio eachcci:cias
io reascnit was recuited,bv'*hom itwas resuirei,iior::'*iiom.,,rras
it obraineCancilhe
''vas
3i:10unirno l'Jaieit
obraiiec:
60. F{aveyou everbeenrefuseCa bond?
If yes,by whom and reason:
6 1 . W e r e y c u o r y o u r s p o u s ee ! ' e rs u r n m o n e do r s u b p o e n a etdo c o u r Ti n a c i v i l a c t i o n o r
n r ^ ^ o o A i n s ' i nt h i s s t a t eo r e l s e ' , v h e r eo,r c o u l d s u c h a p o s s i b i l i t ye n s u ea s a r e s u l t o I a r e c e n t
Pl,
Vrevvslll
occurrence
or transaciion'?
_
If yes,inCicate
beiorveverycivii actionor proce:dingin
Ini ciaLs
which you or your spousewerea party to or likel,v
to becomea partythereto.Give dates,
type of actionor proceeding,
wherherplaintiff; defendant,
petitioneror winress,court and
ciisposirion.
6?. lVtar is vour Dresentsajarvor rvage?
\!hrc is ;roursDouse's
sa]ar
F/ Or rvage?
Waarw3s l/our 3i'er3eeyerriy incorrie over rhe casr ih;ee
6i
D o .,ou ha,ie ri r-rrw\ ^vnl lr- v
+^n
ll Vllr
j^. n1 ',,. ,- ' Ji ,\ 1J Ll :r ii , -U9v
r -L\ fi -i -I i-,
U
fhr-,,
L],rr:rj
;",ears?
liour prucio ai ulcCllDsrion?
ho''v:::ucr l
The sourc:l
lio',,voiten'?
Dc i'ou o\l'i1 i.r'i'"'icf,i estace?
ir
ves.
"vna[
i s ! t s i'eiue?
Location:
6s
Do y'ouow'nany bonds,goveriatentor orher? a
If yes, ',vharis rheir curenr
vaiue.)
6 6 uc i'ou owrrany'corporate
siock?
6 7 Do you havea ban-kaccount?
If _res,what is theirvalue?
If yes.completethefollorving:
S a v f n g sa c c o u n t
Barft
Number'
Averagebalance(s)
Ini.cials
Ii
-L.l.
,,oJv
\-J!
Checking.{ccount
Bank
Nurnber
Averagebalance(s)
r ! [ o n e v] l r r k e t a n d / o r N O W a c c o u n t
Nur'^rber(s)
Averagebalance(s)
NarireanCaddressot bank(s)
Location:
Policeagenc./:
CounDisoosirion:
(enienne.
v v
. 5 v l l v 9 .
Da t e :
Locarion:
CourtDisposirion:
(r-n
ton..o.
v v r l \ v l l U ! .
Date:
Location:
Age:_
Violationcharged
P o l i c ea q e n c v:
fniE,ials
CourtDisposition:
Sen f.'".o.
v v a r l v l l v ! .
Date:
Age._
Violarionchargeci
a
Location:
P ( \ l l a o
A v l l v v
a d o a - 1 t
r f Y . - r i L
/
.
.
C o u nD i s p o s i r i o n :
Sentence:
69. I{a''reriou eve: beensunaJrlonei.
subpoenaeC,
recuesled
or orher.viserequired,to testif'
betbreany nTunicioal,stateor federalagenc,r.
conr-niries
or orherinvesrigativebodv?
If 'res,gil'e corrrDiete
derails:
iC.
Ha','el,,oue'/'errecej',,ei a suJTijlonsibr anl.vioiaric;nof ine f;sn aiid qamq la,vs.?
If
'i 3s.ccn:rielethe
-oiicrvrng:
'v'io
laricn.
i)ate:
cc'
Locaiion:
P:naiii':
7i.
P o i i c e. i q e : c ' i i n i ' c i , . ' e i :
I{ar"evou e'ierbe:n aresieCibr. or chargeC'.v'ith,
a vioiationof ihe Cisord,erl;r
oersonslct
or cii'orCinance?
Date:
Ii;,rs5,insen the infomrarion
iequiredbelol,v.
'.
Violation:
Location:
CounDisposition:
Penairu:
Dare.
P o i i c eA g e n c ' ri n v o l v e d :
V i oi a r i o n :
Locetion:
Ponr
M l g l l
A se'
Ase.
CourtDisposition:
itrr'
t
.
lJ r te'
Location:
V i oi a t i o n :
A se'
C o u r tD i s p o s i t i o n :
fni cia1 s
' F
P e
n .r I trz'
v.r4al/,
PoIiceAgencyinvolved:
r
72. Flav'eyou everbeenalresied,indicteC,or convictedfor any violationof rhecriminal
law?_
If yes,complerethe informationrequirecbelow:
Date:
V'iolarion:
Location:
A oe'
CourtDisposition:
Penait'r:
Date:
PciiceAgencyinvoiveC:
Violation:
I oe.
Location:
Penair;:
73
PoIice A genc;-invoiveC:
i{ave !'ou e!'er hacl: cinalnal or er:est record expunsec?
if i'es. give coilclere
C e l a i i sc e i o r v .
71
liave !'ou ever beenheld as a mateial '.virness?
**
Dare:
Violation.
a
Location:
Your Ase:
if yes,insen the informarionbeiow.
^'
_ L0un ulspostnon:
Policeasencv:
V i oI a t i o n :
Date:
Location:
Penalt'r:
A oe'
CoqrtDisposition:
PoiiceAsencvinvolved:
75. !{a','evou ev'erbeenheidasa suspicious
personor investigated
by any law enforcement
or
r00)
fn:-ciaLs
p.ivatesecurit,v
agencyfor any reason?-
if yes,give detairsberow.
75' I{3'"'e!'ou e'/erbe:n t-ingennntei rcr an;rreason,nor to
subn:iningycur appiicatjonfor
ln',,'....,
cirri-'ruvrrjeo[
w'irh this agency?
_
l!-l.ren
lliere
Frnn
If ,ves,cornolerefie foll0rvine:
p.lrcose
SUBl'E RSIrv-E.rFFtt t^ ttn *t
71
'{-re';6uioui' cr hg'ie'r'ou3','3tbeen.e neniber of in1,'oi-g:::izarion.
assocjaticn-n:overnenl
or :rouD-whrch ai';oceiesihe ovenit-ro,,v
of oui ccnsiiiirionalfbrE
of gol-erru-aentor
wiucn seeksio alie: ihe ibnn of ihe
-o!'er:tmenrof ihe UrureCStatesby unconstiruricriaior
unialvfuimeans.or who's purposeani intentis to ,rnja.,.vrul]y
denv or circurnventt,hecivii
n-z]:cs
of r:r;rperscnin rheuniied Sraieso.this Srare?
t
78' Aie you iiow, or haveyou el'erbeen,affiiiateCor assoclated
with any of rhe organizations
or srouDsCescibedin questionT7above?
79' 'A-re
you norvassociating,'vith,
or ha,.'eyou e,/erassociateC
rvith.any individuals,including
reiatives,
who you kno'uv
orhav'ereasonto belie,reue, orhavebeen,membersof any
organization
or qroupsdescribedin question77 above?
R 0V ' r
Hrr d
t ' e' \ G
' nu
rrp
n F -^ll^ir^J
^rL^
Q
y\ , u
srv/ es- i )c ii -S- or.rl s uo
r s o l i c i t e Co
t h e r st o s i g n a n y p e t l t r o ns p o n s o r e C
o r i s s p e db y a n , v
fniEials
organrz3tron
or groupdescribed
in question77ve,oranypetitionwhich
has as its
purposethe aidingof any person,cause
or progam connected
in any way with
organizrrions
gouDs
or
descibedin quesrioni7. aoove?
6 !.
flave vou everpanicipatecin a.nl/of the foilorving
aciivities:.
a' Aitencanceor panicipationin any parade,
pickecune,deiegarion,
demonstarion,
;di'\'r'
: i - s : r i r ruruirir'
innrrn
n
r
.
r
^
r
o
n
r
n
ui PIUJc'-L
sponsoreior organiz:db,uany or?aniz3,tion
or _group
descibei in quesrjon77 above?
_
b
\ ' /'
r " riP
- ' : r:rL
n
. - tLi ^L- l u l l^ f ^
IP rJv-v
rrs
Ur l, ^u. rvl li,'.rc
u t i fi ]/ xnonev, dues, ccnri buti ons, or d,onati ons
to anv
n i z e r i .r..,vr -r a ^ .
