BURNSVILLE POLICE DEPARTMENT by pengxiuhui

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									         ANYWHERE POLICE DEPARTMENT
       BACKGROUND INVESTIGATION FORMS


           APPLICANT’S NAME:
       POSITION APPLIED FOR:
          RETURN PACKET BY:
BACKGROUND INVESTIGATOR:




Anywhere Police Department
101 Center Parkway
Anywhere, MN 55337
952-895-****  Fax 952-896-****
                          ANYWHERE POLICE DEPARTMENT
                        BACKGROUND INVESTIGATION FORMS

                             TABLE OF CONTENTS



             General Information
             Personal Data
             Education
             Residence & Family Relationships
             Military and Selective Service
             Employment
             Financial Data
             Credit Check Information
             Litigation
             Motor Vehicle & Drivers License History
             Medical History
             Autobiography
             Sample Releases:
               Release Type I – General
               Release Type II – Medical
               Release Type III – Military
               Release Type IV – Employment Eligibility
               Release Type V – Credit




Anywhere Police Department            •1•                  Background Investigation Forms
City of Anywhere, Minnesota
POLICE DEPARTMENT
101 Center Parkway
Anywhere, Minnesota 55337
952-895-4600  Fax 952-895-4640


                              IMPORTANT! Read Immediately
The following items are required to be supplied by the applicant. Please make arrangements for each of the
following requests to be supplied to your Background Investigator. Whenever possible the applicant should have
this information sent to the Background Investigator directly from the agency providing the information. It is
recommended that the applicant make these requests as early as possible as there is often a considerable
delay in receiving the information which will result in a delay of the applicant’s background being
completed. Note that many of the agencies that provide this information charge a fee. This fee is incurred by the
applicant and will not be reimbursed by the City of Anywhere whether or not the applicant is hired for the position
applied for.

1. A certified copy of your Birth Certificate. Copy will be returned at the applicant’s request.

2. A certified driving history for any state other than MN in which you have held a Driver’s License (the
   Background Investigator will run your MN record). Other states will have requirements and forms
   necessary to obtain a copy of your driving record in that state. It is the applicant’s responsibility to obtain and
   forward this information to the Background Investigator. There are online services available that will supply out-
   of-state driver’s license records.

3. An original credit report current within the past month. This is available through Equifax at
   www.Equifax.com, TransUnion at www.TransUnion.com, or Experian at www.Experian.com.

4. A copy of your Income Tax returns from the past three (3) years.

5. A copy of all Bank Statements for the past six (6) months.

6. Social Security Earnings Information beginning at age 16. This requires Social Security Administration
   form 7050-F4. (The form is in your packet, but please verify online that you have the most up to date form.) It
   may be downloaded online at: www.ssa.gov/online/ssa-7050.pdf. The applicant will need to compute how
   many years of history are required to obtain information back to age 16. This information does not need to be
   certified. The applicant should request “Detailed Earnings Information” in section 2 and indicate the number of
   years. This information must be mailed directly to the Background Investigator (section 5) at the Anywhere
   Police Department. If you do not know your Background Investigator’s name, address it to “Background
   Investigation Unit”. This information will not be accepted from the applicant directly. Request this information
   early as it takes several weeks to receive.

7. High School and College Transcripts. The applicant should request these items directly from the school
   registrar’s offices. These need to be sent directly to the Background Investigator from the educational
   institution.

8. Upon Request Only — Medical Records. Upon request, the applicant will need to forward copies of medical
   records directly from the physician’s office to the Background Investigator. Do not request and send these
   records until instructed to do so by your Background Investigator.




Anywhere Police Department                              •2•                         Background Investigation Forms
City of Anywhere, Minnesota
POLICE DEPARTMENT
101 Center Parkway
Anywhere, Minnesota 55337
952-895-4600  Fax 952-895-4640


To:            City of Anywhere Applicant
From:          Background Investigator
               Anywhere Police Department
Subject:       GENERAL INFORMATION – BACKGROUND INVESTIGATION AND
               COLLECTION OF PROTECTED DATA


Background Notification Forms: Please be advised that the Anywhere Police Department is
commencing the background investigation process for the purpose of considering your application for a
position within the City of Anywhere.

Directions to Applicant for Completing the Background Investigation Forms:

1.    Read and sign the Background Information Advisory (Form A), which explains the intended use of
      this data and the purpose for its collection.
2.    Read and sign the Data Practices Rights Advisory (Form B).
3.    Read and sign the Data Practices Advisory Form for Protected Information (Form C), and complete
      Form C-1, following mailing instructions outlined therein.
4.    When completing this form, please print clearly and give complete and accurate information. If you do
      not, you may be removed from further consideration. USE ONLY BLACK INK.
5.    A set of releases is contained at the end of the packet. Please complete the proper release forms as
      indicated in the Background Investigation Form. You will have to copy extra releases. Therefore,
      complete the Background Investigation Form first and then determine the type and number of releases
      you will need.
6.    If you find that there is not enough space to answer a specific question, provide as much information
      as space permits. Then, continue your response on individual sheets of paper. Include the number of
      the question and maintain the same format as in the Background Investigation Form.
7.    If a question does not apply to you, please write "N/A" (not applicable).
8.    Be sure to sign the forms and date them.
9.    Be sure to complete and sign the Autobiography.
10.   Include any requested documents.
11.   Call _____________________, Background Investigator, at 952-895-4600, with any questions.
12.   Mail or personally deliver the completed forms and documents to:
                               ____________________________
                               Background Investigator
                               Anywhere Police Department
                               101 Center Parkway
                               Anywhere, MN 55337



Anywhere Police Department                           •3•                          Background Investigation Forms
City of Anywhere, Minnesota
POLICE DEPARTMENT
101 Center Parkway
Anywhere, Minnesota 55337
952-895-4600  Fax 952-895-4640


