WPD Aux Application 2008 by liuhongmei



Read every question carefully. ANSWER EVERY QUESTION LEAVING NO BLANK SPACES. If questions do not
apply you must state so. A candidate may be rejected if he/she intentionally made a false state of material fact or practiced or
attempted to practice any deception or fraud in this application, in an examination or in the securing of his/her eligibility for
The candidate shall personally prepare this form. All entries except the signature must be printed legibly in block letters.
Entries must be made in either blue or black ink. If you need additional space to answer a question, use a separate sheet of
paper and precede each answer with the number of the question being answered.

1.    What is your full name?
                                               Surname                     First                             Middle

2.    Give any other names you have used or been known by. Attach a statement giving reasons
          (If none state so)

3.    Where were you born?
                                                                     Residence at time of birth

4.    Birth certificate
                                Number              City or town             County                State           Country

5.    Date of birth                      day of                                           ,       19

6.    Where do you now reside?
                                               Number                                         Street

           City or Town                                            State                                           Zip Code

7.    With whom do you reside?

      Give floor                     Apt No.                North, East, South West, Front, Rear

8.    Telephone Number        Home                                                 Work


9.    In chronological order state each and every place in which you have resided since you left elementary school.

       From           To                     Address                            City or Town           State          Zip
      Mo./Yr.        Mo./Yr.

10.   List all places where you have registered to vote: ( If none, so state)

      County                   State              Year                County                   State           Year

                                                  ARRESTS, SUMMONSES, ETC

11.   Were you ever arrested or taken into custody in this state or elsewhere? (Include all investigations as a
      juvenile such as Juvenile Aid Bureau investigations)            Yes or No
                                                                      How many times?
             Indicate below ALL arrests including Juvenile Delinquent, Youthful Offender and Wayward Minor

        Date     Violation           Location            Charge              Court Disposition              Police agency
                Act Charge                              Reduced to             or Sentence                   Concerned

12.   Were you ever served with a summons or subpoena in other than a civil action (include traffic violations,
      parking, etc. in this state or elsewhere)?                 Yes or No
                                                                 How many times?
      Indicate below EVERY summons or subpoena you received in other than a civil action.

      Date          Offense            Location                  Court Disposition          Age            Police Agency

13.   Were you or your spouse ever summoned or subpoenaed to court in a civil action or proceeding (including
      a Domestic 209A, restraining order) in this state or elsewhere? Could such a possibility ensue as a result of
      a recent occurrence or transaction?                           Yes or No

      Indicate below every civil action or proceeding in which you or your spouse were summoned or subpoenaed,
      or in which you or your spouse were a party and also contingent possibilities as described above.

                    Action or                     As plaintiff, defendant, petitioner,
      Date          Proceeding                    respondent, witness                                 Court Disposition

14.   Have you ever owned any pistols, revolvers, firearms or dangerous weapons? Yes or No
      If yes, give details including make, model serial number, caliber and years of possession. If you possessed any
      pistol license give the number and issuing agency. If other than firearms describe weapon fully.

                                                 SUBVERSIVE AFFILIATIONS

      Instructions:      The words "Subversive Affiliation" as used in questions 15 to 21 inclusive, shall mean any
      group or organization which supports, or which is in sympathy with the principals of Communist or any
      other subversive doctrine.

      Answer Yes or No to each question. If the answer given is "Yes", explain details in separate affidavit to be
      attached to this form.

15.   Have you ever by word, mouth or writing advocated, advised or taught the doctrine that the government of
      the United States of America, or of any state, or of any political subdivision thereof should be overthrown
      or overturned by force, violence, or any unlawful means?

16.   Are you now or have you ever been a member of any subversive organization?

17.   Have you ever been connected or affiliated in any manner with or have you ever attended any meetings
      of any subversive organization?

18.   Have you ever paid, collected or solicited any money, dues, or contributions to, for or on behalf of any
      subversive organization?

19.   Have you ever participated in any parade, picket line, delegation or demonstration sponsored or organized
      by any subversive organization?

20.   Have you ever been a member of or attended any school, camp, class or forum sponsored by any
      subversive organization?

21.   Have you ever signed or solicited others to sign any petition sponsored or issued by any subversive
      organization, or any petition which has as its purpose the aiding of any person, cause or program connected
      with any subversive organization?

