Docstoc

Trainee_Application

Document Sample
Trainee_Application Powered By Docstoc
					                                    Name:_______________________________________
                                          Last              First       MI




STOP!     Do not complete these forms unless you have completed an entrance exam
          application AND have received confirmation from Human Resources.
          www.jobs.cityofchesapeake.net
          The following forms will not be accepted at the entrance exam if you are
          not on the list to take the exam.

                       INSTRUCTIONS
This instruction sheet, the Release Form and the Personal History
Statement are required to be completed and turned in at the test site.

Notarization is required on the Release Form and page 21 of the Personal
History Statement.

Items will not be notarized at the test site. This must be completed prior
 to you turning them in.

Do not fold any of the paperwork!

    All responses should be truthful. OMISSIONS OR INCOMPLETE
    APPLICATIONS COULD DISQUALIFY YOU.

    If unsure of an exact date, use approximate date. (ex: appx. May 1998)

    All juvenile and adult incidents, arrests, convictions and/or illegal drug use
    must be listed on your application.

    Print legibly or type your responses. Blue or black ink. Do not leave any blanks.

    If additional space is needed for your responses, use only the provided
    supplemental pages.



                                          _____________________________________
                                          Applicant’s Signature
                              Release Form


                                                ______________________________
                                                Name (Print)
                                                ______________________________
                                                Social Security Number
                                                ______________________________
                                                Date of Birth



To Whom It May Concern:

   As an applicant for employment with the City of Chesapeake Police Department,
hereby authorize the release of such information as may be requested by the City of
Chesapeake Police Department, or its agents. This information to include, but not be
limited to my background, character, education, credit rating, medical and mental he
and such other information and supporting documents as may be requested by the C
Chesapeake Police Department, or its agents.

   I hereby authorize the photocopying of any and all such records or information th
you may have concerning me.


                                                ______________________________
                                                Signature

                                                ______________________________
                                                Date


City/County of __________________
Commonwealth of _______________

The foregoing instrument was acknowledged before
me this _______ day of _____________, 20____.

________________________________________
Notary Public

My commission expires: ____________________
              NAME:_________________________________
                   LAST           FIRST         M.I




   CHESAPEAKE POLICE DEPARTMENT




APPLICANT PERSONAL HISTORY STATEMENT
POSITION APPLYING FOR: Police Officer Trainee

INSTRUCTIONS: FILL OUT THIS QUESTIONNAIRE COMPLETELY AND ACCURATELY. ALL
STATEMENTS IN THIS QUESTIONNAIRE ARE SUBJECT TO VERIFICATION. IF THE SPACE
PROVIDED IS INADEQUATE, USE THE SUPPLEMENTAL PAGES PROVIDED FOR YOU. TYPE
OR PRINT LEGIBLY IN INK ALL RESPONSES. INCORRECT STATEMENTS COULD
REMOVE YOU FROM EMPLOYMENT CONSIDERATION.



1.   Name                                                     /   /_______
            Last        First                 Middle   Social Security #

     List other names you have used or been known by. Include maiden
     names, married or adopted names, or nicknames.
     _________________________________________________________________


2.   Present Mailing Address
                                   Number     Apt.            Street
                                   ________________________________________
                                   City         State         Zip Code

     Permanent Mailing Address________________________________________
                              Number                     Street
                              ________________________________________
                              City         State         Zip Code


     Telephone Number:   Home (   )    -     Business (   )         -______
     Alternate Number:        (   )    -______
     E-mail Address:________________________________________


3.   Date of Birth:     /      /   Place of Birth:____________________
                                                  City          State
4.   Are you a U.S. Citizen? Yes        No_____
     U.S. citizenship and proof of such is required for this position.

