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FOREST CITY POLICE DEPARTMENT
AN EQUAL OPPROTUNITY EMPLOYER
145 East K Street, Forest City, Iowa 50436
Phone: (641) 585-2113 Fax: (641) 585-2096
Website: www.fcpolice.org
PERSONAL HISTORY
Name in full (last, first, middle)
Social Security Number
List any nicknames or alias, married surnames
Place of Birth (city/state)
Are you a U.S. citizen?
□ Yes
Birth date (month, day, year)
Driver license state of issue
□ No
E-mail Address
Driver license number
CONTACT INFORMATION
Current mailing address
Phone numbers available
(_______)________________________
Residence
__________________________________________________________________________
Street address (including apartment number if applicable)
_________________________________________ ________________ _______________
City
State
Zip Code
Permanent address if different than above
(_______)________________________
Cell phone
Phone numbers available
(_______)________________________
Office
__________________________________________________________________________
Street address (including apartment number if applicable)
_________________________________________ ________________ _______________
City
State
Zip Code
(_______)________________________
Alternative
EDUCATION RECORD
High Schools Attended
High schools attended
Address
Dates Attended
Year Graduated
College/University Attended
Name of School &
Location
Dates Attended
mo/yr
mo/yr
Credits Received
Page1
Field of Study
Major
Minor
Degree Obtained
1. If you are working toward a degree, please give the anticipated completion date: ______________________________________________
2. Has any disciplinary action, including scholastic probation and dismissal, ever been taken against you during your academic career?
______ Yes ______ No If yes, complete the following: _____________________________________________
School
_______________
Date
Type of action taken: _____________________________________________________________________________________________
3. List awards, honors, citations, athletic endeavors, and any other special recognition you received. Include high school and college.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
4. List any special abilities (computer skills, typing, etc), special interests, and hobbies: ___________________________________________
_______________________________________________________________________________________________________________
5. List languages, including American Sign language, in addition to English that you speak, read or write fluently : _____________________
_______________________________________________________________________________________________________________
6. If you are licensed or certified to practice a trade or profession, complete the following:
Specialty: _________________________________________________________ License issued by: ______________________________
INTERNSHIPS
Name of business/entity _______________________________________ From(mo/yr) ________________ To (mo/yr) _______________
Address ____________________________________________________ City _________________________ State __________________
Duties/job assignment: __________________________________________________ Supervisor: ________________________________
Name of business/entity _______________________________________ From(mo/yr) ________________ To (mo/yr) _______________
Address ____________________________________________________ City _________________________ State __________________
Duties/job assignment: __________________________________________________ Supervisor: ________________________________
RESIDENCE HISTORY
Dates
From
To
Street Address
City
Page 2
State
Zip Code
FINANCIAL RECORD
1. What is the total amount of your monthly financial obligation? ____________________________________________________________
2. Are monthly financial obligations kept current? _______ Yes ________ no
If no, explain: ___________________________________________________________________________________________________
_________________________________________________________________________________________________________________
3. Do you have any sources of income other than your salary? _______ Yes _______ No
COURT RECORD
1. Have you ever been arrested or charged with any violation, including traffic citations, but not parking tickets? _______ Yes _______ No
(List all such matters even if not formally charged, or not court appearance, or found not guilty, or matter settled by payment of fine or
forfeiture of collateral).
Date
Place (City/County/State)
Charge
Disposition
Details
2. Has any member of your immediate family, i.e. spouse, parents, brother, sister ever been arrested for any violation other than traffic?
_______ Yes _______ No
If yes, list below
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
3. Have you ever been a plaintiff or defendant in any court action (including protective orders/divorce)? _______ Yes _______ No
If yes, give date, place, court, names of parties involved, nature of action, and final disposition.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
SELECTIVE SERVICE/MILITARY RECORD
1. Have you ever (check all that apply):
Registered with the Selective Service, if applicable? _______ Yes _______ No
Applied for a position with any branch of the Armed Forces of the United States? _______ Yes _______ No
Been rejected by any branch of the Armed Forces for any reason? _______ Yes _______ No
Been inducted into any branch of the Armed Forces? _______ Yes _______ No
(If yes, complete below sections)
Been on active duty in any branch of the Armed Forces? _______ Yes _______ No
(If yes, complete below sections)
Page 3
SELECTIVE SERVICE/MILITARY RECORD CONTINUED FROM PERVIOUS PAGE
Dates of active duty (month, day, year)
Branch of military service
Highest rank held
serial number if different than ssn
From_______________ to _______________
Type of discharge_______________________________________________________________
Date DD-214 ____________________ Form recorded where ___________________________
County ___________________________________ State ______________________________
Member of Reserve/Nation Guard?
_______ Yes _______ No
Service Branch ____________________
Location: _________________________
Was any type of disciplinary action taken against you in the service? _______ Yes _______ No
Nature of disciplinary actions: __________________________________________________________________________________________
ORGANIZATION MEMBERSHIP (Optional)
Are you now, or have you ever been a member of any club, society, or organization? ________ Yes _______ No
If yes, list below. Do not abbreviate.
