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					                             GLENDALE POLICE DEPARTMENT
                                    6835 NORTH 57th DRIVE
                                  GLENDALE, ARIZONA 85301



Name:


Job Title:                                                      Date:


Background Investigator:

                               APPLICANT QUESTIONNAIRE

This questionnaire and the information gathered will be used in the polygraph and background
phases of the employment evaluation process. Disclosures of a negative nature will not
automatically bar you from employment. An extensive background check will be conducted into
your personal history. Your answers to the following questions will be verified by checks of
records kept by police agencies, court, and social service agencies, and by interviews with
persons you have listed on your background packet. School records may be checked and
employment will be verified. These answers will also be verified by a polygraph examination.

Regardless of the outcome of this process, you are not entitled to any information or paperwork
that has been obtained by the Glendale Police Department for the purpose of completing the
employment background investigation.

It is mandatory that all spaces requiring written explanations are completed on this form.

If you deliberately give false or misleading information, or omit relevant
information, you will be disqualified.

                                         DIRECTIONS

1.    Complete this packet in black ink in your own handwriting.
2.    Review each answer carefully and ensure your answers can be easily read.
3.    Answer each question completely. Do not omit any information that is requested.
4.    If you need additional space, use the Additional Information/Clarification Form(s) at the
      end of this questionnaire.
5.    Do not leave any question blank. If it does not apply to you, write N/A in the blank.
6.    Please wait to sign the Affirmation, located at the end of this questionnaire, until in the
      presence of the investigator.




                                                                   e621d109-6b67-4a41-8845-7ff64e712992.doc
                                      PERSONAL DATA



Full Name:
              Last                                      First                       Middle

Address:
                           Street                          City, State                       Zip Code

Home Phone #:                                      Business Phone #:
Message Phone #:                                   Email Address:

Height:               Weight:          Hair:                    Eyes:

Age:                 Date of Birth:                      Place of Birth:

Social Security #:

Have you ever used another name?      Yes          No                   If yes, please list them:

Name Used                                                                Dates Used




List all addresses (city and state only) where you have resided in the last ten (10) years,
starting with your present address. Include addresses during military service. If you rented at
any of the addresses listed, include name, address and phone number of your landlord or
property management on the Additional Information/Clarification Form(s) provided at the end
of this packet.

              Dates
                                                         City                                State
       From                To




                                               2
                                      MARITAL STATUS

Single           Widowed             Married           Date of Marriage:

                  Date of                                         Date of
Divorced                                        Separated
                  Divorce:                                        Separation:

If you are currently married:
Spouse’s (maiden) name:                                      Date of Birth:
City/State of Marriage:

                                          RELATIVES

List all your immediate family members (parents, siblings, and children).

           Name                  Relationship                    Address             Age




List all your spouse’s immediate family members (parents, siblings, and children).

           Name                  Relationship                    Address             Age




                                                3
                                       REFERENCES

Give three (3) references (not relatives, significant others, or former supervisors) who are
responsible adults and have known you well during the last five (5) years. Contact information
must be complete.



Name:
Address:
                              Street                          City, State           Zip Code
Phone #:                                   Email Address:
Relationship to You:                                                Years Known:



Name:
Address:
                              Street                          City, State           Zip Code
Phone #:                                   Email Address:
Relationship to You:                                                Years Known:



Name:
Address:
                              Street                          City, State           Zip Code
Phone #:                                   Email Address:
Relationship to You:                                                Years Known:




                                              4
                                   EDUCATIONAL HISTORY

List all schooling you have attended or are attending (High School and above):

Name of High School,         Location            Dates     Units/Credits   Graduation       Type of
College, or University    City and State        Attended    Completed         Date          Degree




Have you ever entered a law enforcement training academy?         Yes        No
If yes, which one(s)?

                    PRIOR LAW ENFORCEMENT APPLICATION HISTORY

Have you ever applied for a sworn or civilian position with any other law enforcement agency,
or are you currently in the process with any other law enforcement agency?