5.   Do you have a valid driver's license? Yes     No_____
     If yes, ________________________________________________________
               State          License Number          Expiration


                                        (1)
6.   Have you ever been issued a driver's license from another state
     other than the one listed above? Yes        No_____
     If yes,
                State          License number        Expiration
             __________________________________________________________
                State          License number        Expiration


7.   Have your driving privileges with Virginia or any other state ever
     been suspended or revoked for any reason?     Yes    No____
     If yes, which state?            Date ________
     Explain reason: _________________________________________________
     _________________________________________________________________
     _________________________________________________________________


8.   Do you have any unpaid parking tickets in this or any other state?
     Yes ____ No ____
     If yes, explain. List the city, state, charge and reason why this
     is outstanding.
     __________________________________________________________________
     __________________________________________________________________
     __________________________________________________________________


9.   As a driver, have you ever been involved in a reported or non-
     reported auto accident? Yes       No _____


     If yes, give the following information:
                             LIST ANY CITATIONS     DISPOSITION/
     DATE      CITY/STATE    ISSUED TO YOU          OUTCOME




                                   (2)
10.   List all moving traffic citations issued to you and the outcome.

      Include all citations from the time you started driving until now.
      Use approximate dates if exact date is unknown.
      Include all citations issued in Virginia and/or other states.
      Note: If you pre-paid a fine, you were convicted of that offense.
      **   Citations which no longer show on your record MUST be listed.

      List in order of occurrence starting with the most recent.

                                             DISPOSITION/   FINE PAID?
      DATE     CITY / STATE     CHARGE       OUTCOME          YES/NO




11.   List all non-moving violations issued to you in this or any other
      state. (expired inspection, no seat belt, expired tags, etc.)


                                             DISPOSITION/   FINE PAID?
      DATE     CITY / STATE     CHARGE       OUTCOME          YES/NO
                                      (3)




12.   Have you ever been arrested, taken into physical custody, been
      issued a misdemeanor citation (exclude traffic citations),
      released on your own signature or turned yourself in for any
      reason?
      Yes     No____

      Note: Summonses regarding pet or animal offenses must also
      be listed.
      If yes, explain by giving the information below:
         DATE     AGENCY / LOCATION         CHARGE       DISPOSITION




      Explain in detail all entries above. Use the attached supplemental
      sheets if necessary.
      ________________________________________________________________

      ________________________________________________________________

      ________________________________________________________________

      ________________________________________________________________


13.   Have you ever been convicted of a felony or misdemeanor?
       Yes      No ____
       If yes, explain by giving the information below:

         DATE    AGENCY / LOCATION          CHARGE        SENTENCE




      Explain in detail all entries above. Use the attached supplemental
      sheets if necessary.
      _______________________________________________________________

      _______________________________________________________________

      _______________________________________________________________
                                      (4)
      UNDETECTED CRIMES

14.   Have you ever committed, participated in or been present when any
      of the crimes below were committed or attempted:
                     Yes       No                        Yes      No

      Murder         ___       ___         Larceny        ___     ___
      Arson          ___       ___         Shoplifting    ___     ___
      Pedophilia     ___       ___         Burglary       ___     ___
      Rape           ___       ___         Manslaughter    ___    ___
      Robbery        ___       ___         Assault/Battery ___    ___
      Vandalism      ___       ___

      Explain any “yes” answers and give dates:___________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________

15.   Have you ever been questioned by any Law Enforcement authority for
      any reason other than traffic offenses or motor vehicle accidents?
      Yes ____ No ____

      If yes, give details, date and outcome: ____________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________


16.   Have you ever purchased, sold or been present during the
      purchase or sale of anything you believed to have been stolen?
      Yes ____ No ____

      If yes, please explain. Give details of the date, the item purchased
      price, current location of the item and reason you knew/felt the
      item(s)were stolen._________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________


                                     (5)
17.    Do you know of, associate with, or reside with any known criminals or
       convicted felons?
       Yes ____ No ____
       If yes, give details of your relationship with the individual(s)
       and the criminal conduct/acts they are responsible for:____________
       ___________________________________________________________________

18.   Have you ever used or introduced into your body by any means any
      illegal drug or substance?
      Yes      No_____

       Complete the drug use chart on the following page. If you have never
      used any illegal drug, you must indicate so by placing an “X”
      in the “NO” column by each drug.
       Note:     Juvenile/Adult “experimentation” MUST be listed!