                          BACKGROUND INFORMATION ADVISORY FORM
                                         (Form A)
The Background Investigation Forms are to determine whether to select you for a position within the City of
Anywhere. Certain information requested on the application is classified as private data under the
Minnesota Data Practices Act, Minnesota Statute Chapter 13.01 et seq., and may be released only to you,
to those in the appointing authority whose jobs reasonably require access to the data, to those authorized by
state or federal law to have access to the data, and to those for whom you provide a written informed
consent authorizing disclosure. The public data you supply is available to anyone who requests it.
Before you are certified as eligible for appointment or considered as a finalist for the position, the following
information on the form is private: your name, your address, your telephone number, your eligibility for
licensure and your status with respect to licensure. When you are certified as eligible or considered as a
finalist, your name becomes public. For this purpose, the Data Practices Act defines a finalist as an
individual who is selected to be interviewed prior to selection.
You are not legally required to provide any of the requested information. However, if you do not do so, we
will not be able to process your application or consider you for appointment to a position. We ask for this
information for the following reasons:
1.      To distinguish you from all other applicants and identify you in our personnel files;
2.      To enable us to verify that you are the individual who applied for the position;
3.      To enable us to contact you when additional information is required, send you notices and/or
        schedule you for interviews;
4.      To determine if you meet the minimum licensing requirements, if applicable;
5.      To determine whether or not your conviction record may be a job-related consideration affecting your
        suitability for the position you applied for;
6.      To enable us to ensure your rights to equal opportunities and to meet affirmative action goals;
7.      To meet federal reporting requirements; and
8.      To make processing more efficient.
Before you are certified as eligible for appointment or considered a finalist for a position, only the following
information you have been asked to provide is public: Veteran's status, relevant test scores, rank on
eligibility list, job history, education and training, and work availability. The remainder is private. If you are
certified as eligible or become a finalist, your name becomes public.


I HAVE READ AND UNDERSTAND THE INFORMATION STATED ABOVE.



Signature of Applicant                           Date                     Witness




Anywhere Police Department                              •4•                         Background Investigation Forms
City of Anywhere, Minnesota
POLICE DEPARTMENT
101 Center Parkway
Anywhere, Minnesota 55337
952-895-4600  Fax 952-895-4640


                                DATA PRACTICES RIGHTS ADVISORY
                                            (Form B)

To:




Re:     Name:
        Date of Birth:
        Social Security #

The above-identified individual has made application with the Anywhere Police Department for employment.
In order to fully evaluate the suitability of the applicant for employment with the department, it is necessary to
gather and collect certain information concerning matters, which may be classified as private under the
Minnesota Government Data Practices Act. To the extent the information that is being requested from you
could result in your supplying private or confidential data about yourself, the Data Practices Act requires that
you be advised of certain uses of the information.
The data being requested is for the purpose of determining whether or not the above-named applicant
would be a suitable candidate with the Anywhere Police Department. The data collected is intended to be
used to evaluate the applicant's suitability for employment within this department. If you are affiliated with a
state agency, statewide system or political subdivision, the responsible authority, as defined in Minnesota
Statute Chapter 13.02, Subd. 16, or a designee, must provide all requested public data and all requested
private data, if the applicant gave a valid release. You should be aware that the applicant has signed a
release by which he/she has authorized you to respond to this request for information and provided the
information this department is requesting from you.
If you are not one of the previously cited agencies, you are under no legal obligation to provide the
information which is requested; but if you fail to do so, it may result in this department being unable to fully
evaluate the applicant's suitability for employment with this department, which in turn could harm the
applicant's chance for employment with our department. The information you do provide about the applicant
will be considered to be personnel data under the legal definition of the Data Practices Act. As such the
information you provide may be classified as public data or private data. Public data is data that is
accessible to anyone upon request. Private data is accessible only to the subject of the data, his/her
authorized representative, or otherwise made available by law or court order.
If you have any questions as to the specific classification of a specific piece of information you provide, you
should contact: ______________________________, Background Investigator, Anywhere Police
Department, 101 Center Parkway, Anywhere, MN 55337, Phone 952-895-4600.

I HAVE READ AND UNDERSTAND THE INFORMATION STATED ABOVE.



Signature of Applicant                          Date                    Witness


Anywhere Police Department                             •5•                        Background Investigation Forms
                   City of Anywhere, Minnesota
                   POLICE DEPARTMENT
                   101 Center Parkway
                   Anywhere, Minnesota 55337
                   952-895-4600  Fax 952-895-4640



                DATA PRACTICES ADVISORY FOR PROTECTED INFORMATION FORM
                                         (Form C)

The Minnesota Government Data Practices Act requires you to be informed that the following information,
which you have been asked to provide on the attached form is considered private data – your full name, any
and all previous names by which you are known regardless of whether or not they were your legal names,
your date of birth, your race, your sex.

The purpose and intended use of this data is to conduct the background inquiries which under the POST
Board's Rules, Minnesota Rules pt. 6700.0700, the agency is required to conduct before you can be
licensed as a Peace Officer and/or appointed as a Peace Officer in this agency. The specific use for each
category of data is described below:

1.     To conduct a thorough and complete criminal history and felony background check, all names by
       which an applicant is or has been known must be listed.
2.     In order to access driver's license data, date of birth must be supplied.
3.     In order to complete and send for evaluation fingerprint cards as required by statute, the race and
       sex of the person fingerprinted must be entered on the fingerprint card.
4.     In order to access criminal history data, date of birth, race and sex must be supplied.
5.     A complete criminal history and felony background check, driver's license check and fingerprint
       evaluation are required minimum selection standards of Peace Officers in Minnesota, pursuant to
       Minnesota Rules pt. 6700.0700. These checks are conducted to determine whether there are any
       job-related factors which affect your suitability for employment.

This data will be used solely for the above mentioned purposes. This data will not be made available to the
hiring authority. The data will be forwarded to the background investigator for completion of the criminal
history inquiries as required under Minnesota Rules pt. 6700.0700. Information gained by use of previous
names, date of birth, or race, will be forwarded to the Data Practices Advisory for Protected Information
Form hiring authority without reference to date of birth, age, or race. You are not legally required to provide
the requested information. However, if you do not, the agency will be unable to conduct the required
background inquiries and will not be able to process your application, and the agency will not be able to
consider you for appointment with the City of Anywhere.