                          Date                                       Reason not
       Agency                        Position Title    Status                           Polygraphed?
                         Applied                                       Hired




                                                 5
                                  EMPLOYMENT HISTORY

List all places of employment for the last ten (10) years. Begin with your present or most
recent employer and work backwards. List all periods of unemployment, periods of schooling,
military service, etc. OMIT NONE. Please keep in proper sequence.


Employer Name:                                                Phone:

Address:                                 City:                         State/Zip:

Dates of Employment:      From:                  To:                   Salary:

Position(s) Held:                        Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                       Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:



Employer Name:                                                Phone:

Address:                                 City:                         State/Zip:

Dates of Employment:      From:                  To:                   Salary:

Position(s) Held:                        Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                       Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:



Employer Name:                                                Phone:

Address:                                 City:                         State/Zip:

Dates of Employment:      From:                  To:                   Salary:

Position(s) Held:                        Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                       Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:




                                             6
                                  EMPLOYMENT HISTORY
                                                             Phone:
Employer Name:
Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


                                            7
                                  EMPLOYMENT HISTORY

Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:


Employer Name:                                               Phone:

Address:                                City:                         State/Zip:

Dates of Employment:      From:                 To:                   Salary:

Position(s) Held:                       Immediate Supervisor’s Name:

Supervisor’s Direct Phone:                      Supervisor’s Email:

Type of Work Performed:

Reason for Leaving:



                                            8
                                     FINANCIAL STATUS

List all the sources of your income at present:

                                                                                        Monthly
  Type of Income                         Firm Name or Source
                                                                                        Amount
     Your Salary                                                                   $
   Spouse’s Salary                                                                 $
        Other                                                                      $
        Other                                                                      $
        Other                                                                      $
        Other                                                                      $
                                                                          Total $

List all obligations now owing, and individuals or firms with whom you have credit dealings.
Include child support payments (use the Additional Information/Clarification Form(s) at end of
this packet, if necessary).

     Type of         Name of Person or Firm of                           Monthly
                                                      Unpaid Balance                     Past Due
    Obligation        Obligation and Address                             Payment
Mortgage or Rent

Automobile Payment




List all bank accounts you presently have. Include type of account (e.g. savings, checking, etc.)

  Name of Bank or                  Address                     Type of                 Present
    Institution                   City, State                  Account                 Amount




                                                  9
                                     DRIVING HISTORY

Current Driver’s License:

State:                Expiration Date:                     License #:

Previous Driver’s License Information (List all states/countries where you have been licensed):




                               MILITARY SERVICE HISTORY

Are you in compliance with the Selective Service Law?     Yes       No           N/A
Have you ever served in the Air Force, Coast Guard, Navy, R.O.T.C., or any other military or
semi-military organization?  Yes        No

If yes, list them below. If there was more than one period, list them separately.

Month & Year                                 Date of
                      Organization                         Type of Discharge           Rank
  Entered                                   Discharge




Did you receive any disciplinary actions in the military (such as Court Martial, Article 15,
Captain’s Mast, Company punishment, reduced in rank, etc.)?

      Date of
                                             Type of Disciplinary Action
Disciplinary Action




While in the military were you ever incarcerated (brig or guardhouse)?     Yes         No

Were you ever UA, AWOL, missed formation or missed ship movement?          Yes         No



                                               10
                             BACKGROUND INFORMATION

1.    Are you a United States citizen?    Yes        No

2.    Have you ever used a social security number other than the one you provided on page
      two?      Yes       No
      If yes, list numbers(s):

3.    Do you have any prejudices against any group?         Yes     No

4.    Have you ever been a member of any organization which advocates, advises or supports
      the use of force or other unlawful means to deny other persons their rights under the
      Constitution of the United States?   Yes       No