\,!5.ir114dL1url
ur'goup
vr
-r\-JtltUgu
Iin
II q
question
UgSiIOn
v \ : \ . / r r y \desci-ibec
77
/ / above?
nrtT
Saieor iisurburionof any wrrnen or prinredrn
fn.-lfrPt...brsvr
nrPn:ror'i
vg(d
vt
v\J,
pubiishedby a s'ouDor organizeiion
descnbecin questionjT
reproCuced,
or
or by any of irs
a ooatn)
s<'v^l,LJ.
d. P"rchased
or
n l ls r! \ l l q . - a l 1
V
. ' lo e -
5 \ v l { L J ,
8i.
l l J l l v e
i<')
ii-vou fns.,ve:ei'.1TS" to anv, r i : h c
v!
-{av
r h n , yr -v ,\ . r{ L,f rv -. j .[ l v. l '. t J^. - ^
suv
iv Y
-\trln'
. \ g r 9 t 1 - .
. !
J. rlI
L J-d:
>
iVtOTORVEHICLE HISTORY
83'
I{aveyou et/erreceiveca sutnmonsfor violationof the NIotorvehicie
otherstate?(E.xciude
Parkingviolations)below.
Date
3-l
Offense
Locarion
Laws in thisor arly
If yes,inten rherequiredinformadon
CounDisoosition
policeAeency
-"v
as !'oui \[otor !'eilcie R.:gisi;arion
Cenlncare,
Ddver'sor othervehicieoperator,s
1icense
e,ier re'ioked?
Suscendei?
if ves.which iicense?
l!}ea'l
. \v nerel
ll-irv?
Was ,v"our
R.egisn'adon
Cenif;cateor Drjver'sLicenseever restored,?
When?
Where?
85-
Have)-oueverbeenin"'olvecj
in a motor venicieaccidenrercheras a registered
orvner.
operator,passenger
or peiestrian,which resuiteC
in properiydamageor personaiinjury to
you or somecneeise?
If ,ves,gi,zecietails:
Ini cial s
86'
Do;roucurTently
orhavel/ou everpcssessed
anyofrhefollowing?If yes,providethe
[oi lowing informarion
:
a
a
vlororv'ehicieooerator'sLicense.srate:_
DareIssued:
Expires:
LicenseNumber:
placedupon license:
Conditions
Nanielssuecio if dirierentnom apolicani'scurenrnarne:
CornrnercirlV'ehicieCperator'sLicense:_
Siare:
T;rpe:
LicenseNurnber:
E.r:ires:
Date IssueC:
Conditior:s
p iac:i'rponlic--nse:
:_
Stare:
Darelssued:
l- Y'1 li-aq'
Condincnspiacei
\-a-neissuec,
ro if diliere::troni acciicar:i'scurg:ir:r.ane:
Date Issuei:
i icenseNumber:
Bi-an-nuai
due:
Is this licensecu:;ent?
Conditionsplaceiuponlicense:
\\
t;
Nane issuecto if cifferenrfroriracoricanr'scurent nalxe:
87
Do y'oucurre::riy
or have.vou,*irhin thepastfive;re:rsolvnecl
a motor vehicie,powerboator
airc:anof an;rkinci?_
Troe
If yes.providetheroiiorving
informarion;
Resisrrarion
Number State
iVlake
& ]{odel year
presentlvOrvneC?
fni-ciaIs
88.
List nameand addressof company
which can'iesyour autoor orher rype craft
insurance:
89.
I{as your auto or othertype cra-ftinsurancseverDesnrevokei or refi:sed?
.If yes,
give detuls:
90.
Ltsl beiorvali crcfessic",nal.
civic ari sociaicr.gariz:rions
of w'hicirluou113',,,e
been r
nei:ber williii: lie iasi fh'e 'r'ears.('Ctnerth.anlaboror frai:nai)
91. What voluntesror corutxunityactivitieshaveyout."greedin within the last five years?
Providethe nameand addressof the sponsoringorganization
or group and a d,escription
of
Lheactivities performeC.
fni cial
s
92'
93.
Do ,voupossessexperiiseor competence
in a particulartrade,skill or techrology?
If yes,bnefly describeyour level of expefence
andcomDetence.
Wharhobbiesancisponsdo you engagein?
N o t e : I f t h e r ei s o t h e r i n f o r m a r i o nw h i c h m a v b e i ' e i e v r r f .d i r e c r l v
o r i n d i r e c r l v ,t h a t t h i s
a g e n c vs h o u i dh a v ek n o w l e d g eo f i n o r d e rt o c o n d u car t h o r o u g h
background
i n v e s d g a d o no f v s s , a s a c s n d i d e t ef o r e m p l o l ' m e ni tn c h i se g e n c y ,
or insufficient
spacewas providedabovefor completeauslyers.
you rre requiredto add tbis
additional information on a separateskeet(s).InCicate
the ouesiionnurnberihe add.ed
infoi':iation applies.to.Attach any additionallasesai the backof this
fbrm. InCicate
belo'wthe numberof aicitionaipagesartached.You are remindedthat any
false
d e l i b e r a r em i s s t r t e m e not f f a c t sc a n r e s u l ti n
or
_ v o udr i s q u a l i f i c e t i ofno r e m p l o y m e n tb y
thisagency.
A c c : l i o n a io a g e sa t t a c h e i :
Iniuials
STATE OF NE}V JERSEY
COUIYTT.OF
I,
being duly sworrtrdeposeand say
arnthe abovenarnedperson- I personallyread
andenteredanswersto eachand
evervquestionthereinand i do soiernniysrvear
thateachand every answeris full.
cmeand correctin evervresDect.
A p p i i c a nt ' s S i g na t ur e :
Drte signed:
Srvori:beforeme this
day of
r999.
(Seel)
Sr g n r r u r e
DCNCT\\?JTEBELOWTiiis LD.E
SICNATLT.EOF .{PPLIC.J}T SIGNEDI.\ PR.ESENCE
OF IWESTiGATOR.
Invesrige
tor:
Agencv:
\ t,--1n
I'a
t:
NOTE:.- Theappiicant
mu:i providethree,.f.r.nces'frorn
fgnutation
end :hilitrr
r-,,Frl'- ^^-li^^-r
Hif'l'Jf,**jf,.y.:J,llrpl':g
J,DPI tl- {-rYr.r\r
t^APPLICATION.
. ,
|
-
reputabiecitizenswho have
il[..H;?o
n.,o,
ifti rE3';
il ;i&:ilT:T.
,w^.r lvr
ulg
Llullg)
nr:rr:-r,rr'-r?^F
R a- .
REFTRENCES
illAy Nor BEivrEMBERs
oF
Ybffiifr#&i6ffiiiirl'
, rv r rvt\
lJ,c
I .cll
recttvro rbirs
a g e nc v .
l F a F r < ' -
J-tl.,l-LI€lJ->
I
APPT,ICANT
REFERENCR
E EOUEST
R_EFER..ENCE
FOI1:
who is seeking
NAMIJ
enrpioymerrt
with the
asa
Position
I. theabovenamedappjicantrequests
that
serve
Reference'sName
as 3 personalreierencefor rneand to provice this compieted
reference
forrn to the abovenamed
agenc"''I hereinfequestandauthonzeyou to provide'any
informationrequiredin compietrng
thg :oilowlng
;orin.
Y o u a r e i - e o r r i r e r Jt o r e q n n n r l ' - r r i . f , , : r , ,
an
dinp.oui;rnginroimari
on,#';'J:ffi ::L'r:Tri,il
i!:fff f;i'jTjJn?,}Kffi fi[.,
ihe positionI seek- I hereinauthorizeyou to proi'idetiri rJquredinformation
evenif it that
inforrnationmight unfavorabi,v
impactupon my apolicailonrvirhthe abovenamedlaw
en:brcement
agenc./.
.
'\;-21!
Date:
:P
.1:
:rnlr.r-r
TC THE VOUCHER:
As a voucher,you arerecuted to resDonrtfirllv an,.1
in:thr,rllliin &e answersvcu
prcvicie
beiowanci
in iny otrr..,h.i"fb;;il;r*";;";";;;;il#-H;
il;canr
WhO SeekS elnninr,,rnenr rr;ith elaW efifOfCen:ent agenC;r.
The vouchershouidreaCcarefullyand respondtuthnriiy io all cuestior:.s
and in all sraten:enrs
prcvidedbeforesigr^ingtlus referencefonn. All infoi-rnaiion
prcviciedinrrsr
^i i uJLhe
Y ^uvu bviire
vv nroviriert,
v ouc her and ' ,^ z i rl i .:.i
tJ p e ts o n a l
' i ^" ' ^* --
l ;c w i e dge
of ,i e vouche:.
vrv
:,ffi
i'trprovid.ed
JH:
:,'i#
Ii;l;li'";:,
fffrffi5;F:",ff
!i?,[T.":i:.;#
il]*xl:,an
daII
i;ii
the staiernentsand information
herein by me is tn:eto the bestof my knor"leige, and
I aiir not reiateci any way to the applicant.I wili, uDonrequest,grve fi.rrtlrerfacis concEming
_in
the applicantas-ima,upossess.I understand
thatmy^response
wifi be considered
to be
conflcientiai
and noi providedto the aoplicant.