                                                         (Answer ALL Questions)

22.   Are you a native born or naturalized citizen?
                                                                     Indicate Which

      If you are of foreign birth, or are naturalized citizen fill in the following:

      Country of birth.

      Port or place of departure for the U.S.                                                     Date

      How were you transported to the U.S.
                                                                               Ship, train, plane, bus. etc.

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

      Place or port of entry into the U.S.                                                        Date

      If a naturalized citizen, give the name and address of the person who sponsored you upon arrival?

      First address after arrival into the U.S.

      How did you obtain citizenship?

      Petition No.                              Date                              Court

      State                                     Certificate No.

                                                      MEDICAL HISTORY

23.   Have you ever had or been examined or treated for a nervous or mental disorder by a private physician or at
      a clinic, hospital, sanitarium or other institution or while in the military or naval service? Yes or No
      If "Yes" give details

24.   Has any member of your immediate family ever had, or been treated for a nervous or mental disorder?
      Yes or No                    If "Yes", give details including relationship

25.   Have you ever received psychiatric or psychoanalytical treatment? Yes or No

26.   Do you use, or have you used narcotics, marijuana, barbiturates, sleeping pills, etc.? Yes or No
      If "Yes", give details

27.   Were you ever classified 4F? Yes or No

      Local board no.                       Address                                              Date

      Give reason or reasons for 4F classification

28.   Have you ever had or been examined or treated for ANY major illness, injury or physical defect?
      Yes or No

      If "Yes", give full details

29.   Are you or were you ever a disabled veteran? Yes or No

      If "Yes", give full details

30.   Did you ever file a claim for Workmen's Compensation? Yes or No
      If "Yes", give full details

                                                     (Answer ALL Questions)

31.   What is your occupation?

32.   What is your Social Security Number?                                        State where issued

33.   List below, chronologically, earliest dates first, each and every place in which you were employed.
      OMIT NONE. Give correct full addresses. Give dates of idleness between each period of employment in
      proper sequence. (Include all part-time employment)

       From           To            Name and present address       Place of employment          Reason for leaving
      Mo / Yr        Mo / Yr        of employer

34.   Were you ever discharged or asked to resign from employment? Yes or No

      If "Yes", how many times                   Give details of discharge or forced resignation below

      Employer                 Employer's Address         Date               Supervisors name             Reason

35.   Were you ever subjected to disciplinary action in connection with any employment? Yes or No

      If "Yes", give full details

36.   Did you ever receive complaints from the Police Department or any other regulatory authority in connection
      with any employment? Yes or No                         If "Yes", give full details

37.   Have you ever applied for a Civil Service Examination? Yes or No                          If "Yes", state year,
      position, locality and results

38.   Were you ever, or are you now on any civil service list? Yes or No

      If "Yes", state the year, position, number on list and whether federal, state or municipal. If state or
      municipal, indicate the state or municipality.

39.   Were you ever rejected from any civil service position? Yes or No
      If "Yes", give details, position date, locality, reason for rejection.

40.   Have you ever previously submitted an application for employment to the Police Department of the
      City of Worcester? Yes or No                       If "Yes", state year                    List No.
      Application No.

                                                       SOCIAL STATUS
                                                     (Answer ALL Questions)

41.   Marital status

42.   If single, do you live with your parents? Yes or No

43.   If "No", give reasons

44.   Give the following information regarding marriage or marriages.
      How many times have you been married?
      When                   Where                       By Whom                                   Wife's maiden name

45.   Are you living with your spouse? Yes or No

46.   Were you ever legally or voluntarily separated? Yes or No                                How many times?

47.   Were you ever divorced or had a marriage annulled?        Yes or No                      How many times?

48.   If ever separated, annulled or divorced indicate which below and fill in required information.

      Separated, annulled,        Date Issued         By Whom                Where issued      Offending         Reason
      or divorced                                                            (Court / State)   Party
      (indicate which)                                                                         (By Law)

49.   Were you ever the parent of any children, whether alive or deceased? Yes or No

50.   List below, every child born to you

      Name                             DOB                  Place of Birth                     With who and where
                                                                                               does child reside

51.   Are you now supporting all children born to you, including adopted or step-children? Yes or No

      If so, state full details

                                                         MILITARY SERVICE
                                                         (Answer ALL Questions)

52.   Have you ever served in a military or naval organization of the United States? Yes or No

53.   Have you ever served in a military or naval organization of any foreign government? Yes or No
      If "Yes", give full details