       DRUG                     YES   NO     DATE FIRST USED   DATE LAST USED
       Cannabis (Marijuana,Pot,
       Weed, Reefer, Mary Jane)

       Hashish, Hashish Oil
       Cocaine (Coke, Snow,
       Candy)
       Crack (Freebase Rocks,
       Rocks)
       Barbiturates, Hypnotics,
       or “Downers”
       Amphetamines (Ecstasy,
       Speed,”Uppers”)
       Methamphetamine (Crank,
       Crystal Met, “Ice”)
       LSD or other    (Shrooms,
       Hallucinogens     Acid)
       PCP (Angel Dust, Hog,
       Peace Pill)
       Heroin or other
       Opiates (Smack, Dope)
       Inhalants (Huffing,
       Sniffing, Bagging)

       Anabolic Steroids

       Pharmaceutical drugs
       not prescribed to you

      List the name(s) of the pharmaceutical drug(s)not prescribed to you,
      the reason you used it and how you obtained the drug:_______________
      ____________________________________________________________________

                                       (6)
19.   Is there any other illegal drug, narcotic or substance not listed
      above that you have introduced into your body?
      Yes      No _____
      If yes, please list it here and include the same information as
      above: ____________________________________________________________

      ___________________________________________________________________


20.   Have you ever sold or purchased any illegal drug?
      Yes ____ No ____
      If yes, please explain by giving the type of drug, date(s) and
      circumstances: ____________________________________________________

      ___________________________________________________________________


21.   Have you ever cultivated or manufactured any illegal drug?
      Yes ____ No ____
      If yes, give detail of incident, date and type of drug (s)_________
      ___________________________________________________________________
      ___________________________________________________________________


22.   Have you ever temporarily stored or “held” any illegal drug, narcotic
      or substance? (EXCLUDE ENTRIES FROM QUESTION #18)
      Yes      No _____

      If yes, please explain giving date(s), type of drug and
      circumstances: ___________________________________________________
      __________________________________________________________________
      __________________________________________________________________



23.   Have you ever been present when drugs were bought, sold or used?
      Yes ____ No ____

      If yes, please give date(s), type of drug and detail of each incident:

      ___________________________________________________________________

      ___________________________________________________________________

      ___________________________________________________________________
                                    (7)
      EDUCATION

24.   The Virginia State Code requires Police Officers to possess a high
      school diploma or its equivalent. Please indicate your current
      status with regard to this requirement. A college degree is not
      required for this position.
                I possess a high school diploma
                I possess a GED certificate
                I possess a college degree(s).
                Please include the type of degree, name of college and
                the year degree was attained: _________________________
                _______________________________________________________


25.   List the educational institutions you have attended starting with
      your high school to the present. Include any colleges, vocational,
      military, or business schools.

      Name of School    City / State      Dates of Attendance Certificates/
                                                              Degree Earned




      EMPLOYMENT HISTORY

26.   List all jobs you have held within the last 10 years.

      Begin with your most current employment.
      Include military service, part time, temporary or volunteer employment.
      DO NOT LEAVE ANY BLANKS!

      Correct phone numbers and addresses must be listed.