(PLEASETYPE OR PRINTBY HAND ALL RESPONSES
REQUIREDBELO\ry)
VOUCHER:
Nar:re:
Soc.Security
No.
H o n r cA d c i r e s s :
Inlcials
Phone:
BusinessAddress:
(Optional)
Phone:
OCCUPATION:
How long haveyou personallyknownthe appiicant?
officer?
In ;rouropinion would the applicantrnakea good iaw enforcement
rf -'n' \,vp!-p
i''' danger,would you want the applicant to be the officer assigneCto assistyou?
LI
jwLl
tYu^v
rLl
I
.W-trv
In your opinion, do rnostDersonswho k-no.wthe applicanrasrvell as you agreewith your
of ihe appiicant?
assessment
\\;ir.""?
W1ratdo you beiievethe applicant'smost significantatti'outesare?
workto impro\;euponandhow would
shouidthe appiicant
In;rouropinion,whatdeficiencies
officer?
larvenforcement
t6atimprovementhelp the applicantto be a successful
Inicials
Do you personallyknow of anyz
reasonwhy the atplicantshouldnot be hiredasa law
enforcenaent
oficer?
Gn a scaiefroi:i one to ten, wherewoulciyou placethe aolrlicantas an individualwho possesses
all of ihe character,qualities,personaiityand mentalabilig neccssaily
to be agoocia:rd
successf,rllaw eCcrcementoffrcer?
Or a scaietom one to ten.whe:edo.voupiaceyour ievelof com.fonandwiilingressio
sel-;eas a :eibrencefor this acplicani.klo..r-ing'.-hai
tils agenc.vwiii grve sigruficanrweig!.t
ic youi t.5;6,nsesrn Cetern:-Lrng
w.helheror noi to einploi"'tbrisacpiicantas a law en-forceieent
cff.cer?
Pleaserefum this referenceby mail to the personnoted below as soon
as possible:
Inicials
End Of An Application
NextPage,
BeginsAnother
ci.
APPLICANTNO.
BACKGROUN
D INVESTIGATION
QUESTIONNAIRE
INSTRUCTIONS: Read through this entire questionnairebefore completing the required
information.
Answer eYeryquestion.If a question doesnot apply to you, write DNA in the spaceprovided
for the
answer' A candidate wiII be reiected from the selection processwho has intenfionally made
a false
statement or ptxaticec;'or $ttemp-ted,,to,,praf.tice'anv,;:deceufion
opjffeud,ifi this,::'qugstronnaire,
in any
examination, inten'lew; or in securing exgibitity,,lor,employment.,Anvmisstatement
of fact is reason
for disqualfficationfor emDloymerlt,,'61
may be punlsnetl by law as per N.J.S,,ZC:zg_Zr2C:2g_3,and
2C:28'7. The questi0nnatre,:::,lrltjst
be prepareuby the apphcant,wrth the excepuonof,,ReferenceInformation. Referenceswill comptete,date,andsrgn,**o uwn,,:regurred,,inforqration
for suomissionwith this questionnaire.All entries,exceptsrgnanrre,,
musr De Dr.rnrerlregibly,by tne applicant in black ink. If there
is insufficient spaceavailablefor answsrtng".dl-lrr,:guestruui
rse,the i:onfinuauon pages provided. In the
event more continuationpagesare needed,,you.
ftrir#,,,,In8K9
coples of a blank continuationpage and submit
as needed.Precedeeachansweron confinuatloniirp-ages::W11X
ne,coffespond.mgsection title and number of
the questionbeing answered.
UPON COMPLE TI ON, TEIS.. OU]E,SjFTONff*IR.E"MIIST BE NO TARI ZF,D.
PRINTNAME
Last(IncludeMaidenName)
Frrsr
-
MAILING ADDRESSNumber& Street(or R.D.#)
Counly
-
Middle
-
{-lty or Town
State
Home Phone Numoe'
Cell Phone Number
/\
tl
/\
t\ l, /
\
-,t
E-Mail Address
Web SiteAddress
IF CURRENTRESIDENCEIS DIFFERENTFROM ABOVE, COMPLETE THB FOLLOWING:
RESIDENCE LOCATION Number & Streer,ApartmentNo.
City
State
County
Home PhoneNumber
()
AN EQUAL OPPORTUNITYEMPLOYER
Zip Code
READ THIS IIVFORMATIOIVCAREFULLY BEF ORE
COMPLETI]YG THIS OTIESTIOIYIVATRE.
NOTICE:
This is to inform you that this background investigation questionnairewill remain a
permanentpart of your file with the
. Your failure to neatly and
thoroughlycompletethe requiredinformationwill be reflectedin a negativemanner.The
Background Investigation Questionnaire (BIQ) and additional required documents
listed on the back cover shall be submitted to the
by the
(BIQ) submission deadline date. Any required documentsnot provided at that time
must be submittedto the
. If you do not submit a completed
questionnaire,
your participationin the selectionprocesswill be terminated.
Pursuantto the Privacy Act of 1914 (P.L. 93-579),I reahzethe disclosureof my social
securitynumber is voluntary.I also realize my social securitynumber will be used for
the purposeof facilitatingthe backgroundinvestigationauthorizedby submissionof this
questionnaireto the
An applicantwho has not supplieda social
securitynumber may inhibit his/heradvancementin the selectionprocess.Any infornation releasedas a result of this questionnaire,including the furnishingof a social security
number,shall be used for the expresspurposeof processingthe applicant'sbackground
investigationwithout delay.
APPLICANT NOTICE:
You are requiredto promptly report any significantchangesin your personalbackground
informationor involvementin any incidentwhich mieht resultin criminal or civil charses
beingbroughtagainstyou while you are an applicantin tht
selection process.This includes,but is not limited to: changesin your address,employment,
or marital stafus;motor vehicle accidentsor summonses;chargesor convictions for any
offense/crime;civil matters(bankruptcies,liens/judgments,etc.); or involvement in any
incident*lt--qttcould194 Locriminal or civil charges.Failure to advise the Recruiting &
of anv of this information
could adverselyaffect your statusin the selectionprocess.
WITHDRAWALS:
Any concerns
or requests
thatanapplicant
may haveregardingwithdrawal from this selectionprocess
mustbe directed
to the
,AN
applicationfor withdrawalwill be completedat this time.
The picture attachedto this questionnairewill be used solely by investigative
personnelin the courseof their duties to accuratelyidentify the applicantwhen
verifuingthe accuracyof the informationcontainedin this backgroundinvestigation questionnaire.
ATTACHPICTURE}IERE.
A. PersonalData
l.
Full name:
LastName
First Name
Middle Name
2.
List and explainany othernamesyou haveused,or havebeenknown by, includingnicknames:
3.
Placeof Birth:
City
4.
State
Birth Certificate:
CertificateNumber
5.
City
County
Date of Birth:
State
Zip Code
Age:
Month
6.
Z\p Code
County
Height:
Day
Year
Weight:
Eye Color:
Hair Color:
List ALL scars,marks,and/ortattoos(Full descriptionand locationof all):
Pursuant to Federal Privacy Act of 1974 (5 U.S.C. Section 552a (note b)), the State Police is requesting the voluntary disclosure ofyour social
security humber lfyou gite your consentfor the useofyour social security number,it may be used: (l ) to |erify your identity: (2) toaidinthe
processing ofyour application; (3) to aid in the completion of a criminal history bockground check; and (4) to aid in the collection offmancial
obligations. The provision ofyour social securit.vhumbet demonstratesyour consent to its vsefor any of the purposes set forth above and that
you understand that your consent is voluntary and that ifyou do not consent, no adverse action or inference will be taken or drawn.
7.
SocialSecuriry
Number:
8.
Haveyou everpreviouslytakena writtenexamination
for employment
asa
Police?
Date
9.
E Yes
Class#
E No
IfYes, list dates:
Date
Class#
Date
Class#
Haveyou everpreviouslysubmifted
informationfor a background
investigation
to the
anypublicemployment?EYes
UNo
IfYes,Iist dates:
Date
Dat€
Class#
Policefor
B. Citizenship
10. Are you a cttizenof the United States?
E Native Born
11. Have you ever renouncedyour lJnited Statescitizenship?
f
Narurahzed
E Yes
12. Are you now or have you ever beena crtizenof anothercountry?
E Xot aCitrzen
E Xo
f
Y.r
E Xo
If yes,explain
13. If you area naturalizedcitizen,fiIl in the following:
Country of birth:
Port or place of deparfurefor the United States:
Date:
How were you transportedinto the United States?(Ship,Plane, Train, etc.)