5.    Have you ever lied under Oath or on a sworn document?        Yes        No

                  EMPLOYMENT/LAW ENFORCEMENT EXPERIENCE

6.    Have you ever been a peace officer in any state?       Yes      No
      If yes, Agency name and location:

7.    Have you ever been counseled, written up, suspended, served an intent to terminate or
      disciplined in any manner, by any of your employers?  Yes        No
      If yes, why:

8.    During the past year, have you falsified sick time by calling in sick when you were not
      sick?    Yes      No
      If yes, why:                               # of times:              Last time:

9.    Have you ever taken merchandise or goods (that you were not authorized to take) from
      a company where you worked? Please check one:
           No, never
           Yes, items with a total value of less than $25
           Yes, items with a total value of between $26 and $99
           Yes, items with a total value of between $100 and $499
           Yes, items with a total value of $500 or more

10.   Have you ever taken money (that you were not authorized to take) from a company
      where you have worked?    Yes       No
      If yes, how much:           How many times:                  Last time:




                                                11
11.   How many vehicular accidents have you been involved in while "on duty" or that were
      work related? __________
      How many of those were you at fault?

12.   Have you ever falsified information regarding damage to departmental equipment
      and/or vehicles?    Yes       No

13.   Have you ever failed to report damage to departmental equipment and/or vehicle you
      were responsible for?    Yes      No

14.   Have you ever used illegal drugs while at work?     Yes        No

15.   Have you ever used illegal drugs while employed with a law enforcement agency?
      Yes      No        N/A

16.   Have you ever consumed alcohol while “on duty” or at work?      Yes         No

17.   Have you ever engaged in any type of sexual activity while at any place of employment?
      Yes      No

18.   Did you ever cover up a violation for a fellow employee?
      Yes       No

19.   Did you ever lie or commit perjury in court testimony or any other official proceeding,
      including an internal affairs investigation?  Yes       No

20.   Have you ever been fired or terminated from any employment?           Yes        No
      If yes, name of employer(s):

21.   Have you ever resigned from a job to avoid being fired or terminated? Yes             No
      If yes, name of employer(s):

22.   Did you ever work without reporting it (even on the side) while collecting unemployment
      benefits?   Yes       No




                                             12
                                        DRIVING RECORD

23.     How many traffic citations have you had since you started driving?

                                                              Year
      Incident               Brief Description                               Location            Disposition
                                                            Received
                          Going 60 in a 45 and no                                         Paid fine, driving school,
      Ticket: Speeding,
                           proof of insurance in             2001        Prescott, AZ      found not responsible,
      No Insurance
                                  vehicle                                                         sentenced
1.
2.
3.
4.
5.

      Check here if further space is needed to list citations and continue them on the Additional
      Information/Clarification Form(s) at end of this packet.

24.     How many automobile accidents have you been involved in where you were at
        fault? __________

25.     Have you ever been a driver, or a passenger, in an accident where injuries or damage
        occurred and you left the scene of the accident (hit and run)?  Yes        No

26.     Have you ever falsified information on an accident report or given police false
        information during a traffic stop, accident or other police investigation? Yes                         No

27.     Have you ever been involved in a "Road Rage" situation?                     Yes        No

28.     Do you currently have automobile insurance as mandated by this state? Yes                              No

29.     Has your insurance ever been canceled?                Yes            No

30.     Has your insurance ever been placed in “high risk”?                   Yes         No

                                      FINANCIAL HISTORY

31.     Have you ever filed Bankruptcy?          Yes           No
        If yes, when:                                   Where:

32.     Have you ever been referred to a collection agency or had your wages garnished?
        Yes      No

33.     Have you ever had your property repossessed?                   Yes          No


                                                       13
34.   How many times in the past year have you had a check returned for insufficient
      funds? __________

35.   Has a landlord ever served you with an eviction notice?     Yes          No

36.   Have you ever been the subject of a lawsuit by a former landlord or property manager?
      Yes      No

37.   Are you currently delinquent with any child support obligations? Yes           No   N/A

38.   Have you ever failed to make child support payments that you were legally required to
      make?    Yes        No       N/A