The information obtained by use of protected class data will be available to you and those in the appointing
authority who have a bona fide need for the data. The data may also be used for other purposes necessary
for the administration of law, rule or ordinance but will be disseminated only as required by law. If you are
certified as eligible for appointment to a position or are considered a finalist, your name becomes public.

I HAVE READ AND UNDERSTAND THE INFORMATION STATED ABOVE.



Signature of Applicant                         Date                    Witness



Anywhere Police Department                            •6•                        Background Investigation Forms
City of Anywhere, Minnesota
POLICE DEPARTMENT
101 Center Parkway
Anywhere, Minnesota 55337
952-895-4600  Fax 952-895-4640




                              PROTECTED INFORMATION FORM
                                       (Form C-1)


Please read carefully the attached Data Practices Rights Advisory (Form B). After reading, please
sign and date the form. Forward both the signed Data Practices Rights Advisory and the Data
Practices Advisory for Protected Information Form (Form C) to:

                     ____________________________
                     Background Investigator
                     Anywhere Police Department
                     101 Center Parkway
                     Anywhere, MN 55337
                     Ph: 952-895-4600



 FULL NAME:
 DATE OF BIRTH:
 RACE:
 SEX:



 LIST ANY AND ALL OTHER NAMES BY WHICH YOU ARE OR HAVE BEEN KNOWN:
 1.
 2.
 3.
 4.
 5.
 6.




Anywhere Police Department                    •7•                    Background Investigation Forms
                 City of Anywhere, Minnesota
                 POLICE DEPARTMENT
                 101 Center Parkway
                 Anywhere, Minnesota 55337
                 952-895-4600  Fax 952-895-4640




                                      SIGNATURE PAGE
                             (THIS STATEMENT MUST BE SIGNED)




I certify that all of the statements by me in this application are true, complete, and correct to the
best of my knowledge and belief, and are made in good faith. I understand that any false
information or omission of information from this application may be cause for rejection or dismissal
if employed.



I HAVE READ AND UNDERSTAND THE INFORMATION STATED ABOVE.


________________________________________                        ____________________
Signature of Applicant                                          Date


________________________________________
Witness




Anywhere Police Department                      •8•                     Background Investigation Forms
                ANYWHERE POLICE DEPARTMENT
          BACKGROUND INVESTIGATOR'S REFERENCE SHEET

This information is for quick reference; some questions will be repeated.

1.     Name:                                             Social Security #:
       Nickname:                                         Date of Birth:
       Where were you born?_____________________________________________________
       Have you ever changed your name?                                              [ ] Yes [ ] No
       If yes, list other name(s) used:



2.     Current Address:



       Home Phone:                                       Cell Phone:
       Business Phone:                                   Pager:
3.     Current Employer(s):
       Address:



       Business Phone:
       May we contact your employer?                                                 [ ] Yes [ ] No
4.     Driver's License Number:
       Driver's License State:
5.     Skills Course Completed At:
       Date of Completion:                                                                     _____
6.     Do you have a Peace Officer license?                                          [ ] Yes [ ] No
7.     Have you ever been employed as a Peace Officer with another agency?           [ ] Yes [ ] No
       If yes, which law enforcement agency?




Anywhere Police Department                     •9•                        Background Investigation Forms
                       ANYWHERE POLICE DEPARTMENT
                     BACKGROUND INVESTIGATION FORMS

                                  PEACE OFFICER LICENSE
1.     Academic Law Enforcement Education, completed at:
       Name:                                                        Phone #:
       Address:
       City/State/Zip:
       (Please complete and sign four original Type I release forms for each college attended.)
       Date Completed Academic Education:
       Skills Course, Law Enforcement Education, completed at:
       Name:                                                Phone #:
       Address:
       City/State/Zip:
       (Please complete a Type I release form for this school.)
       Date Completed Skills:
       Date of Passing Skills Examination:
       If you were trained out of state, please complete the following:
       Training Program:                                          Phone #:
       Address:
       City/State/Zip:
       Date of Completion:
       Length of Course:
       Date of Certification:
       Date of Passing POST Reciprocity Exam:

2.     Are you "eligible for a license"?                                              [ ] Yes [ ] No
       If yes, when does your eligibility expire:
       (Please attach a photocopy of POST Board eligibility letter.)

3.     Are you currently licensed as a Police Officer?                                [ ] Yes [ ] No
       If yes, please provide the following information:
       POST License #:
       Date Originally Issued:
       Expiration Date:
       Current Number of C.E. Hours for this Renewal Period:
       (Please attach a list of all your Continuing Education.)

4.     Current state of your Police Officer license. (Please attach a photocopy of your license
       certificate and current renewal card.)

       _____ Valid-Active Status                      _____ Valid-Inactive Status
       _____ Lapsed                                   _____ Surrendered
       _____ Suspended                                _____ Revoked


Anywhere Police Department                          • 10 •                 Background Investigation Forms
5.     Have you ever possessed a part-time Peace Officer/Constable license?           [ ] Yes [ ] No
       If yes, which one:


       Current status of this license:
       _____ Valid-Active Status                      _____ Valid-Inactive Status
       _____ Lapsed                                   _____ Other (please explain)




6.     Has the POST Board ever taken disciplinary action against your license?
                                                                                      [ ] Yes [ ] No
       If yes, please explain:




                                             CITIZENSHIP
7.     Are you a native born or naturalized citizen?                                  [ ] Yes [ ] No

8.     If you are a naturalized citizen, fill in the following:

       Country of Birth:
       Port or Place of Departure to the USA:
       Date of Departure:

       How were you transported to the USA:
       [ ] Ship [ ] Plane [ ] Train [ ] Other:

       Name of transport conveyance and/or company you arrived on:

       Port or Place of Entry into the USA:
       Date of Entry:

       Name/address of persons who sponsored you on arrival:
       Name:                                               Phone #:
       Address:
       City/State/Zip:

       First address after arrival:


Anywhere Police Department                         • 11 •                  Background Investigation Forms
       How did you obtain citizenship? Give details:


       (Please complete a Type IV release form.)