Name of transportconveyanceand/orcompanyyou arrivedon:
Port or place of entry into the United States:
Date:
If a naturalized citizen,statethe name,addressand dateof birth of the personwho sponsoredyou on arrival:
14. First addressafter arrival:
15. How did you obtain citizenship?
16. PetitionNumber.
Date:
Court:
17. List countywhereyou arecurrentlyregistered
to voteandall countieswhereyou wereeverregisteredto vote.
Ifnone,checkbox E
County:
State:
Year:
County:
State:
Year:
County:
State:
Year:
C. SocialStatus
18. Are you: f, single
f married
E civil union E separated E divorced
E widow
U widower
19. Completethe followingon eachcurrentandformerspouse,
civil unionpartneror fiancee.If none,checkbox E
Name: Last
First
M.l. (Maiden)
Full Address: Number & Street
Relationship:
City
Date of Birrh:
State
Zip Code
Home Phone:
(
Occupation:
Name of BusinessiErnployerand Full Address:
)
Work Phone:
()
Name; Last
,,,;,
, ,,
First
i ,, ,r ,:rM,t,, (Maiden)
Relationshio:
.
.
:
Date ofBirth:
l
'
Statg ',
Zir: Code
cirv
ftromePhone:
, (,
Name of BusinesVEmployerand Full Address:
,Occlipatio,'n;
'
, , ' ) .,, , ,
WorkPhone:
(
)
20. Completethe followinginformationon your currentdatingrelationship
or partner.If none,giveyour mostrecent
pastdatingrelationshipor partner
Name: Last
Firsr
Full Address: Number & Street
M.l. (Maiden)
Reiationship:
City
Date of Birth:
State
Zip Code
Home Phone:
(
Occupation:
Name of Business/Employer
and Full Address:
)
Work Phone
(
)
21. Maniage/CivilUnion(s):
Date.
Where:
By Whom:
Spouse/Civil
Union Partner'sFull Name (includemaidenname):
Date
Where:
By Whom
Spouse/Civilumon Partnerlg Fuli Name (rnclude maidenrnameJ
2 2 . If separated,statereason:
^n
How many times were you separated?
24. If separated
or divorced,whatis thepresentaddress
andphonenumberof yourcurrentor formerspouse/civil
unionpartner?
(
Name
Full Address
PhoneNumber
25. List every separation,annulment,or divorcebelow.
Date:
E s.pu.",.d
Where Issued(Court or State):
Reason:
Piaintiff:
fl Annulled E Diuo...d
Defendant:
26. Are you the biologica1,adoptive,foster parentor stepparentor legal guardianof any children (whether children are
alive or deceased?
If deceased,explain:
E Yes
fl xo
21. List below the information on any child identifiedunderquestion26.
Name:
Date of Birth:
Placeof Birth:
Daleof birth:
Flacesf Biflh,:,
With Whom and Where
Does Child Reside?
Name:
.
:
.
.
.
.
I
WittiWhom anOWhete
Does Child Reside?
Dateof Birth:
Name:
Placeof Birth:
With Whom and Where
Does Child Reside?
Additional information
D Y.s
f
No
Seecontinuationpage
lfyes,
28. Are you courtorderedto pay child supportfor anyofthe childrenlistedin question#27? fl Yes ENo
to
whom
the
probation
dept.
involved,
or
for eachchild includewherethechild supportis paid,courtinformation
explainamountin arrearsandwhy.
supportis paid,andthe amountofchild supportpaid.Ifyou aredelinquent,
29. Have you ever beeninvolved as a plaintiff or defendantin a paternilyproceeding? E Y.t
E No
If yes, statefull details:
30. Family information: Father,mother, father-in-law,mother-in-law,currentand past stepparents,sisters/brothers,step
statein answer'
half-brothersand half-sistersnames:If deceased,
brothers/sisters.
Name:
Relation
Date of Birth:
Home Phone:
Full Address with Zip Code:
(
)
Work Phone:
Occupation:
Name of Businessor Employer:
Nane:
Relation:
Date,ofBntbl
Occupatioaq
of E:nployer:
N4meof Business
Work Phsne:
Name:
Relatron:
Date of Birth:
()
Home Phone:
F u l l A d d r e s sw i t h Z i p C o d e :
Occupation:
( ':'.
.,:.,
'....'.,,,,
) ,.
(
Name of Businessor Emplover
)
Work Phone:
(
)
Name:
Relation:
Full Addresiwith:Zip Code:
Date ofBirth:
Home,Phone:
t
OccupatiOtr,:
Name of Businessor Employer:
rI
,WorkFhone:
('' , , )
Additionalfamilv information E Y.s
D Xo
Seecontinuationpage
31. If currentlyengaged,
list parentsandstepparents
of fianceeor partner:
Name
Relation:
FullAddresswith Zin Code:
Date of Birth:
Home Phone:
(
Occupation
Name of Businessor Emplover:
)
Work Phone:
()
Relation:
Name:
Full Addresswith Zip Code:
Date:of,Birth:
tr{orneP'hsne:
1,,.
,(,, ,,,, ,,,.,,) ,,
Occupation:
Name of Businessof Employer:
Work'Fhone
(
I
Name:
Relation:
Date of Birth:
Full Addresswith Zip Code:
Home Phone:
(
Occupation:
Name of Businessor Employer
(
Name:
Reiation;
.tl
Horne Phone:
,{
Occupation:
Narne of Busingss or Enployer:
E Yes
E No
)
Work Fhone:
(,
Additionalinformation
)
Dateof tsirth;
' : i
FullAddresswith Zip Code:
)
Work Phone:
,)
Seecontinuationpage
32. List full names(first,middle,last- includemaidenname)ofthreefriendsand./or
associates
other than references
(listedon page23); employers,past or present;or dating relationship/partner.
Name:
Relation:
Full Addresswith Zip Code:
Date of Birth:
Home Phone:
()
Occupation:
Name of Businessor Employer:
Narne:
Relation:
Work Phone:
(
FullAddress with Zip Code:
Horne,Phone:
(i,
Occupation:
Name of Businessof Employer:
Relation:
FullAddresswith Zip Code:
')
Dateof Birth:
Home Phone:
(
Occupation.
,)
S/ork Phone:
(
Name:
)
Date of Birth:
Name of Businessor Emolover:
)
Work Phone:
()
D. Residence
to Present
From
33. Wheredo you now reside?
Number & Street
()
Counfy
City
PhoneNumber
Zip Code
Phone No.'
LandlordName:
Floor No. _
Apt. No.
State
(
)
Address:
Zip Code
State
County
City
No. & Street
or anyotherrealproperty?
34. Do you haveanyownershipinterest(eitherfull, partialor joint) in this residence
Block
List lot/blocknumbers:Lot
Other real properff, list location, including State/CountyLotlBlock:
otherthanyour spouse,civil unionpartner,parentsor siblings,list completeinformation
35. Ifyou residewith someone
below.Include any and all personswith whom you havelived during the pastfwo years.
Date of Birth:
Relationship:
Full Name ( Maiden):
Work Phoneand Ext.
EmployerandAddress:
Occupation:
(
(
:,!::. :,. : .:... . ,1:.:. :
(
(,,
::
Datesof Residence:
Work Phone and Ext.
EmployerandAddress:
(
)
Seecontinuationpage
E No
E Y"r
'' .i),''
Date of Birth:
Relationship:
Additional information
Dates of,Residence:
Wofk Fhone,andExt-
Ernolover,and AddresS:
Occupation:
)
Dateof.Birth,
Relationship,l
Full Name ( Maiden):
Datesof Residence:
Work Phone and Ext
Employer and Address:
Occupation:
)
Date of Birth:
Relationship:
Full Name ( Maiden):
Dates.ofResidence:
Work:Fhone and Ext;
Employer and Address
@gupat!on,
)
Date of,Birth:
Relationship,;1
:Full Naroe ( Maiden):
Datesof Residence:
36. Past Residences:In chronological ordeq startingwith the most recent past residence,stateeachand every previous
residencesincebirth (include collegeresidence,summerhomes,military residence,etc.)
(Apartment#)
FullAddress:
FROM:
Yr.
:FROM:
Mo.
Yr.
F u l l . { d d r e s:S, ,:, , , { A p a 1 t - m e a t , : # ) :
ito:
Mo;
, i i i i , :
:
: : :
:
. : . r
: r
: :
r r
Iandlord:,Phone No.:
I-andlofd Name:
(
:
Statb:
ZIP:f,ode:
Mo.
)
County:,
(Apartment #)
Landlord PhoneNo.:
Landlord Name:
TO:
(
Ciry:
Mo.
County:
Yr,
Fuil Address:
FROM:
Zip Code:
Yr.
Gily;
Mo.
Landlord PhoneNo.:
()
State:
City:
Mo.