39.   Have you ever made false claims on insurance policies?     Yes           No

40.   Have you ever failed to file a Federal or State tax statement?     Yes         No
      If yes, list year(s):

41.   Have you had any issues, or do you currently have any unresolved issues with the
      Internal Revenue Service?    Yes       No

42.   Have you ever deliberately lied on your income tax return for personal gain?
      Yes      No

43.   Do you gamble?          Yes   No
      If yes, how often and what forms:

44.   Do you currently have any outstanding gambling debts?        Yes          No

45.   Have you ever used your employer’s money to gamble with?           Yes         No

46.   Were you ever employed by a gambler, or have you ever booked any type of bet?
      Yes      No




                                              14
                                     CRIMINAL HISTORY

47.     Have you had the police to your residence for any reason?      Yes       No

Domestic Violence is defined in the law as certain criminal acts committed between persons
who have been involved in a relationship who live together in the same household (or who have
lived together in the past); or persons who have a child in common or are expecting a child
(regardless of whether they have resided in the same household); or persons related to one
another in the following ways:
        Spouse                   Child               Grandparent            Former Spouse
        Brother                  Sister                 Grandchild                  Parent
The crimes defined in the law are:
        Assault             Criminal Damage           Endangerment             Imprisonment
      Intimidation             Kidnapping                Trespass            Disorderly Conduct
           Reckless display or discharge of a deadly weapon or dangerous instrument

48.     Has any law enforcement agency ever responded to your residence, temporary or
        permanent, for any reason relating to domestic violence? Yes       No
        If yes, please provide the details:



49.     Have you ever committed any act of domestic violence according to the definition
        provided?     Yes        No
        If yes, please provide the details:



50.     Have you ever been the subject of a court order of protection (restraining order) or
        injunction prohibiting harassment?   Yes        No

51.     Have you ever been the subject of an investigation by a child protective services or child
        welfare agency?   Yes       No

52.     In the past 10 years how many physical fights have you been in (other than your job as
        a peace officer)? __________

53.     Have you ever been affiliated with or a member of a gang?      Yes       No

54.     Have you ever observed or been present during the commission of any crime?
        Yes      No

55.     Have you ever been questioned as a suspect in a crime?       Yes       No

56.     Were you ever the subject of a civil or criminal prosecution (lawsuit)? Yes          No


                                                15
57.   Have you ever been connected with a criminal investigation of any kind, in any manner?
      Yes      No

58.   Have you been arrested (e.g. held in police custody, cited and released, etc.) for any
      reason?    Yes      No
      If yes, what for:

59.   Have you been convicted of, pleaded guilty to, or pleaded no contest to misdemeanor or
      felony charges?   Yes       No
      If yes, what for:

60.   Have you ever had a warrant issued for your arrest?         Yes         No

61.   Have you ever been on court ordered probation?        Yes         No

62.   Have any of your relatives (including your spouse) or your spouse’s relatives ever been
      convicted or imprisoned for a crime?      Yes     No
      If yes, please list name(s) and relation(s):


      Charge(s):

63.   Have you ever stolen or taken without permission any property from a business (i.e.
      shoplift) or other people? Please check one:
            No, never
           Yes, items with a total value of less than $25
           Yes, items with a total value of between $26 and $99
           Yes, items with a total value of between $100 and $499
           Yes, items with a total value of $500 or more

64.   Did you ever buy/sell anything that you suspected was stolen?           Yes         No

65.   Did you ever buy/sell anything that you knew was stolen?          Yes          No

66.   Are you now in possession (e.g. on person, at residence, in car, etc.) of any stolen
      property?   Yes       No

67.   Have you ever paid, or been paid, to participate in any sexual act?           Yes        No




                                              16
68.    Have you ever intentionally sought out or viewed child pornography, including via the
       Internet?  Yes        No

The next section of questions asks about specific criminal offenses. Respond to each criminal
offense as it applies to you. For each criminal offense, mark ALL ANSWERS THAT APPLY. Be
sure to mark at least one response for each offense. Even if you were in the military and were
in violation of the offenses under the UCMJ, make sure you include these offenses. Also,
include any offenses committed as a juvenile.