54.   If you have NOT served in the military state reason.

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

56.   Give all periods of active service
      From                          To                                            From                    To

      From                         To                                             From                    To

57.   What was your home address at the time you entered the service?

      Give branch of service                                                 Rank held

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

59.   What type of discharge or separation? (honorable, dishonorable, medical etc.) Be Exact

60.   Has you discharge or separation notice ever been corrected or changed? Yes or No

61.   What was the nature of the change? Changed from                                            to

62.   Where you ever court-martialed, tried on charges, or were you ever the subject of a court, deck court,
      captain's mast or company punishment or any other disciplinary action? Yes or No

63.   Number of times                      If "yes", give details of charges and dispositions.

64.   Reason for discharge or separation from armed services.

65.   Are you now or were you ever an active or inactive member of the reserve forces (any branch) of the
      United States or any foreign government? Yes or No                        If "Yes" state which active or inactive
      Branch                              Unit                                       Rank

      Address                                                                From                         To

66.   Were you ever the subject of disciplinary action in the National Guard or other military reserve organization
      (any branch)? Yes or No
      If "Yes", give detail of the charges and dispositions.

                                                     SELECTIVE SERVICE
                                                     (Answer ALL Questions)

67.   How many selective service classifications have you had?

68.   List all classifications you have had.

69.   If not in 1A, state reasons

70.   Selective service number                                           Local board


71.   Last classification                                                Date classified

                                                        (Answer ALL Questions)

72.   List all schools and colleges you have attended

      From            To                                             Day or              Exact
      Mo/Yr          Mo/Yr             School                        Evening            Address              GPA

73.   What college degree or professional licenses do you possess?

74.   Were you a member of a social, labor or fraternal organization? Yes or No
      If "Yes", list below all such organizations you were a member.

75.   If you possess any of the following, complete the information below.

      Item                Number                State                County               Date     Expires
      Owner's Reg.

      Chauffeur License

      Operators License

76.   Did you ever possess a chauffeur's license issued by any state other than Mass.? Yes or No
      If "Yes", give city and state                                                        When

77.   Was your Owner's Registration Certificate, Chauffeur's or Operators license ever REVOKED? Yes or No

      SUSPENDED? Yes or No                                  Which License?

      When                          Where                                 Why

78.   If answer to previous question is "Yes", was such registration certificate or drivers license ever restored?

      Yes or No                         When

79.   Have you ever been involved in a motor vehicle accident either as a registered owner, operator, passenger or
      pedestrian, which resulted in any personal injury, property damage to you or anyone else? Yes or No

      If "Yes", give full details

80.   Give name of your Father, Mother (maiden name), Sisters and Brothers

      Relationship             Name                         Address                 Occupation                  Alive/Deceased

81.   Have you ever been fingerprinted? Yes or No                              If "Yes" fill in the following

      When                                   Where                                            Reason

82.   Do you have any knowledge or information, in addition to that specifically called for in the preceding
      questions which is or which may not be relevant, directly or indirectly in connection with any investigation or
      your eligibility or fitness for the position of Worcester Auxiliary Police Officer, including but not limited to
      knowledge or information concerning your character, physical or mental activities, family, associations,
      criminal record, traffic violations, residence or otherwise? Yes or No

      If "Yes", give full details

By signing below I certify that all information on this application is correct to the best of my knowledge.
I understand that any misinformation may lead to my dismissal from the Worcester Police Department
Auxiliary Unit.

                                                               Candidate sign and date here

        Candidate Checklist of Required Items

     This application filled out completely

     Copy of your current drivers license

     Copy of your Massachusetts Class A License to Carry Firearms

     Copy of MCJTC Reserve Academy Diploma

     Copy of OC training certificate     ,

     Copy of Monadnock Baton training certificate

     Copy of current First Responder Card

     Copy of BLS CPR/AED card

     Certified Birth Certificate

     Copy of your Social Security Card

     Recent Credit Report

     Copy of DD214 (Previous military only)


     Massachusetts Criminal Justice Training Council Reserve Intermittent Police Academy

     First Responder & CPR?AED training and required recertification

     Firearm training and biannual requalification

     Oleoresin-Capsicum (OC) training

     Monadnock Expandable Baton training

     Handcuff and Booking Procedure training

     Officer Safety and Survival Techniques

     Continuous in-service training provided and taught by Worcester Police Department
     Training Division officers


To top