Landlord Name:
TO:
Yr.
State:
Zip Code:
County:
)
,,;,:; : ;:; '::;:;(ApartmClt
#)
FntlAddrgss.,'
TO:
Crty:
Mo.' Vr.
Irrlo.
State:
(Apartment#)
Mo.
I
State:
(Apanment #)
Full Address:
ciry:
Yr
FROM:
(Apartment#)
Yr.
FullAddress: ,,,
TO:
,, (Apartment#)
Yr.
Yr.
(Apartment#)
Yr.
State:
Mo.
,
TO;
{Apartment #)
Yr.
FROM:
Mo.
( A p a r t m e n#t )
Yr.
FROM:
State:
(Aparrmenf#)
Yr.
Zip Code
tandlord Narne:
r:statg;
Zip Code;
(Apartment#)
LandlordName.
Counry:
LandlordPhoneNo.:
(
State:
Zip Code:
(Apartment
#)
FullAddress:
LandlordName:
)
Counry:
State:
Zip Code:
Landlord PhoneNo.:
(
)
Counry:
Yr.
(Apartment#)
Landlord Name:
TO'
Mo.
," '
Yr.
TO:
Mo.
Landlord:PhoneNo,:
Yr.
TO:
Mo.
Counfy:
(,,,)
LandlordPhoneNo.:
()
State
Zip Code:
County:
Yr.
TO:
#)
{Apartmenl
FullAddress:
City:
Mo
LandiordPhoneNo.:
Landlord Name:
TO:
Mo.
)
Counry.
Yr.
City:
Mo.
Zip Code;
()
FullAddress:
FROM
Landiord PhoneNo.;
(
TO:
Mo.
)
Counry:
''.'.
Mo.
City:
Yr.
Zip Code:
tandlord Name:
State;
City:
Mo.
LandiordPhoneNo.:
Yr.
Full Address:
FROM:
Landiord Name:
(
cilv:
Mo.
)
Counryl
TO:
Full Address;
fROM:
LandlordPhoneNo,;
L?ndlordName:
Yr
Mo.
\-r t)/ ,
Mo.
)
County:
{
FullAddress:
FROM:
Zip Code
Z)p,'Code:
City:
Mo,
LandiordPhoneNo.:
Yr.
Mo.
Full Address:
FROM;
\
)
Countyi
LandlordName:
State:
City:
Mo.
(
t
Fuli Address:
FROM:
Tip Code:
Landlord Phone No,:
TO:
City:
Mo,',' Yr.
County:
Yr;
Mo
ciry:
Mo.
Zip Code:
LandlordName:
Starc:
FullAddress:
FROM:
LandlordPhoneNo.:
LandlordName:
t.
TO;
FROM:
Yr'
Counry:
()
City:
Mo.
.:
(,i:..,,..',.,.':',,
),:,',,'::,,:,,,'
Wr
Full Address:
Yr.
Zip Code:
,!.q4dlordPhone No.:
TO:
FROM:
Mo.
Na4e :
,Landlor.d
LandlordName:
Landlord PhoneNo.:
()
State;
Zip Code:
Countyl
Mo. Yr,
Additional information
E Yes
I
No
Seecontinuationpage
E. Education& Intern StudyPrograms
Uponreceiptof thisapplication,
I will immediatelyordertranscripts
from all collegesI aftendedandhavethemsentby
thecollegedirectlyto:
(Proper fee must be forwarded to the collegeby the applicant.)
Date Transcripts Requested:
37. List (mostrecentdatesfirst)all postsecondary
schoolsattended,
includingtradeschoolsandcolleges/universities:
Name of College:
City/Town of Collese:
List Major:
County:
Io
From
Degree: Date of Graduation: # CreditsEarned;
Month
CirvlTownof Collese:
State:
Yr.
Month
Name of College:
City/Town of College:
List Major:
(
)
County;
Degree: Date of Graduation: #,Oredits,Ebrned; ,:'Fron:t
List.lMajor
Collese PhoneNo.:
rr.
Month
No.:
[on"*.ln"ne
To
Yr.
Yr
Month
County:
State:
To
From
Degree: Date of Graduation: # CreditsEarned:
U Yes
)
Monrh
Y I
[l Xo
Zip Code:
ColleeePhoneNo.:
(
M
Additional information
Zip Code.
Seecontinuationpage
3 8 . College Intern ProgramInformation:
to
Company or OrganizationName
Dates Participated-
Immediate Supervisor
Additional information
Area Code & TeleohoneNumber
E Yes
E Xo
Seecontinuationpage
3 9 . List chronologically(mostrecentdatesfirst) all schoolsattended,grades9 through 12.I will submit the form
provided requestingrecords from all high schoolsI attended.
Date Transcripts Requested:
School:
PhoneNo.:
Fro.Month/Year
Address: Number& Street
Month/Yeer
City/Town
Sohsol:
FfOm
,
State
(., , , ,)
State
Zip Code
School:
PhoneNo.:
From-
Address: Number & Street
Month/Year
City/Town
Sffioo1:
P;gp
State
' , . : ., , : , , ,
,' ,,T"
, : .,
MonfliAy'Fr,
Address::,:Number& Slfeet
(
ToMonth/Year
::..1
M.rinih/Yeqr
)
Zip Code
,
County
P.honeNo.:
( : ' , , ,' , l ; , 1 . )
CiTAOwI}
School:
P h o n eN o . :
From
Address: Number& Street
Additional information
County
P-hqneNo,:
MnnrLlV*"'
CrrylToyt
)
Zip Code
-.rr:::.::
l,,TO
MnnrhlVpor
rNurnber
& Street
Adrlress:,',
(
To-
City/Town
f
Yes
E No
()
To
State
Zip Code
County
Seecontinuationpage
40. List any suspensions,expulsionsor disciplinaryaction takenby the college,high school or trade school attende{.
School:
Year:
Reason:
School:
:Year:
:ReaSon:
School:
Year:
Reason:
Additional information
E Y.s
I
,.:,:,,::.,','
Xo
Seecontinuationpage
training(i.e.,teaching,
41. List otherformalschoolingor specialized
EMI tradecedification,SCUBA,counseling,
intemprograms,etc.).Submitrespective
certification
documents.
A.l
Date Anended
School /CourseName
Location
Certification
Date Attended
School /CourseName
Location
Certification
Date Attended
School /Course Name
Location
Conificatior
Wereyou everor areyou a memberofany social,ftatemal,chantable,educationalor nonprofitorganizations(include
organizations)?
collegiateteam,club,andcollegeftatemity/sorority
D Yes E No Ifyes, list everysuchorganization.
From
Mo
To
YT
Mo
OrganizationName
Tlpe of Organization
Yr
OrganizationAddress and PhoneNo.
Additional information
E Y.r
E Xo
Seecontinuationpage
F. SelectiveService
43. Draft RegistrationNumber (Male applicantsonly):
RegistrationDate:
To obtainyour Draft Number,cali (1-847-688-6888),
or visit www.sss.gov.
43a.Date you faxedyour "Requestfor Military Records"to (314)801-9195:
G. Militarv Service
44. Haveyou everservedin an activemilitaryorganization
of theUnitedStates?E Yes E No
4 5 . Haveyou everservedin a militaryorganization
of anyforeigngovemment?B Yes
I IVo If yes,give details:
46. Give branchof service:
Military Specialty:
41. Rankheld:
4 8 . How manyperiodsofactivemilitarysewicehaveyouhad(drafts,enlistrnents
or recallsto service)?
Notethe branch
ofservice:
49. Give period or periods of activeservlce.
From
To
From
To
From
To
From
To
from the servicewere issuedto you?
50. How many dischargesor separations
honorableconditions):
(honorable,dishonorable,
51. List type of discharge(s)or separation(s)
Be exact.
E Yes
52. Has your dischargeor separationnotice ever beencorrectedor changed?
f, Xo
53.Ifyes,whatwasthenafureofthechange?Changedfromto
or wereyouthesubjectofa summarycourt,deckcoud,captain's
tried on charges,
54. Wereyou evercoufi-marnaled,
or anyotherdisciplinaryaction?
mast,companypunishment,
fl Yes
E No
Numberof times:
55. Ilave you everbeenthe subjectof a militarypoliceinvestigation? EYes
andfactssunoundingtheincident:
Ifyes, give detailsof allegation(s)
ENo
whichresultedin disciplineor counseling?
in command
56. Haveyou everbeenthe subjectof an inquiryby someone
If yes,explain:
f xo
E Yes
States
57. Are you now or were you everan activeor inactivememberof the ReserveForces(any branch)of the United
or the National Guard of any stateor any foreign government?
E tSo If yes,statewhich - activeor inactive
E yes
Branch:
Rank:
Unit:
Resiment:
From:
Address:
10
To:
H. Employrnent
58. PresentandPastEmployers
List all presentemployer(s)first,includingpart{ime andself-employment.