Organization
City and State
Dates
List position(s) held and extent of activity
VOLUNTEER ACTIVITIES/EMPLOYMENT
Volunteer Activities (including volunteer fire fighting, police or sheriff reserve and civic activities)
Organization
City and State
Dates
List position(s) held and extent of activity
EMPLOYMENT
Name of Employer
Dates of employment
Address
Position and type of work
City & State
Name of supervisor
Telephone
Reason for leaving
(
)
Page 4
Salary
EMPLOYMENT CONTINUED
Name of Employer
Dates of employment
Address
Position and type of work
City & State
Name of supervisor
Telephone
Reason for leaving
(
)
Name of Employer
Dates of employment
Address
Position and type of work
City & State
Name of supervisor
Telephone
Salary
Reason for leaving
(
)
Name of Employer
Dates of employment
Address
Position and type of work
City & State
Name of supervisor
Telephone
Salary
Reason for leaving
(
)
Name of Employer
Dates of employment
Address
Position and type of work
City & State
Name of supervisor
Telephone
Salary
Reason for leaving
(
)
Name of Employer
Dates of employment
Address
Position and type of work
City & State
Name of supervisor
Telephone
Reason for leaving
(
)
RELATIVES
Father
Employer
Address
Street Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Occupation
Mother
Employer
Address
Street Address
City/State/Zip Code
City/State/Zip Code
Birth date
Salary
Telephone
(
)
Occupation
Page 5
Salary
Relatives continued
Spouse (If wife, include maiden name)
Employer
Address
Street Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Occupation
Children
Child’s Name
Child’s Name
Address
Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Birth date
Child’s Name
Child’s Name
Address
Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Birth date
Telephone
(
)
Telephone
(
)
Other relatives (brothers, sisters, step parents, step brothers, step sisters)
Name and Relationship
Name and Relationship
Address
Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Birth date
Name and Relationship
Name and Relationship
Address
Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Birth date
Name and Relationship
Name and Relationship
Address
Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Birth date
Name and Relationship
Name and Relationship
Address
Address
City/State/Zip Code
City/State/Zip Code
Birth date
Telephone
(
)
Birth date
Page 6
Telephone
(
)
Telephone
(
)
Telephone
(
)
Telephone
(
)
REFERENCES
Give three references (not relatives, present employers, or school teachers) who are responsible adults of reputable standing in their communities,
preferably those who have know you well during the last five years. if retired, give former occupation.
Complete name
Occupation
Home address
Home phone
(
)
Business phone
(
)
Business and address
Complete name
Occupation
Home address
No years acquainted
Home phone
(
)
Business phone
(
)
Business and address
Complete name
No years acquainted
Occupation
Home address
No years acquainted
Home phone
(
)
Business phone
(
)
Business and address
Give three social acquaintances.
Complete name
Occupation
Home address
Home phone
(
)
Business phone
(
)
Business and address
Complete name
Occupation
Home address
No years acquainted
Home phone
(
)
Business phone
(
)
Business and address
Complete name
No years acquainted
Occupation
Home address
No years acquainted
Home phone
(
)
Business phone
(
)
Business and address
Page 7
FOREST CITY IOWA POLICE DEPARTMENT
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I, ______________________________________________________________________, do hereby
authorize a review of and full disclosure of all records concerning myself to any duly authorized personnel of
the City of Forest City Iowa, whether the said records are of a public, private or confidential nature, including
criminal histories.
The intent of this authorization is to give my consent for the full and complete disclosure of records of
educational institutions; financial or credit institutions, including records of loans, the records of commercial
or retail credit agencies (including credit reports and/or ratings) and other financial statements of records
whenever filed; medical and psychiatric treatment and/or consultation, including hospitals, clinics, private
practitioners, and the U.S. Veteran’s Administration; employment and pre-employment records, including
background reports, efficiency ratings, complaints or grievances filed by or against me; and the recollections
of attorneys at law, or of other counsel, whether representing me or another person in any case, either criminal
or civil, in which I presently have, or have had an interest.
I understand that any information obtained by a personal history background investigation which is developed
directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my
suitability for attending law enforcement training. I also certify that any person(s) who may furnish such
information in good faith concerning me shall not be held accountable for giving this information, and I do
hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such
information. I further release the City of Forest City and the Forest City Police Department from any and all
liability which may be incurred as a result of collecting such information.
I HEREBY SWEAR AND AFFIRM THAT EACH STATEMENT AND ALL INFORMATION IN OR
SUPPLEMENTING THIS APPLICATION (PERSONAL AND PHYSICAL EVALUATION) ARE
COMPLETE, TRUE AND ACCURATELY RECORDED TO THE BEST OF MY KNOWLEDGE. I
UNDERSTAND THAT PROVIDING FALSE, MISLEADING AND/OR INCOMPLETE
INFORMATION ON THIS APPLICATION IS GROUNDS FOR EXCLUSION FROM THE
SELECTION PROCESS OR DISCHARGE IF DISCOVERED SUBSEQUENT TO ATTENDING
TRAINING.
I have read and fully understand the contents of the “Authorization for Release of Personal Information”.
_____________________________________________________________________
(Signature of Applicant)
_____________________________________
(Date)
Page 8