Wisconsin Pardon Application by nze57533

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									                                   WISCONSIN STATE PATROL EMPLOYMENT APPLICATION                                                        Original
                                                              Wisconsin Department of Transportation
                                                             SP4406 9/2003 s.230.16(1), Wis. Stats.                                     Reinstatement


Important Instructions:
This application must be completely filled out and clearly printed in black ink. Your answer to any particular question may not
necessarily eliminate you from consideration. Failure to complete this form may result in disqualification of this application. If a question
does not apply to you, write, “N/A” in the space provided. The Division of State Patrol requests this information to complete the
employment background verification. The information obtained is used exclusively for the purpose of employment consideration.
Any falsification on this form will result in disqualification of your application or if discovered after employment may be
grounds for discharge. Conviction of any offense will not necessarily preclude employment of an applicant unless
circumstances substantially relate to the requirements of the position for which you are applying.
DOT complies with the American with Disabilities Act.

Position Applied For


Legal Name (Last, First, Middle)                                                                            Social Security Number


Birth Date (Mo/Day/Yr)                                                    Sex                               Area Code - Home Telephone Number
                                                                                Male           Female
Residence Street Address                                                                                    Residence County


Mailing Address (if different from Residence Address)                                                       Area Code - Work Telephone Number


List any aliases, nicknames, or maiden name of your present legal name



The following information is obtained for Affirmative Action purposes only
RACIAL / ETHNIC (Check only one)
     1 Black (Not Hispanic)                             3 American Indian/Alaskan Native                         5 White (Not Hispanic)
     2 Asian or Pacific Islander                        4 Hispanic (Mexican, Puerto Rican, Cuban)

                                                   Investigation Number                                     Reviewed By
 FOR OFFICE USE ONLY

                                                                  RESIDENCY HISTORY
            List chronologically, starting with most recent address, all past residences during the past seven years.
   Include addresses while attending school if away from home and all military addresses. (Use additional sheets if needed.)
  Dates (Mo/Yr)                    Street Address (Include apartment number),              If rented, give name, address, and telephone number
  From      To                              City, State and Zip Code                               of person responsible for rent collection
NO    YES
               Is there a location in which you spend a regular part of your free time? (Example, parents' residence, friends'
               residence, or home town.) Any location where you would be well known other than listed above? Please tell us
               that area.


               Do you have any special skills, abilities, experiences, hobbies, etc. which may enhance your qualifications for
               the position? If so, please describe.


               Were you ever subjected to disciplinary action in connection with any employment? If yes, give details.



                                             PERSONAL INFORMATION
        Please list the required information for your father, mother, children, (include adopted/step),sisters, brothers
Relationship             Name                             Address                          Occupation            Area Code -
                                                                                                                 Telephone




                                                      REFERENCES
 Give three references (not relatives, former employers, fellow employees or school teachers) who are responsible adults of
         reputable standing in their communities. (IF involved in law enforcement, PLEASE use space on next page.)
                      Name and Address                              Area Code -           Area Code -            Best Time to
                                                                  Home Telephone         Work Telephone            Contact
                                                          EMPLOYMENT HISTORY
NO        YES
                  Are you presently a permanent, classified state civil service employee? If yes, complete the following.
Class Title                                                     Agency                            Pay Range                Seniority Date



                      List all employers, beginning with the most recent, and work back. Include all part time employers.
                  Account for all time periods. If unemployed, indicate dates. Make additional copies of this page if necessary.
      Employer Name                                             Employer Address                                           May we contact?
1
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
      Employer Name                                             Employer Address                                           May we contact?
2
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
      Employer Name                                             Employer Address                                           May we contact?
3
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
      Employer Name                                             Employer Address                                           May we contact?
4
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
      Employer Name                                             Employer Address                                           May we contact?
5
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
      Employer Name                                             Employer Address                                           May we contact?
6
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
      Employer Name                                             Employer Address                                           May we contact?
7
                                                                                                                                Yes          No
Position Held                       Begin Salary   End Salary   Hours Per Week     Duties


Supervisor Name                     Area Code-Telephone         Employment Dates   (Mo/Yr)         Reason for Leaving
                                                                From               To
                                                    ACQUAINTANCES
                       Give three social acquaintances, not in law enforcement, in your own age group.
                      Name and Address                               Area Code -           Area Code -            Best Time to
                                                                   Home Telephone         Work Telephone            Contact




List names of Wisconsin State Patrol Troopers & Inspectors & any other Law Enforcement Officers with whom you are acquainted.