                                    (8)
______________________________________________________________________

  Name of employer:________________________________________________
  Address, city, state, zip:_______________________________________
  Area code and Phone number: (    )_____-_______
   Your job title/duties:___________________________________________
   Name you were known by: _________________________________________
   Full-time      Part-time      Voluntary ____
   Dates of Employment: From:                To:______________

   Name of Supervisor:                     Title:____________________
   Beginning Salary:                   Ending Salary:________________

   Details of reason for leaving (“Personal Reasons” and “Will Discuss
   with you in person” is not an acceptable reason):
   _________________________________________________________________
   _________________________________________________________________
   Have you ever been written up, counseled or disciplined for ANY
   reason? If so, list reason and outcome: _________________________
   _________________________________________________________________
   _________________________________________________________________
_______________________________________________________________________


   Name of employer:________________________________________________
   Address, city, state, zip:_______________________________________
   Area code and Phone number: (    )_____-_______
   Your job title/duties:___________________________________________
   Name you were known by: _________________________________________
   Full-time      Part-time      Voluntary ____
   Dates of Employment: From:                To:______________

   Name of Supervisor:                     Title:____________________
   Beginning Salary:                   Ending Salary:________________

   Details of reason for leaving (“PERSONAL REASONS” AND “WILL DISCUSS
   WITH YOU IN PERSON” IS NOT AN ACCEPTABLE REASON):
   _________________________________________________________________
   _________________________________________________________________
   Have you ever been written up, counseled or disciplined for ANY
   reason? If so, list reason and outcome: ________________________
   _________________________________________________________________
   _________________________________________________________________

                                 (9)
________________________________________________________________

Name of employer:________________________________________________

Address, city, state, zip:_______________________________________

Area code and Phone number: (      )_____-_______

Your job title/duties:___________________________________________
Name you were known by: _________________________________________
Full-time      Part-time      Voluntary ____
Dates of Employment: From:                To:______________

Name of Supervisor:                        Title:___________________
Beginning Salary:                      Ending Salary:_______________

Details of reason for leaving (“Personal Reasons” and “Will discuss
with you in person” is not an acceptable reason):
_________________________________________________________________
_________________________________________________________________

Have you ever been written up, counseled or disciplined for ANY
reason? If so, list reason and outcome: ________________________
_________________________________________________________________
_________________________________________________________________
__________________________________________________________________

Name of employer:________________________________________________
Address, city, state, zip:_______________________________________
Area code and Phone number: (    )_____-_______
Your job title/duties:___________________________________________
Name you were known by: _________________________________________
Full-time      Part-time      Voluntary ____
Dates of Employment: From:                To:______________

Name of Supervisor:                        Title:___________________
Beginning Salary:                      Ending Salary:_______________

Details of reason for leaving (“Personal Reasons” and “Will discuss
with you in person” is not an acceptable reason):
_________________________________________________________________
_________________________________________________________________

Have you ever been written up, counseled or disciplined for ANY
reason? If so, list reason and outcome: ________________________
_________________________________________________________________
_________________________________________________________________


                                (10)
 ___________________________________________________________________

 Name of employer:________________________________________________
 Address, city, state, zip:_______________________________________
 Area code and Phone number: (    )_____-_______
 Your job title/duties:___________________________________________
 Name you were known by: _________________________________________
 Full-time      Part-time      Voluntary ____
 Dates of Employment: From:                To:______________

 Name of Supervisor:                      Title:___________________
 Beginning Salary:                    Ending Salary:_______________

 Details of reason for leaving (“Personal Reasons” and “Will discuss
 with you in person” is not an acceptable reason):
 _________________________________________________________________
 _________________________________________________________________

 Have you ever been written up, counseled or disciplined for ANY
 reason? If so, list reason and outcome: ________________________
 _________________________________________________________________
 _________________________________________________________________
__________________________________________________________________

 Name of employer:________________________________________________
 Address, city, state, zip:_______________________________________
 Area code and Phone number: (    )_____-_______
 Your job title/duties:___________________________________________
 Name you were known by: _________________________________________
 Full-time      Part-time      Voluntary ____
 Dates of Employment: From:                To:______________

 Name of Supervisor:                      Title:____________________
 Beginning Salary:                    Ending Salary:________________

 Details of reason for leaving (“Personal Reasons” and “Will discuss
 with you in person” is not an acceptable reason):
 _________________________________________________________________
 _________________________________________________________________