       Petition Number:                                                    Date:
       Court:                                                     State:
       Certificate Number:

                                          EDUCATION
9.     List chronologically (earliest dates first) all schools and colleges you have attended:
       (Please complete 4 Type I release forms for each school.)
                                                    From           To
       Name of School/Address                      Mo. Yr.        Mo. Yr.          Last Grade/Term




       Phone#_____________________




       Phone#_____________________




       Phone#_____________________




       Phone#_____________________

10.    What college degree(s) do you possess?


       Undergraduate Major In:
       Grade Point Average (cumulative):
       Total Credits Achieved Toward Degree:
       Graduate Major In:
       Names of Faculty Advisors:


11.    Other than English, what languages do you:
       Speak:
       Understand:



Anywhere Police Department                      • 12 •                     Background Investigation Forms
12.    List any problems with school (absenteeism, tardiness, poor grades, other disciplinary
       problems), including college:

            Date             School                        Problem / Explanation




13.    It is understood I will immediately forward transcripts from all high schools and colleges
       attended to the following address: (Proper fee must be forwarded to the high school or
       college by the applicant.)

                             ____________________________
                             Background Investigator
                             Anywhere Police Department
                             101 Center Parkway
                             Anywhere, MN 55337

14.    List all awards received from high school and college:




15.    List all internships you have completed, including location, dates and phone #:
                                                                                       Dates
              Internship                   Location / Phone #                         From/To




                     RESIDENCE & FAMILY RELATIONSHIPS
16.    Where do you now reside:

       Address:
       City/State/Zip:
       County:                                     Home Phone:


Anywhere Police Department                      • 13 •                   Background Investigation Forms
17.    How long have you resided there:

18.    With whom do you reside?

       Name:                                                 DOB:
       Relationship to you:_________________________________ Cell Ph:
       Occupation:
       Place of Employment:
       Employment Address:
       City/State/Zip:

       Name:                                                 DOB:
       Relationship to you:_________________________________ Cell Ph:
       Occupation:
       Place of Employment:
       Employment Address:
       City/State/Zip:

       Name:                                                 DOB:
       Relationship to you:_________________________________ Cell Ph:
       Occupation:
       Place of Employment:
       Employment Address:
       City/State/Zip:

       Name:                                                 DOB:
       Relationship to you:_________________________________ Cell Ph:
       Occupation:
       Place of Employment:
       Employment Address:
       City/State/Zip:

       Name:                                                 DOB:
       Relationship to you:_________________________________ Cell Ph:
       Occupation:
       Place of Employment:
       Employment Address:
       City/State/Zip:


19.    In chronological order, state each and every place in which you have lived since age 18,
       beginning with your present address. Include all addresses while you were in school and
       the military. For each address listed, indicate if someone owned the property other than
       you. If so, include names, addresses, and phone numbers for the property managers or
       owners, even if you did not pay rent (i.e., stayed with a friend rent-free for the summer,
       etc.) (Complete a Type I release form for each property owner/management firm of rental
       property.)




Anywhere Police Department                     • 14 •                  Background Investigation Forms
         From         To
        Mo. Yr.      Mo. Yr.            Address/City/State/Zip – Phone #

       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________
       ________ ________ _____________________________________________________
                         _____________________________________________________
                         _____________________________________________________



Anywhere Police Department           • 15 •                 Background Investigation Forms
20.    Since age 18, list each adult you have ever resided with (roommates, significant others,
       friends) excluding your parents and immediate family. For each person listed, include
       current address and home and work phone numbers. Reference each person to the
       residence number in question 18.

       Name                        Address                                   Phone (H,W,C)


                                                                             ________________


                                                                             ________________


                                                                             ________________


                                                                             ________________


                                                                             ________________


                                                                             ________________


                                                                             ________________

21.    Marital status:       [ ] Single             [ ] Separated            [ ] Widowed
                             [ ] Married            [ ] Divorced

22.    List all former spouses:
                                  Date Married
                 Name              From / To                 Current Address/Phone #




23.    Are you a parent to any child, deceased or living?                         [ ] Yes [ ] No




Anywhere Police Department                       • 16 •                Background Investigation Forms
24.    List children below (including children born to you and adopted/step-children):
                                     Date of                  With Whom/Where/
           Name                       Birth             Caretakers Relationship to applicant




                                                 ______________________________________

25.    Which of the above listed children are you current supporting?




26.    Give the following information on your father, mother (maiden name), sisters and brothers:
       (If deceased, please indicate)

       Father's Name:
       Address:
       City/State/Zip:
       Date of Birth:                                    Place of Birth:
       Home Phone:                                       Work Phone:
       Occupation:                                       Employer:
       Employer Address:

       Mother's Name:                                    Maiden:
       Address:
       City/State/Zip:
       Date of Birth:                                    Place of Birth:
       Home Phone:                                       Work Phone:
       Occupation:                                       Employer:
       Employer Address:

       Name:                                             Relationship:
       Address:
       City/State/Zip:
       Date of Birth:                                    Place of Birth:
       Home Phone:                                       Work Phone:
       Occupation:                                       Employer:
       Employer Address:

Anywhere Police Department                     • 17 •                      Background Investigation Forms
       Name:                                           Relationship:
       Address:
       City/State/Zip:
       Date of Birth:                                  Place of Birth:
       Home Phone:                                     Work Phone:
       Occupation:                                     Employer:
       Employer Address:

       Name:                                           Relationship:
       Address:
       City/State/Zip:
       Date of Birth:                                  Place of Birth:
       Home Phone:                                     Work Phone:
       Occupation:                                     Employer:
       Employer Address:

       Name:                                           Relationship:
       Address:
       City/State/Zip:
       Date of Birth:                                  Place of Birth:
       Home Phone:                                     Work Phone:
       Occupation:                                     Employer:
       Employer Address:

       Name:                                           Relationship:
       Address:
       City/State/Zip:
       Date of Birth:                                  Place of Birth:
       Home Phone:                                     Work Phone:
       Occupation:                                     Employer:
       Employer Address:

27.    List names of three friends and/or associates. Do not include former employers or school
       teachers: Include number of years known.