ThenCHRONOLOGICALLylist all
previousemployment,beginningwith themostrecentpastemployment
backto theageof 18.OMIT NONE.If applicable,includedatesof militaryservice,school(notworking),part-timeandsummeremployment,
andunemploy- AttendingCollege.
ment.For example:9197to 6/98Unemployed
From:
To:
M".
)t
EmployerName and CompleteAddress:
Occupation:
t/.
M".
ImmediateSupervisor:
PhoneNumber& Ext.
ReasonFor Leaving:
()
F{9,T,1,,.,,, To:
EmployerName and Complete Address
Occupation:
;l4t;.rIFl
Immediatb'Subervisor:
: :: :: ' :, ,
:l ir: .
: : : , , . .:
From:
:: ::. . .
::.
::
To:
Mr.
\a.
.:
:, : .t.:
ReasonForLeaving:
Employer Name and CompleteAddress:
Occupation
t/.
Mo.
Immediate Supervisor:
PhoneNumber & Ext
ReasonFor Leaving:
()
F r o m ; , ,, , , ,
'
Employer Narne and Complete Address:
Occupation;
t "
,:,"',.
.,,Mo:',,i..r":Yr.
i
ReasonFor Leaving:
To:
From:
Mo.
\t
EmployerName and CompleteAddress:
M".
Occupation
\f .
lmmediate Supervisor:
PhoneNumber & Ext
ReasonFor Leaving:
()
From,
, .,,,'
1 I o : ' ' ,, ,
EmployerName and CompleteAddress:
Occupation:
,.,..,.:,.:i
.Mt.l,.:G.
146.:
Y1.
'
Immediate Supervisor:
PhoneNumber & Exr.
ReasonFor Leaving:
]::]
...:',..':()
From:
M".
EmployerName and CompleteAddress:
lu.
\a.
Occupation
t/a
Mo.
Immediate Supervisor:
PhoneNumber & Ext.
ReasonFor lravins:
()
Ftom:, ,, ,
ht
,, ,.
------_---::.i.
+
EmployerNa:neandComptrete
Address:
:Mo.:, :Yr.
Mb. : ,":',Yr.':
ImmediateSupervisor:
, ,',,',: .:
'
. ' , : ,
Occupation:
: l :
,r)
r
PhoneNumber& Ext,
: ,
, .
Reason,For
L,eaving;
: ' : : : : :
t\
Additional former employment E Y.s
E No
Seecontinuationpage
11
.
59. Are you now or haveyou ever engagedin any businessasan owner(activeor silent),partner,or corporatemember?
ENo
EY.r
If yes, give details:
60. Were you ever subjectedto disciplinaryactionin connectionwith any employment?E Yet fl Xo
If yes,explain:
6I.
Were you ever terminatedor askedto resignform employment(this doesnot include being laid off)?
List eacheventbelow.
How manytimes?
E xo
E Yrr
Date:
Reasonfor Discharge:
PhoneNo. and Ext'
tmmeAiateSupervisor:
()
Emplover Name & Address:
Date:
Reasonfor Discharge:
PhoneNo. and Ext
Immediate Supervisor:
()
Additional termination or resignation B Y.s
Exo
Seecontinuationpage
62. Whether or not employed in a specificarea,have you everbeenprofessionallylicensedor certified(i.e., law, real
estate,nursing)? E Yes
E No
If yes,iist:
If so, is licenseor certificationcurrent? E Y"s
E No
If no, explain:
63. Hasanysuchlicenseor permitbeenrevoked,cancelledor suspended?EYes
INo
64. Were you ever or are you a member of a social,labor or fraternalorganization? E Yes
If yes, list every such organization.
To
From
Yr.
Mo
Mo
Mo
Yi
.M;..
D Xo
OreanizationName:
Type of Organization:
OrgamzationName:
Type of Organizattonq
Y T
T0
From
Ify"t, give details:
Yi
OrganizationAddressand PhoneNo,:
(\ )/
Additional information
f] Y.t
Seecontinuationpage
D No
T2
insurance
or otherfederal,stateor localbenefitsor assis65. Haveyou everappliedfor andreceivedunemplolnnent
tance? E Y.t
Exo
If yes,explain:
Local Office:
BenefitAssistanceGiven:
Address:
Give periods:
From
To
From
To
From
To
From
To
Additional information
E Ytt
f
Seecontinuationpage
Xo
publicassistance
or
insurance,
workman'scompensation,
66. Haveyou everappliedfor or receivedanyunemployment
allowanceor benefit?
disabilityinsurance
pageIfyes, explainon continuation
E Y"s E No
agencies.
submitted
to otherlaw enforcement
67. List applications
P h o n eN o .
Organizafion& Address
Additionalinformation
I
Y.r
Test Date
App. Date
Withdraw
Date
Reject
Yes/No
Seecontinuationpage
E Xo
6 8 . Have you ever attendeda police academy? D Y.s
Status
E Xo
Dates
If yes, where?
Reasonfor discontinuine:
13
Graduated?
I. Financial :
pension):
loans(mortgages,
homeequity,education,
69. List all FinancialLiabilities;creditcards,utilities,insurance,
AccountNo.:
Original Amount:
Typetr oan/CreditCardl
,Sgcou6t:fls,1
Address:
Name of Institution:
Tloe Loan/Credit Card:
Monthly Payments:
PresentBalance:
Address:
Name of lustitution:
Oiig-inal,$mount:
Amount of Arrears:
Monthlv Pavments:
Present,Balance:
AmountofAnears:
' l . , ., , , . : . .: :: . i : ' , , , 1 1 : ,
Account No.:
Address:
Name of Institution:
Type Loan/Credit Card:
Originai Amount:
Monthlv Pavments:
PresentBalance:
Address:
Narneof Institufion:
Typel-oan/CreditCard:
. l t l
i ' :
Accourtt,No.:
0risiflal:Amount:
AccountNo.:
OriginalAmount:
,:
i,,
OriginalAmount:
Amount ofArrears:
Address:
Monthiy Payments:
PresentBalance:
Amount ofArrears:
Address:
Name of Insfitution:
Type LoarlCredil Card:
A0boirrtt,No,;
Monthlv:Pavments:
PresentBalance:
Name of Institution:
Tloe Loan/Credit Card:
Amount of Arrears
Monthfl,PaVments:
:PresentBalance:
+lpunt bfAnearsl
l' ' 1", .
, . ,. ' , " . ,
AccountNo.:
Address:
Name of Instirution:
Type Loan/Credit Card
Original Amount:
Monthly Payments:
PresentBalance:
Address:
Name of lnstitution:
Type Loan/CreditCard:
. a
Account No.:
i
r.
OrigioalAmount:
Amount of Arrears:
.
Monthlv Pavments:
PresentBalance:
Amount ofArrears:
ii,
10. Do you have any debtnot listedabove? E Yes
[l Xo
If yes, give detaiis:
withholdingdeductions,
hasanypartof yourwageseverbeenwithheldandpaidto anotherparty
71. Otherthanstandard
to satisrya debt,obligationor for anyotherpurpose? E Yes E No If yes,give details:
72. Do you havea lien or judgmentpendingagainstyou? E Y.s
t4
E No
If yes,give details:
73. Have you everhad a lien or judgmentagainstyou? E Y.s
D Xo
74. Are you a co-signeron an outstandingloan? D Y.t
E Xo
If yes, give details:
If yes, give details:
Refuseda bond? E Yes
f No
75. Have you everbeenbonded? E Y"r
With respectto eachtime bondedor refused,give details below:
Bonded
P h o n eN o .
Full Address
Refused By Whom
(
)
Date
ReasonBonded/Reasonrefused
Additional information
D No
E Y.s
Seecontinuationpage
E Xo
76. Have you everpetitionedfor bankruptcy? E Y.r
f
No
If yes,give details:
77. List currentassets(include all stocks,bonds,savingsaccbunts,checkingaccounts,money market accounts,current
holdings,pensionfunds and real estateproperfy,etc.).
Full Addressor Location.
Tloe,Name of Asset:
AccountNo.:
DateAcquired:
Co-owuer:
Co-ownerAddress:
Original Value
PresentValue
Co-ownerPhoneNumber:
Full Addressor Location:
of,Asset:
f,ypeA{ame
AecouatNo.:'
DateAcquired:
Co-owner:
Co-ownerAddress:
O:igiualVatue:
PresentValue:
Co-owner PhoneNumber:
l5
TypeAJame of Asset:
Full Address or Location
Account No.:
Date Acquired:
Co-owner:
Co-owner Address:
::r:.:.