 Have you ever been written up, counseled or disciplined for ANY
 reason? If so, list reason and outcome: ________________________
 _________________________________________________________________
 _________________________________________________________________

                               (11)
____________________________________________________________________

 Name of employer:________________________________________________
 Address, city, state, zip:_______________________________________
 Area code and Phone number: (    )_____-_______
 Your job title/duties:___________________________________________
 Name you were known by: _________________________________________
 Full-time      Part-time      Voluntary ____
 Dates of Employment: From:                To:______________

 Name of Supervisor:                      Title:___________________
 Beginning Salary:                    Ending Salary:_______________

 Details of reason for leaving (“Personal Reasons” and “Will discuss
 with you in person” is not an acceptable reason):
 _________________________________________________________________
 _________________________________________________________________

 Have you ever been written up, counseled or disciplined for ANY
 reason? If so, list reason and outcome: ________________________
 _________________________________________________________________
 _________________________________________________________________

__________________________________________________________________

 Name of employer:________________________________________________
 Address, city, state, zip:_______________________________________
 Area code and Phone number: (    )_____-_______
 Your job title/duties:___________________________________________
 Name you were known by: _________________________________________
 Full-time      Part-time      Voluntary ____
 Dates of Employment: From:                To:______________

 Name of Supervisor:                      Title:___________________
 Beginning Salary:                    Ending Salary:_______________

 Details of reason for leaving (“Personal Reasons” and “Will discuss
 with you in person” is not an acceptable reason):
 _________________________________________________________________
 _________________________________________________________________

 Have you ever been written up, counseled or disciplined for ANY
 reason? If so, list reason and outcome: ________________________
 _________________________________________________________________
 _________________________________________________________________

                               (12)
27.   Have you experienced periods of unemployment?
      Yes     No ____
      If yes, give the dates:

      From:              To:___________
      From:              To:___________
      From:              To:___________

      Reasons for unemployment: _____________________________________
      _______________________________________________________________


28.   Have you   ever been terminated, discharged, or asked to resign
      from any   position for derogatory reasons?
      Yes        No _____
      (Include   terminations outside the previous 10 years listed)

      If yes, complete the following:
      Name of employer/company ______________________________________
      _______________________________________________________________
      Address                       City                     State
      _______________________________________(____)______-___________
      Supervisor's name/Title                      Phone Number

      Dates of employment: From:          To:__________
      Position held:_________________________________________________

      Details of termination: _______________________________________
      _______________________________________________________________
      _______________________________________________________________

 ______________________________________________________________________

      Name of employer/company ______________________________________
      _______________________________________________________________
      Address                       City                     State
      _______________________________________(____)______-___________
      Supervisor's name/Title                      Phone Number

      Dates of employment: From:          To:__________
      Position held:_________________________________________________

      Details of termination: _______________________________________
      _______________________________________________________________
      _______________________________________________________________
                                      (13)
29.   Have you ever been forced to resign or been terminated from any
      position due to conflicts with supervisors, co-workers, schedules,
      or position held?   Yes      No _____
      If yes, explain: ________________________________________________
      _________________________________________________________________
      _________________________________________________________________


30. Have you ever accepted, taken or given away merchandise, supplies
    or food from an employer?
    Yes ____ No ____
    If yes, please complete the following:
    Name of Employer _______________________________________________
    Your position/Title: ___________________________________________
    Items taken: ___________________________________________________
    ________________________________________________________________
    What was the value of the items: _______________________________
    How many times did this occur? _________________________________
    Dates of Occurrence(s): _________________________________________
    Was this done without permission? ______________________________
 _______________________________________________________________________
    Name of Employer _______________________________________________
    Your position/Title: ___________________________________________
    Items taken: ___________________________________________________
    ________________________________________________________________
    What was the value of the items: _______________________________
    How many times did this occur? _________________________________
    Dates of Occurrence(s): _________________________________________
    Was this done without permission? ______________________________