If you have been questioned by police about one of these offenses or have been named in a
police report concerning one of the described offenses, check the “I have been accused of it”
box and any other boxes that might apply for that offense.

69.    ARSON – Intentionally setting a fire to destroy something or cause damage.
            I have been accused of it.
            I have committed it.
            I have been arrested for it.
            I have been tried in court for it.
            I have been convicted (or pled guilty or no contest).
            None of the above.

70.    FORGERY – Signing another person’s name to a document without their permission.
            I have been accused of it.
            I have committed it.
            I have been arrested for it.
            I have been tried in court for it.
            I have been convicted (or pled guilty or no contest).
            None of the above.

71.    EMBEZZLEMENT – Theft of money or valuables entrusted to you.
            I have been accused of it.
            I have committed it.
            I have been arrested for it.
            I have been tried in court for it.
            I have been convicted (or pled guilty or no contest).
            None of the above.




                                                 17
72.   RAPE OR ATTEMPTED RAPE – A forcible sex act other than child molest, including
      sexual abuse.
           I have been accused of it.
           I have committed it.
           I have been arrested for it.
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.

73.   SEXUAL CHILD ABUSE OR MOLEST – Include sex or sexual contact with a minor
           I have been accused of it.
           I have committed it.
           I have been arrested for it.
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.

74.   ASSAULT, RESISTING ARREST, HOMICIDE
           I have been accused of it.       Which crime(s):
           I have committed it.             Which crime(s):
           I have been arrested for it.     Which crime(s):
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.

75.   BURGLARY, THEFT, BREAKING AND ENTERING
           I have been accused of it.       Which crime(s):
           I have committed it.             Which crime(s):
           I have been arrested for it.     Which crime(s):
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.




                                                18
76.   CRIMINAL DAMAGE (VANDALISM/GRAFFITI)
           I have been accused of it.
           I have committed it.
           I have been arrested for it.
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.

77.   SEXUAL CRIMES – i.e. self-exposure, obscene phone calls, peeping tom, beastiality (sex
      with animals), sex in a public place, etc.
            I have been accused of it.       Which crime(s):
           I have committed it.             Which crime(s):
           I have been arrested for it.     Which crime(s):
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.

78.   DRIVING UNDER THE INFLUENCE OF ALCOHOL
           I have been accused of it.
           I have committed it.
           I have been arrested for it.
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.

79.   VEHICULAR ASSAULT OR VEHICULAR MANSLAUGHTER
           I have been accused of it.
           I have committed it.
           I have been arrested for it.
           I have been tried in court for it.
           I have been convicted (or pled guilty or no contest).
           None of the above.




                                                19
                                            SUBSTANCE ABUSE

80.       Illegal use of drugs/controlled substances
                                                                               How
                     Have you ever sold,                          If yes,
                                            Have you ever used,               many
                          smuggled or                               how                 Date first   Date last
  Type of Drug                                    tried or                    times
                     transported for sale                          many                   used        used
                                            experimented with?              after age
                       or personal gain?                          times?
                                                                               21?
      Marijuana       Yes        No          Yes       No

  Cocaine/Crack       Yes        No          Yes       No
Methamphetamine/
                      Yes        No          Yes       No
     Speed
       Heroin         Yes        No          Yes       No

       Opium          Yes        No          Yes       No

      Morphine        Yes        No          Yes       No
  Hallucinogens
 (i.e. LSD/Acid,
    Mescaline,        Yes        No          Yes       No
mushrooms, angel
 dust, PCP, etc.)
       Peyote         Yes        No          Yes       No

      Hashish         Yes        No          Yes       No

      Steroids        Yes        No          Yes       No
 Any other illegal
                      Yes        No          Yes       No
 drug or narcotic
   Illegal use of
                      Yes        No          Yes       No
prescription drugs
 Use of inhalants
 (i.e. glue, spray    Yes        No          Yes       No
    paint, etc.)