       Name:                                          DOB:
       Address:
       City/State/Zip:                                H Ph:
       Occupation:                                    W Ph:
       Number of years known:____________________________________________________

       Name:                                          DOB:
       Address:
       City/State/Zip:                                H Ph:
       Occupation:                                    W Ph:
       Number of years known:____________________________________________________




Anywhere Police Department                   • 18 •                      Background Investigation Forms
       Name:                                          DOB:
       Address:
       City/State/Zip:                                H Ph:
       Occupation:                                    W Ph:
       Number of years known:____________________________________________________

28.    List no more than three names of Peace Officers with whom you are acquainted:

       Name:                                                  DOB:
       Address:
       City/State/Zip:                                        H Ph:
       Agency:                                                W Ph:

       Name:                                                  DOB:
       Address:
       City/State/Zip:                                        H Ph:
       Agency:                                                W Ph:

       Name:                                                  DOB:
       Address:
       City/State/Zip:                                        H Ph:
       Agency:                                                W Ph:

                         MILITARY AND SELECTIVE SERVICE
29.    Have you registered with the Selective Service?                           [ ] Yes [ ] No
       If yes, provide Selective Service Number:
       If no, explain why:




30.    Have you ever served in an active military organization of the United States?
                                                                                  [ ] Yes [ ] No
       If yes, give details:




31.    Have you ever served in a military organization of any foreign government?
                                                                                 [ ] Yes [ ] No
       If yes, give details:



32.    Give Branch of Service:
       Military Specialty:



Anywhere Police Department                   • 19 •                   Background Investigation Forms
33.    Rank Held:
       Service Serial Number:
       Name of CO at Time of Discharge:
       (Please complete Type III release form.)

34.    Did you ever apply for the military but later disqualified from the testing process for reasons
       other than medical in nature?                                                  [ ] Yes [ ] No
       If yes, please explain:



35.    How many periods of active military service have you had (drafts, enlistments or recalls to
       service)?



36.    Have you served outside the United States for any periods of time?            [ ] Yes [ ] No
       If yes, give details/locations/dates/etc.




37.    Give periods of active service:
       Location: ___________________________From: ______________To:                           _____
       Location: ___________________________From: ______________To:                           _____
       Location: ___________________________From: ______________To:                           _____

38.    List all medals and decorations awarded you as a member of the armed forces:




39.    How many discharges or separations from the service were given to you?
       Discharges:                            Separations:

40.    What is the type of your discharge or separation (honorable, dishonorable, honorable
       conditions, etc.). Be exact:
       Type:                                     Reason:



41.    Has your discharge or separation notice ever been corrected or changed?
                                                                                     [ ] Yes [ ] No

42.    What was the nature of the change? Changed from:
                                              to:


Anywhere Police Department                        • 20 •                 Background Investigation Forms
43.    Were you ever court marshaled, tried or charged, or were you the subject of a summary
       court, deck court, captain's mast, company punishment or any other disciplinary action?
                                                                                 [ ] Yes [ ] No

       If yes, how many times? _____ Give details of charges, agency concerned, dates and
       dispositions:

44.    Are you now or were you ever an active or inactive member of the Reserve Forces (any
       branch) of the United States, any foreign government, or the National Guard of any state?
                                                                                 [ ] Yes [ ] No
       If yes, state which:     [ ] Active     [ ] Inactive
       Branch:                      Regiment:                                Unit:
       Rank:                        Address:
       From:                                              To:
       (If yes, please complete a Type III release form.)

                                            EMPLOYMENT
45.    Present Employer Information:
       Name of Company:
       Address:
       City/County/State/Zip:
       Work Phone:                                            Date Hired:
       Position:                                              Salary/Wage:
       Duties Include:




46.    Can your current employer be contacted prior to a job offer?                     [ ] Yes [ ] No
       If no, give details:


       (Please complete a Type I release form.)

47.    Are you now engaged in any business as an owner (active or silent), partner, stockholder
       or corporate member?                                                   [ ] Yes [ ] No
       If yes, give details:



48.    List below chronologically (earliest date first), each and every place you were previously
       employed since the age of 16. OMIT NONE. Give correct, full addresses, phone numbers,
       and other requested information. Include all periods of unemployment between jobs, in
       proper sequence. Include all part-time employment and employment that overlaps with
       other employment. (Please complete a Type I release form for each employer.)


Anywhere Police Department                           • 21 •                  Background Investigation Forms
       From (month / year):      Name of Employer:
       To (month / year):        Address:
       Position:
       Salary / Wage:            Immediate Supervisor:
                                 Phone Number:
       Duties:
       ______
       Reason for Leaving:

       From (month / year):      Name of Employer:
       To (month / year):        Address:
       Position:
       Salary / Wage:            Immediate Supervisor:
                                 Phone Number:
       Duties:
       ______
       Reason for Leaving:

       From (month / year):      Name of Employer:
       To (month / year):        Address:
       Position:
       Salary / Wage:            Immediate Supervisor:
                                 Phone Number:
       Duties:
       ______
       Reason for Leaving:

       From (month / year):      Name of Employer:
       To (month / year):        Address:
       Position:
       Salary / Wage:            Immediate Supervisor:
                                 Phone Number:
       Duties:
       ______
       Reason for Leaving:


       From (month / year):      Name of Employer:
       To (month / year):        Address:
       Position:
       Salary / Wage:            Immediate Supervisor:
                                 Phone Number:
       Duties:
       ______
       Reason for Leaving:




Anywhere Police Department    • 22 •                 Background Investigation Forms
       From (month / year):                  Name of Employer:
       To (month / year):                    Address:
       Position:
       Salary / Wage:                        Immediate Supervisor:
                                             Phone Number:
       Duties:

       Reason for Leaving:

       From (month / year):                  Name of Employer:
       To (month / year):                    Address:
       Position:
       Salary / Wage:                        Immediate Supervisor:
                                             Phone Number:
       Duties:
       ______
       Reason for Leaving:

       From (month / year):                  Name of Employer:
       To (month / year):                    Address:
       Position:
       Salary / Wage:                        Immediate Supervisor:
                                             Phone Number:
       Duties:
       ______
       Reason for Leaving:

       From (month / year):                  Name of Employer:
       To (month / year):                    Address:
       Position:
       Salary / Wage:                        Immediate Supervisor:
                                             Phone Number:
       Duties:
       ______
       Reason for Leaving:

49.    Were you ever discharged or asked to resign from employment?        [ ] Yes [ ] No
       If yes, complete the following:

                 Employer                Date Left           Reason for Leaving




Anywhere Police Department                • 23 •                 Background Investigation Forms
50.   Were you ever subject to disciplinary action in connection with any employment?
                                                                                 [ ] Yes [ ] No
      If yes, give details:




51.    Have you, or any corporation or partnership of which you were an officer, director or partner,
       ever possessed a license or permit (excluding drivers license or learners permit) issued by
       any governmental agency?                                                   [ ] Yes [ ] No
       If yes, give details:




52.    Have you ever possessed a professional or occupational license, permit or certificate
       (excluding Peace Officer license)?                                       [ ] Yes [ ] No
       If yes, give details:




       (If yes, please complete a Type I release form.)

53.   Has any license or permit (excluding drivers license or learners permit) issued by any city,
      state or federal agency ever been denied, revoked, suspended or cancelled to you, or to any
      corporation or partnership of which you were an officer, director or partner?
                                                                                    [ ] Yes [ ] No
       If yes, give details:




54.    Have you made application with this or any other police organization?       [ ] Yes [ ] No
       If yes, complete the following:

           Date                            Agency                              Present Status




       (Please complete a Type I release form for each agency.)



Anywhere Police Department                      • 24 •                  Background Investigation Forms
55.    Have you ever been the subject of a background investigation conducted by a law
       enforcement agency which was considering you for employment?            [ ] Yes [ ] No

       If yes, give details: (Include application date, agency, background investigator,
       address, phone number, and status). (Please complete a type I release form for each
       agency.)

       Date:        Agency:                             Investigator:
       Address:
       Phone Number:                      Status:

       Date:        Agency:                             Investigator:
       Address:
       Phone Number:                      Status:

       Date:        Agency:                             Investigator:
       Address:
       Phone Number:                      Status:

       Date:        Agency:                             Investigator:
       Address:
       Phone Number:                      Status:

56.    Have you ever been rejected by or have you withdrawn from any background investigation
       and/or hiring process?
                                                                             [ ] Yes [ ] No
       If yes, complete the following:

           Date          Agency/Investigator                            Reason




57.    List below every professional or social organization in which you are or were a member:

        From       To
       Mo. Yr.    Mo. Yr.    Name/Address                               Organization




                             Phone #_____________________




                             Phone #_____________________

Anywhere Police Department                     • 25 •                   Background Investigation Forms
                             Phone #_____________________




                             Phone #_____________________




                             Phone #_____________________

                                    FINANCIAL DATA
58.    Have you any garnishment, wage assignment or judgment pending against you?
                                                                           [ ] Yes [ ] No
       If yes, give details:
       What Type (garnishment/judgment/etc.):

       With Whom:
       Address:
       City/State/Zip:                                     Ph:
       When Incurred:                         Original Amount:
       Present Amount:                        Monthly Payments:
       Amount of Arrears:
       What Type (garnishment/judgment/etc.):

       With Whom:
       Address:
       City/State/Zip:                                        Ph:
       When Incurred:                            Original Amount:
       Present Amount:                           Monthly Payments:
       Amount of Arrears:
       (Please complete a Type I release form for each name listed above.)

59.    List below all student loans from a governmental or private agency?




60.    Did you ever default on such loan?                                        [ ] Yes [ ] No
       If yes, give details:




Anywhere Police Department                    • 26 •                  Background Investigation Forms
61.    Have you ever been bonded?                                                   [ ] Yes [ ] No
       If yes, with respect to each time bonded, state details as follows:
                                                                                    Reason
       Date Bonded                  Name/Address                                  for Bonding




62.    Have you ever been refused a bond?                                           [ ] Yes [ ] No
       If yes, by whom and why:



63.    What is your present salary or wage?

64.    Do you have any other sources of income?
                                                                                    [ ] Yes [ ] No
       If yes, list below:




65.    Do you own any real estate/properties?                                       [ ] Yes [ ] No
       If yes, describe:




66.    Do you own any stocks or bonds, government or other?                        [ ] Yes [ ] No
       If yes, describe:




67.    Do you have a savings account?                                               [ ] Yes [ ] No
       If yes, complete the following:

       Name of Institution/Address/Phone Number            Account #

                                                           Balance




Anywhere Police Department                      • 27 •                   Background Investigation Forms
       Name of Institution/Address/Phone Number          Account #

                                                         Balance


68.    Do you have money market accounts?                                        [ ] Yes [ ] No
       If yes, complete the following:

       Name of Institution/Address/Phone Number          Account #

                                                         Balance


       Name of Institution/Address/Phone Number          Account #

                                                         Balance


69.    Do you have a checking account?                                           [ ] Yes [ ] No
       If yes, complete the following:

       Name of Institution/Address/Phone Number          Account #

                                                         Balance


       Name of Institution/Address/Phone Number          Account #

                                                         Balance

       (Please complete a Type I release form for each institution named in #67-79; include the
       account number and the type of account after the name listed on the release. Use separate
       sheet if necessary. Also, complete a Type V release form for each institution.)