PresentValue:
Co-owner Phone Number:
Futrl,{ddress
or,Location:
TvneAlarne ofAsset:
.:
Original Value:
'
. , r : : . : : . : . i . : i : . : . r :: :. . ' : t :
Accbunt'Nor:
Datencquired:
ft1,o,ry1e1,,
Co-orvnerAddress;
TypeAlame ofAsset:
OSrgnal,Value:
Full Addressor Location:
Account No.:
Date Acquired:
Co-owner:
Co-owner Address:
Original Value:
PresentValue:
Co-owner Phone Number:
1 8 . Have you filed all federaland statepersonalincome tax refurnsfor which you are required to submit?
D Y.s
fl xo
If no,explain:
79. Haveyou accuratelyreportedall ofyour taxableincome(receipts)
on eachof your own incometax returnsfiled with
the federal and statesovernment? E Y.s
E Xo
If no, explain:
r6
J. General
80. Haveyou everhadproblemsor beenallegedto havehadproblemsdealingwith personsof anotherrace,ethnicorigin, religiousgroup, gender,or sexualorientation? E Y.t
D No
If yes,explain:
or a hostilework
discrimination
othersto harassment,
or beenallegedto havesubjected
81. Haveyou eversubjected
E Xo
environment? E Y"t
If yes,explain:
82. Have you everbeen involved in a personalrelationshipwhere you threatened,assaultedor harassedanotherparly
or had a domesticviolencecomplaint, temporaryrestrainingorderor final restrainingorder enteredagainstyou?
E Y.s B No If yes, explain:
or
assaulted,
or harassed
in whichyouweretbreatened,
83. Haveyou everbeeninvolvedin a personalrelationship
whereyou soughta domesticviolencecomplaint,temporaryrestrainingorderor final restrainingorder againstanotherperson? E Y.t
I
Xo If yes,explain:
ofviolatingthecivil rightsof anotherperson? EYes
84. Haveyou everbeenchargedwith, or accused
ENo
If yes,explain:
85. Haveyou everbeeninvolvedin u
Date
"iuil
Action or Proceedine
"orrn
ugttonin thi. .t"t" -
County:
Action or Proceeding
CourtDisposition
As Piainriff, Defendant Petitioner, Respondent or Witness
Date
State
County
CourtDisposition
As Plaintifl, Defendant Petitioner,Respondentor Witness
Date
"lt"
County
Action or Proceeding
State
Court Disposition
As Plaintiff, DefendantPetitioner,Respondentor Witness
a handgun,firearmpermits,fireanypistolpermits,permitto purchase
or do you possess
86. Haveyou everpossessed
in thisor anyotherstateor areaunderfederaljurisdiction? E Yes E No
armID cards,or firearmdealerlicenses,
Ifyes, give details:
FirearmDealerLicenseNumber
Firearm ID Card
List all firearmsthat you possess/own:
Model
Make/Importer
Serial #
T]
IssuingAgency
Caliber/Gauge
Pistol Permit #
Etc.
K. Arrests,Summonses,
NOTICE,'E*puogements, PTI, and conditional dischargesmust be disclosed
disc|osureisforlawenforcementpurposes.'l::
81.
complaint(s)or
As a juvenile, haveyou ever had any police contact,beentakeninto custody,receiveda summons
I Xo If yes,explain:
chargedwith JuvenileDelinquency? f Y.t
Date:
PoliceAgency Concerned: PhoneNo.
Violatior/Charge if act were committed as an adult:
Age:
()
State
County
Dqle:
Folice Agenry,Concerned: Phone No.
...,..|:i:....''
'
itted as an aduit
Age ;
:
Court Disoosition/Sentence
'.
Date:
.:
: : . : : : ::! . : : :
,, ''(,,":
':'1 t
Court DispositionlSentence:
::
.:.::
Poiice Agency Concerned: PhoneNo.
ViotatioryChargeif act were committed as an adult:
Age:
()
County
Municipality/Township:
,Date;
State
Codnly
\4umcipaliry/To*nship;
t.,, :.t
State
:
Court Disposition/Sentence
State
Court D ispositiorlSentence:
Vjolation/Chalgg if act were cornmitted as an adult:
:AEe:
. ::..:
t
: : : : : : : : . i l
CounSy
Additional information
E Y.t
f
)
:.
Seecontinuationpage
No
or requiredto testifybeforeanyrnunicipal,county,state,or federal
8 8 . Have you everbeensummoned,subpoenaed,
agencyor otherinvestigativebody for a criminal matter? E Yes
fl Xo
If yes,give details:
indicted,or convictedfor any
beenarrested,
complaint,
g9. Sincethe ageof 18years,haveyou everreceiveda summons
city,
personsoffenses,
petty
disorderly
persons,
disorderly
Include
violationoithe law includingfish andgamelaws?
VIOLATIONS.)
@o NoT LIST MOTOR VEHICLE
boroughor counryordinances/violations.
E Y.r E No If yes,explain:
Date
Violation:
Your Age at Time:
Court Disposition:
PoiiceAgencyConcerned:
PhoneNo.
()
Date:
County
Violation:
Your.tge at Time:
CourtDisposition;
Additional information
PoliceAgencyConcerned:
:
lnoo..Io
()
E Y.t
Seecontinuationpage
Uxo
18
State
90. Have you ever had a criminal record expunged, or been acceptedinto a Pre-Trial Intervention or Conditional DisE xo If yes,explain:
chargeProgram? E Y.t
YourAge at Time:
Court Disposition:
State
Counry
Municipaiity/Tvrp.:
Violation:
Date:
PoliceAgencyConcerned:
PhoneNo.
()
MunicipalityiTwp.:
Violatisn:
Date:
YourAse at Time:
Court Disposition:
:
;,
,,, ,
,
l, Cotnty
,1,,i
,
'
PoliceAgencyOoncery,9!:
'()
Additional information
E Y.t
:State
l\16.
, pft611s
Seecontinuationpage
E Xo
9 i . Have you ever been the subject of a criminal investigationor investigatedby any law enforcementor private security
agency for any reason(other than pre-employrnentfor a police dept.)?O Yes E No Ifyes, explain: -
Your Age at Time
Court Disposition
State
County
Municipality/Twp.
Violation
Date
PoliceAgency Concerned
PhoneNo.
()
Your,Age.at Time
C,.o,{DisRositlon
Police Agency Concerned:; : r::: ,i::
FhorreNo.
{
Additional information
E Y.t
Exo
State
County
Municipaliry/Twp.
Violation
Date
)
See continuation page
92. Have you ever beenfingerprinted?(Excludethis applicationandapplicationsfor employmentwith otherpolice departments,but includeif fingerprinted for criminal or noncriminalpurposessuchas licensingor employment.)
E Y.r
I xo
If yes,explain:
L. Motor VehicleHistorY
93. Driver's License(s):
Current:
State
Number
94. Have you ever held or do you hold a driver's licensein anotherstate?
E Y.s
ExpirationDate
E No
Number
State
ExoirationDate
Number
State
Expiration Date
t9
95. VehicleRegistration(s):List all vehiclespresentlyowned/leased:
Year
MakeAvlodel/Color
Lic. PlateNo./State
Exp. Date
InsurancePolicy No.
96. VehicleInsuranceCompany:
PresentInsuranceCo.
Address
PhoneNo.
PresentInsuranceCo
Address
P h o n eN o .
PresentInsuranceCo
Address
PhoneNo.
97. If you do not own or leasea vehicle,whatvehicledo you operate
asyourprimarymodeof transportation?
Make/Jr40del/color
Regisrration/State
InsurancePolicyNo
Owner's Name
98. Have your driving privilegesever beensuspendedor revokedin this or any otherstateor country?
f] Y"s
E Xo
If yes,explain (include datesof revocationand restoration):
99. Haveyoueverbeenarrested
for drivingwhileundertheinfluence
of alcoholor drugsin thisor anyotherstate?
EYe. E No
If yes, list where/when/specificdetail:
Additional information
E Y.s
I
Xo
Seecontinuationpage
100. Have you ever possessed
a chauffeur'sor a commercialdriver'slicense?E Yes
101. Have you ever had your auto insurancediscontinuedfor any reason?f, Yes
20
D No
E Xo
If yes,list:
If yes,explain:
102.Haveyou everreceiveda summons
for a violationofthe MotorVehicleLawsin this or anyotherstate?(Exclude
parkingviolations;.
E Yes
Date:
E No Ifyes,list:
Violation:
Muaicipality:
Disposition:
YourAse at Time:
County
State
PoliceAgency Concerned:
PhoneNo.
()
Eate;
Violation:
Munlcrpa1jty;:'::::::Counry
Disposition;
Date:
YourAgeat Time: Po{ce,Agenc},Concemeo;,,,,,,
Phont}.Jo,,
Violation:
Municipaiify:
Disposition:
YourAge at Time:
County
State
PoliceAgency Concerned:
PhoneNo.