Have you ever abused over-the-counter medication(s)?              Yes        No
If yes, please explain:

                                  GENERAL SUMMARY QUESTIONS

81.       Is there anything not mentioned in this packet you would like to bring to our attention
          at this time?   Yes      No




                                                      20
                                REQUIRED DOCUMENTS

The following documents must be provided before your background can be completed. If you do
not have certified copies, you must bring in the original to be viewed and copied.

   1. High school diploma or G.E.D. or high school I.D. card or 8th grade / junior high
      promotional certificate.
   2. Post high school academic degrees or certificates including police certification and
      official college transcripts.
   3. Certified/original birth certificate or naturalization papers.
   4. Original social security card.
   5. A copy of your current driver’s license, motor vehicle registration(s), and car insurance,
      if applicable.
   6. A copy of your last performance evaluation or report card.
   7. Marriage certificate, divorce decree, bankruptcy dissolution information, if applicable.



                                        AFFIRMATION

Under penalty of perjury (pursuant to Arizona Revised Statutes, Sections 13-2702, Subsection
A.2) I hereby state and declare that the above statements are true. I make this declaration fully
aware that the Glendale Police Department may choose to verify the truth of these statements
through either a polygraph examination, and/or a background investigation. Further, if it is
proven that I have made a false statement, I understand this would be grounds for my
disqualification as a candidate, or termination of my membership.

This form must be signed in the presence of the background investigator/Post Advisor
conducting your interview.


       Applicant’s Signature                                 Social Security Number

Reviewed with applicant:


       Background Investigator/Advisor                               Date




                                                21
                        Additional Information/Clarification Form

Please use this sheet to provide additional information or clarifications of the events/incidents
you provided in the applicant questionnaire. These clarifications give you the opportunity to
describe the situation in detail to the hiring board. Please use one form for each question or
section. Be detailed in your description and give as much information as possible. Make
additional copies of this form as needed.

Question # or Section:                                                   Page #:

Incident/Event:                                              Date of Incident:

Age/Time of Incident:                    Where did the incident occur?

Who was involved?

Describe in DETAIL what happened:




Applicant’s Printed Name:

Applicant’s Signature                                                Date:




                                               22
                        Additional Information/Clarification Form

Please use this sheet to provide additional information or clarifications of the events/incidents
you provided in the applicant questionnaire. These clarifications give you the opportunity to
describe the situation in detail to the hiring board. Please use one form for each question or
section. Be detailed in your description and give as much information as possible. Make
additional copies of this form as needed.

Question # or Section:                                                   Page #:

Incident/Event:                                              Date of Incident:

Age/Time of Incident:                    Where did the incident occur?

Who was involved?

Describe in DETAIL what happened:




Applicant’s Printed Name:

Applicant’s Signature                                                Date:




                                               23
                        Additional Information/Clarification Form

Please use this sheet to provide additional information or clarifications of the events/incidents
you provided in the applicant questionnaire. These clarifications give you the opportunity to
describe the situation in detail to the hiring board. Please use one form for each question or
section. Be detailed in your description and give as much information as possible. Make
additional copies of this form as needed.

Question # or Section:                                                   Page #:

Incident/Event:                                              Date of Incident:

Age/Time of Incident:                    Where did the incident occur?

Who was involved?

Describe in DETAIL what happened:




Applicant’s Printed Name:

Applicant’s Signature                                                Date:




                                               24
                        Additional Information/Clarification Form

Please use this sheet to provide additional information or clarifications of the events/incidents
you provided in the applicant questionnaire. These clarifications give you the opportunity to
describe the situation in detail to the hiring board. Please use one form for each question or
section. Be detailed in your description and give as much information as possible. Make
additional copies of this form as needed.

Question # or Section:                                                   Page #:

Incident/Event:                                              Date of Incident:

Age/Time of Incident:                    Where did the incident occur?