31.   Have ever taken any money from an employer?
      Yes ____ No ____
      If yes, please complete the following:

      Name of Employer _______________________________________________
      Your position/Title: ___________________________________________
      Amount? ________________________________________________________
      How many times did this occur? _________________________________
      Dates of Occurrence(s): _________________________________________
      Was this done without permission? ______________________________
      Explain:________________________________________________________
                                    (14)
      _____________________________________________________________________

        Name of Employer _______________________________________________
        Your position/Title: ___________________________________________
        Amount? ________________________________________________________
        How many times did this occur? _________________________________
        Dates of Occurrence(s): _________________________________________
        Was this done without permission? ______________________________
        Explain:________________________________________________________



32.    What previous employment did you like the most and why?
       ________________________________________________________________
       ________________________________________________________________


        The least liked and why?
        ________________________________________________________________
        ________________________________________________________________



33.    Have you ever accepted employment with any law enforcement agency or
       corrections institution?
       Yes      No ____
       If yes, complete the following:

        Agency’s Name:_________________________________________________

        Address of Agency: ____________________________________________

        Are you still employed with this agency? Yes      No ____

        Position/Title: _______________________________________________

        If still employed, reason for seeking other employment?
        _______________________________________________________________
        If not, details of your resignation/termination?
        _______________________________________________________________
        _______________________________________________________________
        _______________________________________________________________




                                      (15)
34.    Have you ever made application for employment(any position) with
       this or any other law enforcement or corrections agency?
       Yes      No ____

        If you have placed more than one application in with an agency, you
        must complete the information below for each time. Use supplemental
        pages if needed.
      ____________________________________________________________________

       Agency’s Name:________________________________ State
       Year applied: ___________________
       Position applied for: _______________________________________

       Check all the application phase(s) you completed:
       Written      Agility      B-pad       Interview _____
       Background      Polygraph       Psychological_____
       After which phase were you not selected or disqualified from?
       _____________________________________________________________
       Explain the reason you were given:                    _________
       _____________________________________________________________

      ______________________________________________________________


       Agency’s Name:__________________________________State
       Year applied: __________________
       Position applied for: _______________________________________

       Check all application phase(s) you completed:
       Written      Agility      B-pad       Interview _____
       Background      Polygraph       Psychological____
       After which phase were you not selected or disqualified from?
       _____________________________________________________________
       Explain the reason you were given:                    ________
       _____________________________________________________________



                                     (16)
      __________________________________________________________________


        Agency’s Name: ___________________________________State
        Year applied: _________________________________________________
        Position applied for: _________________________________________

        Check all application phase(s) you completed:
        Written      Agility      B-pad       Interview _____
        Background      Polygraph       Psychological _____
        After which phase were you not selected or disqualified from?
        _______________________________________________________________

        Explain the reason you were given______________________________

        _______________________________________________________________

      ____________________________________________________________________

        Agency’s Name: ___________________________________State________
        Year applied: _________________________________________________
        Position applied for: _________________________________________

        Check all application phase(s) you completed:
        Written      Agility      B-pad       Interview _____
        Background      Polygraph       Psychological _____
        After which phase were you not selected or disqualified from?
        _______________________________________________________________

        Explain the reason you were given: ____________________________

        _______________________________________________________________


        MILITARY SERVICE

35.    Are you registered with the Selective Services? (registration for
       military draft) Yes     No_____
       If yes, when?