()
Date:
Municipalityi
\4olation;
D,iiposition:
Counry
Y.ourAge
al irye. Police Agency Concerned:
:
Phone No.
(,,, )
Date:
Violation
Municipality:
Disposition:
YourAge at Time:
County
PoliceAgency Concerned:
Stare
PhoneNo.
()
Additional information
f
Yes
E Xo
Seecontinuationpage
103.Haveyou or a vehicleownedor leasedby you everbeeninvolvedin anyrnotorvehicleaccident?E y"s I No if
yes,statedates,locations,
circumstances:
(NOTE:Obtaina copyofeachaccidentr€port.)
Numberofaccidents:
_
Date
Munrcrpalrry/1wp.
Circumstances
Date
Municipality/Twp.
Circumstances
Municipality/Twp.
Circumstances
Municipality/Twp.
Circumstances
Date
Additionalinformation E Y.r
E No
Seecontinuationpage
21
M. Other Affiliations
104. Are you now,or haveyou everbeen,a memberor an affiliateofany organization,
association,
movement,or group
whichyou knowto advocate
thecommission
of actsof forceor violencedesignedto overthrowthe govemmentof
theUnitedStatesor this state?
Dyes
Euo
105. Are you now,or haveyou everbeen,a memberofany organization,
association,
movement,or groupwhich you
knowto advocatethecommission
ofactsof forceor violencedesigned
to denyotherstheirrightsundertheConstitution of eithertheUnitedStatesor thestateofNew Jemey?
EY"s
flwo
106. Ifyour answeris YES to eitherof theabovequestions,
pleaseprovidean explanation
andthenameofthe organization,association,
movementor group:
f{. Other Information
107. Have you usedor possessed
marijuana/hashish?
fYes
Exo
l}7a.Dateof lastusase: Month
Year
108. Haveyou usedanyotherillegaldrugor drugsotherthanthoseprescribed
or providedby a physicianto you or purchasedoverthecounter(includingtheuseofanabolicsteroids)
in your life?
E yes
fl No
i 09. Haveyou soldan illegaldrugat anytimein your life?
EYe.
E No
110.Haveyou manufactured
anillegaldrugat anytime in your life?
[Yes
ENo
I 1L Haveyou distributedan illegaldrugat anytime in your life?
fYes
ENo
112.Haveyou engaged
in theunauthorized
usageof anyillegaldrugor drugsotherthanthoseprescribed
by a physician
or providedto youby a physicianor purchased
overthecounterwhileemployedin a positionofpublic trust(e.g.,a
swomLaw Enforcement
Officer,etc.)? D yes
E no
22
explain:
113. If your answeris YE,Sto any of the abovequestions,
rl4. Have you everparticipatedin a drug testingprogramandhad a positivetest?
E Y.r
E Xo
If yes,provideexplanation:
with yourappointproblemsin connection
I 15. Are thereanymatterswhichmayinvolvea conflictof interestor any
whicharenot ful1ycoveredby your answelsto this
mentto thepositionof
of ho\ir'you wouldproposeto
If so,pleasesetforththepertinentfactsbelow,includingan explanation
questionnaire?
etc')'
iesolvesuchconflictofinterestor problem(e'g',divestitue,resignation'
knowledge,might reflect adverselyon you or on the
116. Is there any eventor mamerrn your pastwhich, if it were public
if You were aPPointed?
^a
./.)
117. List anyandall web sites,webpages,weblogs,andsocialnetworkingwebgroupsof which you area member,
includingall screennames.
i.
2.
3.
A
+-
5.
1A
L+
O. References
(NOT TO BE SWORNMEMBERS OF THE NJSPORANY OTHER PERSONLISTED IN THIS APPLICATION.)
citizens(norelatives)whowill vouchfor the
Upon completionofthis form,the applicantmustobtainthreereputable
applicant.
honesty,reputationandability ofthe
andsignatureaffixed.
by thereference
portionofthis form shallbe completed
The reference
I, the undersigned,declarethal I am oyer twentJ/'oneyears of age,andI havepersonallyknown the applicantfor at
leflst oneletn I am not rclated in any way to the applicant.
I will upon request,givefurther facts concerningthe applicant that I maypossess.
ALL INFORMATION WILL BE TREATEDAS CONFIDENTIAL
REFEREI{CEOI{E
(PieasePrint)
L_)
Name
Occupation
Address
Business
City, StateZip Code
How long haveyou personallyknown the applicant?
PhoneNo. (_--)
Date of Birth:
Signafure:
Date:
BusinessPhoneNumber
REFERENCETWO
(PleasePrint)
Name
Occupation
Address
Business
Name
(_)--EusinessFloneNnmEEi-
Address
City, StateZip Code
How long haveyou personallyknown the applicant?
PhqneNo. L_)
Date of Birth:
Signature:
Date:
REFERENCETHREE
(PleasePrint)
Name
Occupation
Address
Business
Name
L-_J
BusinessPhoneNumber
Address
City, StateZrp Code
How long haveyou personallyknown the applicant?
PhoneNo. t___-)
Date of Birth:
Signature:
Date:
25
AFFIDAVIT AND CERTIF'ICATIOI{
OFAPPLICANT
andinformationrequested
by the
I will assistin anyway to obtainany andall documents
madein this applicationaretrue,completeandconectto thebestofmy knowledgeand
I certifuthatall ofthe statements
belief, and are madein good faith. I am awarethat any intentionalmisrepresentation
of informationsuppliedby me will
process.
in
my
disqualification
ftom
the
selection
Furthe!
I
authorize
the
result
to verifuanyandall
education,
financialandcriminalhistorymilitary,disciplinary
informationcontainedhereinandto reviewmy employment,
and otherrecordsand informationfrom any sourceasnotedin the duly executedAuthorizationandReleaseForm.
andagreeto the conditionsimposedherein.
I havereadthis CertificationandI understand
Signature:
Date:
(Sign in Ink)
(Print Name)
Stateof:
County ofi
Sworn to and subscribedbefore me this
)o
) -"_
day of
(Print Name and Title)
Signature(Sign in Ink)
Notary Public,my Commission
Expires:
DO NOT WRITE BELOW THIS LINE
Signatureof applicantmadein the presenceof investigator
Date
Signafureof InvestigatingOfficer
26
COI{TI1\UATIOI\ PAGE
2l
CONTII\UATIOI{ PAGE,
28
REQUIREDDOCUMENTS
alongwith this completedBackgroundInvestigation
mustprovidecoPIES ofthe belowlisteddocuments,
All applicants
your collectionof theseREQUIREDDOCUMENTS'Checkthe "En[rr"rilo*"i.". Use ihis Check-offList to organize
(Leaveblankif you have not obtained
wlttr tiris completedQuestionnaire.
closed,,boxonly if the documentis provide-d
'dot Applicable"box if this document
doesnot applyto you' Thesedocumentsandthe
the requireddiument.) Checkthe
whenyou reportto the
personnel
by you to
qoes?ionnui.e
shallbe submitted
completedBackgroundlnvestlgation
PhysicalQualificationTest.
ENCLOSED
n
tr
tr
tr
tr
n
tr
tr
tr
NOT
APPLICABLE
tr
d
tr
tr
tr
tr
tr
Birth Certificate
Naturalization PaPers
SocialSecuritYCard
Driver's License(s)
or vehiclesused)
vehicle Registrations(all owned/leased
or vehiclesused)
Automobile Insurance cards (a11owned/leased
including most recentSavings,Checking,CD's,
Financial Statements(Ali assets,
of anYkind, etc.)
Investments
E
ALL Loans (mortgages,autoloans,sfudentloans,etc')
fl
Federal and StateTax Returns
(tt;l_Llsg$ inciudingail w-2 Form(s), 1099Form(s),and Schedules.)
. to obtaincopiesof prior years'taxreturns,contact:
IRS: 1-800-829-1040 www.irs.ustreas.gov
NJ TaxpayerCustomerServiceCenter: 609-292-6400
.us/treasurv/taxation
www.state.ni
tr
tr
n
tr
tr
tr
n
tr
tr
tr
tr
tr
tr
Most RecentPaY Stub
fl
Permits to PurchaseHandgun
tr
tr
Permits to Carry Handgun
fl
ALL Motor VehicleAccident Reports
tr
tr
n
ALL Court Documents(Criminal, Civil, Family)
n
tr
Firearms PurchaserIdentification Card
PoliceTraining Certificate
ProfessionalLicensesand Certificates
Military SeparationForms (DD-2la)
MarriageiDivorce records,Marriage, Civil Union or Divorce Records
Rentayleasing Agreements(Vehicle.Apartment,Boat, etc')
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from School EY*t
High SchoolTranscriptsRequested
Name of School(s)
E
College Transcripts Requested on (Date)
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EXo