                                FINANCIAL OBLIGATIONS

70.    Give the names and addresses of the individuals, companies or others to whom you are
       indebted and the extent of your debt. Include rent, mortgages, vehicle payments, charge
       accounts, credit cards, loans and any other debits and payments. Include account numbers
       where applicable:

                                                            Account         Total       Monthly
           Type       Name/Address/Phone # of Creditor      Number         Balance      Payment




Anywhere Police Department                   • 28 •                   Background Investigation Forms
                                                               Account           Total       Monthly
           Type       Name/Address/Phone # of Creditor         Number           Balance      Payment




       (Please complete a Type I release form for each listed creditor.)


Anywhere Police Department                     • 29 •                      Background Investigation Forms
                                         LITIGATION
71.    Were you ever a party to a civil action or proceeding in this state or elsewhere, or have you
       been named in a notice of claim that you may be a defendant in a civil action or
       proceeding?                                                                   [ ] Yes [ ] No
       If yes, indicate below every civil action or proceeding:
                                                                    As Plaintiff/
                                                               Defendant/Petitioner/       Court
         Date                Action/Proceeding                     Respondent            Disposition




72.    Have you ever been named as a suspect or arrested in a criminal investigation?
                                                                                   [ ] Yes [ ] No
       If yes, indicate EVERY incident, providing details and original charges and where is
       occurred. Use additional sheets if necessary.




73.    Have you ever been named as a defendant (charged) in a criminal proceeding?
                                                                              [ ] Yes [ ] No
       If yes, give details and disposition:




Anywhere Police Department                     • 30 •                   Background Investigation Forms
74.    Have you ever been convicted for any violation of the criminal law (excluding parking and
       moving traffic violations)?                                              [ ] Yes [ ] No
       If yes, complete information below:
                                                                               Your    Police
                                                                  Court        Age    Agency
         Date                Violation        Location          Disposition   Then Concerned




       NOTE: Conviction of a crime, other than a felony, in and of itself is not an automatic bar to
       employment, but only in so far as it relates to fitness to perform a particular job. Age and time of the
       offense and rehabilitation will be taken into account when considering an applicant.

75.    Have you ever been fingerprinted (excluding only present application with this department)?
                                                                                  [ ] Yes [ ] No
       If yes, fill in the following:
         Date                         Location             Reason for Fingerprinting




            MOTOR VEHICLE AND DRIVERS LICENSE HISTORY
76.    Have you ever received a summons or formal complaint for a violation of the traffic laws in
       this state, or any other state (excluding parking violations)?            [ ] Yes [ ] No
       If yes, insert the information below:

                                                                                        Your Police
                                                                          Court         Age Agency
        Date                  Offense                Location           Disposition     Then Concerned




77.    Was your driver’s license or other vehicle operator’s license ever revoked? [ ] Yes [ ] No
       Was your driver’s license or other operator’s license ever suspended?                [ ] Yes [ ] No
       If you answered yes to either one of the above, complete below:
       Which license?
       Date:                Where:
       Why:




Anywhere Police Department                          • 31 •                     Background Investigation Forms
78.    If you answered yes to question #80, was such license ever restored?        [ ] Yes [ ] No
       If yes, complete the following:
       Date:                  Where:
       Why:



79.    Have you ever been involved in a motor vehicle accident?                    [ ] Yes [ ] No
       If yes, state details:




80.    List all motor vehicles/motorcycles/ATV’s/boats, etc. which are in your name, in joint
       ownership, or which you drive on a regular basis:

       License Plate Number         State Issued         License Plate Number        State Issued




81.    Do you, or did you, possess a Minnesota Drivers License?               [ ] Yes [ ] No
       If yes, complete the following:
       Drivers License Number:
       Type of License:

82.    Do you, or did you ever, possess a driver’s license issued by any state other than
       Minnesota?       [ ] Yes [ ] No
       If yes, provide the following:
       Name of State:
       Type of License:
       (Please complete a Type I release form and list the name of the state.)

83.    List below the company which carries your auto insurance:
       Name of Company:
       Address:
       City/State/Zip:
       Agent Name:
       Agent Address:
       City State/Zip:                                        Ph:
       Policy Number:
       (Please complete a Type I release form for the insurance carrier.)

Anywhere Police Department                     • 32 •                   Background Investigation Forms
84.    Has your auto insurance ever been revoked or refused?                  [ ] Yes [ ] No
       If yes, give details:




              CONTROLLED SUBSTANCE AND ALCOHOL USE
85.    Have you ever used any non-prescription controlled substances (marijuana, cocaine, LSD,
       mushrooms, ecstasy, amphetamines, etc.)?                            [ ] Yes [ ] No

       If yes, please explain. Include dates, type of controlled substance(s), number of times used,
       etc.




86.    Have you ever sold any prescription or non-prescription controlled substances?
                                                                                  [ ] Yes [ ] No
       If yes, please explain. Include dates, type of controlled substance(s), number of times, etc.




Anywhere Police Department                     • 33 •                   Background Investigation Forms
87.    State the extent of your use of alcoholic beverages:




I CERTIFY THAT ALL OF THE STATEMENTS BY ME IN THIS APPLICATION ARE TRUE, COMPLETE
AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND ARE MADE IN GOOD FAITH. I
UNDERSTAND THAT ANY FALSE INFORMATION OR OMISSION OF INFORMATION FROM THIS
APPLICATION MAY BE CAUSE FOR REJECTION OR DISMISSAL IF EMPLOYED.



Signature of Applicant                    Date                Witness




Anywhere Police Department                       • 34 •                 Background Investigation Forms
                             ANYWHERE POLICE DEPARTMENT
                               BACKGROUND INFORMATION

                                   AUTOBIOGRAPHY

                        NAME: __________________________________


Instructions:

1.     Handwritten or print, no typing.
2.     Use ink pen or ballpoint, no pencil.
3.     Use your discretion and pages necessary.
3.     Sign your autobiography by using your normal signature.