Who was involved?

Describe in DETAIL what happened:




Applicant’s Printed Name:

Applicant’s Signature                                                Date:




                                               25
                        Additional Information/Clarification Form

Please use this sheet to provide additional information or clarifications of the events/incidents
you provided in the applicant questionnaire. These clarifications give you the opportunity to
describe the situation in detail to the hiring board. Please use one form for each question or
section. Be detailed in your description and give as much information as possible. Make
additional copies of this form as needed.

Question # or Section:                                                   Page #:

Incident/Event:                                              Date of Incident:

Age/Time of Incident:                    Where did the incident occur?

Who was involved?

Describe in DETAIL what happened:




Applicant’s Printed Name:

Applicant’s Signature                                                Date:




                                               26
                            GLENDALE POLICE DEPARTMENT
                                   6835 NORTH 57th DRIVE
                                 GLENDALE, ARIZONA 85301


                                   IMPORTANT NOTICE

Please complete the following forms and provide them to your background investigator or the
Post Advisor.

Release and Authorization
This form is a release and authorization form allowing the department to conduct your
background investigation. Reminder: This form must be signed and notarized.

If you are 17 years and younger your parent must have this form notarized, if you are 18 years
and older you must have this form notarized.




                                              27
                            GLENDALE POLICE DEPARTMENT
                                   6835 NORTH 57th DRIVE
                                 GLENDALE, ARIZONA 85301



                 NOTICE THAT CREDIT REPORT WILL BE OBTAINED
                                             AND
                          AUTHORIZATION FOR DISCLOSURE
YOU ARE HEREBY NOTIFIED that, pursuant to the Consumer Credit Reporting Reform Act of
1996, Section 604(b) [15 U.S.C. 1681b (b)], the Glendale Police Department intends to obtain a
consumer credit report on you, the applicant, in order to more competently evaluating your
fitness as a prospective employee of the Department.

The report cannot be furnished to us without your authorization (consent) for us to receive this
report.


     I hereby give my consent to allow the Glendale Police Department to
     obtain a consumer credit report on myself.


     I do not give consent to the Glendale Police Department to allow it to
     receive a consumer credit report on myself, the applicant.



Print Name:
                   Last            First           Middle

Signature:

Date of Birth:


Social Security Number:


Phone Number:


Address:




                                              28
                             GLENDALE POLICE DEPARTMENT
                                    6835 NORTH 57th DRIVE
                                  GLENDALE, ARIZONA 85301



                            RELEASE AND AUTHORIZATION
In relation to my application for employment with the Police Department of the City of Glendale,
Arizona, I fully understand the sensitive nature of this position and I recognize the necessity for
a thorough investigation into my background.

In view of this need, I hereby authorize the release of all information as hereafter described by
any individual, partnership, corporation or any other entity, including governmental entities, and
I expressly waive any claim or right of action against any party as a result of the release of the
information as hereafter described.

This release and authorization shall include all of the following information:

       1.      Any information concerning my personal or employment history, to include but
               not limited to, any background investigation information, psychological
               evaluation, or polygraph test results. Information of a confidential or privileged
               nature may be included.

       2.      Any information concerning criminal or traffic matters including, but not limited
               to, arrest, conviction, plea agreements, and reports where I may have been a
               suspect, but never formally had criminal charges brought against me.

       3.      Undeleted DD-Form 214, Certificate of Release or Discharge from Active Duty,
               including, but not limited to, the re-enlistment code (RE), the type and reason
               for release or discharge and any charges, arrests or convictions which arose
               through the military criminal justice system.

I further authorize the City of Glendale, Arizona, to release any information it may obtain
through the use of this authorization and release to any governmental agency that I hereby
expressly waive any claim or right of action against any party as a result of the release of this
information.

                                                   Subscribed and sworn before me this
Date
                                                              day of                       , 2011
Print Name
                                                   Notary
Signature




                                                29

				
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