        _______________________________________________________________


                                      (17)
36.   Have you ever enlisted in any branch of service for any period
      of time?
      Yes      No_____
      If yes, fill out the following:
      ______________________________________________________________
      Branch of service                Rank at discharge

      ______________________________________________________________
      Dates of service                 Type of Discharge


37.   While in the service were you ever verbally reprimanded, written
      up, disciplined, been the subject of judicial or non-judicial
      punishment, charged with Article 15, Captain’s Mast or
      court martialed? (All must be listed, even if it is no longer in
      your record)
      Yes     No_____
      List the charge(s): __________________________________________

      If yes, please give details of each(if multiple occasions) to
      include the date, detail of circumstances and outcome (extra duty,
      drop in rank,pay,counseled, etc.):
      ______________________________________________________________
      ______________________________________________________________
      ______________________________________________________________
      ______________________________________________________________


      Personal

38.   Do you own an automobile?
      Yes      No _____
      If yes, give make, model, and year:


39.   Do you have automobile insurance, assigned risk or
      certification of compliance with the Uninsured Motor Vehicle Act?
      Yes      No _____


40.   Marital Status:
      Single      Married      Divorced      Separated_____


41.   Name of Spouse _______________________________________________

                                    (18)
42.   List your parents, brothers and sisters.

      Father                         Mother________________________
      Bro./Sis.                      Bro./Sis._____________________
      Bro./Sis                       Bro./Sis._____________________


43.   Give the names of three (3) responsible persons, other than
      relatives or past employers, who could provide information about
      your character, abilities, experience, personality and other
      qualities.

      1.   _________________________________________________________
            Name                    Address             Phone number

      2. __________________________________________________________
           Name                    Address             Phone number

      3. __________________________________________________________
           Name                    Address             Phone number



44.   Begin with your present address and list all previous places you
      have resided during the last ten (10) years: List the apartment
      if applicable.

                                              From:       To:______
      Address              City/State

                                                 From:    To:______
      Address              City/State

                                                 From:    To:______
      Address              City/State
                                                 From:    To:______
      Address               City/State

                                              From:       To:______
      Address              City/State

                                                 From:    To:______
      Address              City/State

                                                 From:    To:______
      Address              City/State

                                              From:       To:______
      Address              City/State

                                     (19)
45. As an adult, list all cities and states you have resided in;
    permanent and/or temporary.

                                           ________________________
      City           State                 City               State
                             _              _______________________
      City           State                 City               State
                                           ________________________
      City           State                 City               State


      Financial (Financial irresponsibility in itself is not an
                  automatic disqualifying factor)


46.   Have you ever filed for or declared bankruptcy? Yes ____ No ____
      If yes, please give details to include when, where, why and
      chapter filed.
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________


47.   Within the last 7 years, have any of your debts been turned over
      to a collection agency? Yes _____ No _____
      If Yes, please give details to include when, what account(s),why
      and whether the debt(s)is clear or balance still
      due.____________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________


48.   Within the last 7 years, have your wages ever been garnished?
      Yes ____ No ____
      If yes, please give details to include when, where and why. ____
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________


49.   Within the last 7 years, have you ever had any goods repossessed?
      Yes ____ No ____
      If yes, please explain when, what and circumstances. __________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________

                                    (20)
50.   Have you ever been delinquent on child support, alimony, income
      tax or other tax payments? Yes ____ No ____
      If yes, please give details to include when, where, why and whether
      the account(s)is paid in full and/or currently in good standing.
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________


      I hereby certify that all statements made in this questionnaire are
      true and complete and authorize the verification of this fact by the
      Personnel Officer of the Police Department. I understand that any
      misrepresentation of material facts, in addition to the omission of
      information, could subject me to disqualification or termination.




                                                 ____________________
                                           Applicant's Signature

                                                  _____________
                                           Date


      THIS PAGE MUST BE NOTARIZED



      City/County of ________________________
      Commonwealth of________________________
      The foregoing instrument was subscribed
      sworn before me this      day of________
                                       month
             , by ___________________________
      year
      _______________________________________
      Notary Public’s Signature

      My commission expires _________________



                                    (21)
Use these supplemental sheets to include additional information or to
further explain any responses from your Personal History Statement.
List the question number you are referencing

INITIAL EACH SUPPLEMENTAL PAGE USED




                                                       Initials:_______

                           Supplemental Page 1
                      Initials:________

Supplemental Page 2
                      Initials:________

Supplemental Page 3