––––––––––––––––––––––––––––––––––––––––––––––––––––




Anywhere Police Department                   • 35 •              Background Investigation Forms
Anywhere Police Department
Background Information
Autobiography of __________________________
Page _______ of _______




Anywhere Police Department             • 36 •   Background Investigation Forms
Anywhere Police Department
Background Information
Autobiography of __________________________
Page _______ of _______




Anywhere Police Department             • 37 •   Background Investigation Forms
Anywhere Police Department
Background Information
Autobiography of __________________________
Page _______ of _______




Anywhere Police Department             • 38 •   Background Investigation Forms
                          ANYWHERE POLICE DEPARTMENT
                        BACKGROUND INVESTIGATION FORMS

                                            RELEASES

This section includes the release forms that we use to gain access to a variety of data, as follows:


•   Type I: This is the general release which is used to access data at the following institutions:
    Schools, colleges, vocational/technical institutes, Minnesota POST Board, current and past
    employers, other law enforcement agencies, financial institutions, creditors, Minnesota
    Department of Public Safety, etc.

    NOTE: A separate signed release is needed for each specific agency/institution.
          (Original signatures required.)

•   Type II: This is a patient medical release which can be used for both doctors and hospitals.

    NOTE: The Anywhere Police Department reserves the right to have all medical or health data
    reviewed by a physician to determine the applicant's ability to perform the job.

•   Type III: This release is for access to military records.

    NOTE: A separate release form for each tour of duty is needed.

•   Type IV: This release is for employment eligibility verification.

•   Type V: This release is for credit information.



Original release forms are to be given to the agency/institution where data is sought from by the
Background Investigator. A photocopy of each release form should be maintained by the
Background Investigator and later placed into the background investigation booklet.




Anywhere Police Department                      • 39 •                   Background Investigation Forms
                  City of Anywhere, Minnesota
                  POLICE DEPARTMENT
                  101 Center Parkway
                  Anywhere, Minnesota 55337
                  952-895-4600  Fax 952-895-4640
                                                                                    RELEASE: TYPE I


                        GENERAL AUTHORIZATION AND RELEASE
                     PURSUANT TO MINNESOTA STATUTE 13.05, SUBD. 4
                           MINNESOTA DATA PRACTICES ACT


To:     _________________________________________
        _________________________________________
        _________________________________________
        _________________________________________


I, ___________________________________________________, hereby authorize and grant
my informed consent to permit you, ______________________________, to release to and make
available to the Anywhere Police Department and/or its agents and/or representatives, data
classified as private which concerns me and which may be in your possession.

The data which I authorize to be released consists of private data, as defined by Minnesota Statute
13.02, and has been collected by you as a result of my contacts and associations with you and/or
your agents and representatives. The information for which release is authorized includes all data
which has been collected, created, received, retained or disseminated in whatever form which in
any way relates to my dealing with you or your agency.

I understand that the purpose of permitting the Anywhere Police Department to have access to this
information is to determine my suitability for employment with that department. I further understand
that this information may subsequently be utilized for other purposes relating to my possible
employment with the department, including verification of my records and analysis by consultants
to the department who may review my suitability for employment.

This authorization shall be valid for a period of one year, but I reserve the right to, at any time
period to that expiration, cancel the written authorization by providing written notice to the
department or to you of that fact.


_____________________________________________                     ____________________
Signature                                                         Date
                 City of Anywhere, Minnesota
                 POLICE DEPARTMENT
                 101 Center Parkway
                 Anywhere, Minnesota 55337
                 952-895-4600  Fax 952-895-4640

                                                                                  RELEASE: TYPE II


                 PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION

To:    ____________________________________________
       ____________________________________________
       ____________________________________________
       ____________________________________________

Re:    Patient's Name: _______________________________
       Date of Birth: _________________________________

This is your full and sufficient authorization, pursuant to Minnesota Statute 144.335, to release to
the Anywhere Police Department, its representatives or employees, all medical information
(including but not limited to that which involves treatment for alcohol or drug abuse, sickle cell
anemia, or mental problems) maintained while I was a patient at your facility on any date, with the
following exceptions: None.

The information is needed for the purpose of consideration of my suitability for employment with
the Anywhere Police Department. The authorization specifically includes records prepared prior to
the date of this authorization and records prepared after the date of this authorization during the
pendency of this proceeding. I do not authorize re-release of this information by the third party.

I understand that I may revoke this consent in writing at any time, but that such revocation may
adversely affect the course of the proceeding requiring these records. Upon the fulfillment of the
above stated purpose, this consent will automatically expire without my express revocation. A
photocopy of this authorization will be treated in the same manner as an original. Conversations
by the bearer of this authorization with physicians are authorized by this release form.

_____________________________________________                     ____________________
Signature of Patient                                              Date


I verify that the proceeding requiring this information is still pending and that information provided
pursuant to this authorization will not be re-released for purposes not related to this proceeding.

______________________________________________                    ____________________
Signature of Party Requesting Information                         Date

ATTN PUBLIC FACILITIES: Minnesota Statute 13.05 requires automatic expiration of this authorization one
year from date of authorization
RELEASE: TYPE III
RELEASE: TYPE III   (page 2)
Applicant: Complete Section I   RELEASE: TYPE IV
City of Anywhere, Minnesota
POLICE DEPARTMENT

101 Center Parkway
Anywhere, Minnesota 55337
952-895-4600  Fax 952-895-4640

                                                                                 RELEASE: TYPE V




                             RELEASE FOR CREDIT INFORMATION


To:    Credit Bureau of Minneapolis/St. Paul

Re:    Name:
       Date of Birth:
       Social Security #


I have applied for a position with the Anywhere Police Department. As part of that department's
evaluation of my suitability for employment in this position, a background investigation is being
conducted.

I request and authorize you to release any and all information concerning my credit, credit rating,
and credit bureau reports to the department. Please send this information to:

                     ____________________________
                     Background Investigator
                     Anywhere Police Department
                     101 Center Parkway
                     Anywhere, MN 55337

This authorization shall be valid for a period of one year, but I reserve the right to cancel the
authorization at any time period to that expiration by providing written notice to the department or to
you.


_____________________________________________                    ____________________
Signature                                                        Date

								
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