                                                      MEMBERSHIPS
                      List all professional or civic organizations of which you are or have been a member.
                            Name                                          From                  To                        Type
                                                                          Mo/Yr                Mo/Yr




NO     YES
              Have you ever been the subject of a background investigation conducted by a law enforcement agency which
              was considering you for employment? If yes, complete the following:
         Date                                                               Agency




                                                    DRIVING HISTORY
NO     YES
                                                                 Driver License Number                            State
              Do you hold a valid Driver License?

              Do you hold a valid Driver License from other states than listed above? If yes, list the states:


              Have you ever had a Drivers License suspended, revoked or restricted? If yes, please explain.
                                     USE OF ALCOHOL OR DRUGS AS AN ADULT
NO      YES
                 Do you drink alcoholic beverages? If yes, to what degree?

                 Do you use marijuana? When was the last time you used

                 Do you use non-prescriptive illegal drugs, such as opiates, LSD, cocaine, etc.? When was the last time you
                 used them?


                                                        JUDICIAL ACTION
Note:       Conviction of a crime, other than a felony, in and of itself is not an automatic bar to employment, but only in so far as
            it relates to fitness to perform a particular job. Age and time of the offense and rehabilitation will be taken into
            account when considering an applicant.
NO      YES       Have you ever been charged or convicted of ANY law violation including traffic law, other than parking
                  tickets? If yes, complete the following.
   Date                   Location                Charge/Violation         Final Disposition                   Comments
(Mo/Day/Yr)                                                                                                (Agency and Court)




NO      YES
                  Are you now, or as an adult have you ever been involved as a plaintiff, defendant, petitioner or respondent, in
                  any civil court action? If yes explain (include when, where name and location of court, circumstances, and
                  disposition).




                  As an adult, have you ever been fingerprinted? If yes, complete the following:
     Date                              Location                                           Reason for Fingerprinting
NO      YES
               As an adult, have you ever received a pardon for a crime? If yes complete the following:
     Date         State          County                 Offense                   Age Then              Police Agency Involved




NO      YES
               As an adult, have you ever had any contact with a police agency as a victim, witness, or suspect? If yes,
               please list the following:
     Date                 Location                                Circumstances                         Police Agency Involved




                                                     Job Performance
NO      YES
               Do you know of any reason why you would not be able to perform any job related task or function as
               specified in the job description? If yes, please explain:




               Prior to final appointment, all persons tentatively selected for positions will be required to submit to a hearing
               examination by a physician state's choice at state expense. Will you consent to such examinations?

                              Education History - Attach Copy of Diploma or Transcripts.
Check highest level of education attained:               Some College Beyond High School                   Associate Degree
   GED                                                   Bachelor of Arts                                  Masters Degree
   High School Diploma                                   Bachelor of Science                               PHD, JD. et al

                     High School                           Date (Mo/Yr)        Major Field of Study   Diploma/Degree      Credits
              (Give name AND address)                   From         To                               Granted (Mo/Yr)     Earned




Colleges, Universities, Voc/Tech, and/or                   Date (Mo/Yr)        Major Field of Study   Diploma/Degree      Credits
Trade/Business Schools (Give name AND address)          From         To                               Granted (Mo/Yr)     Earned
             List any problems with school (absenteeism, tardiness, poor grades, other disciplinary problems).
     Date                    School                        Problem                          Brief Explanation




                                                    Military Service
NO     YES
              Have you served in the United States Armed Forces? If yes, complete the following:
 Name Used During Service (Last, First, Middle)        Social Security                   Birth Place                 Birth Date
                                                          Number




                                             Active Service, Past and Present
                Branch of Service                          Dates            (Check One)                 Service Number
                                                    Entered   Released                                 During This Period
                                                                              Officer
                                                                              Enlisted
                                                                              Officer
                                                                              Enlisted
                                                                              Officer
                                                                              Enlisted


                              Reserve Service, Past or Present - If “NONE” check here
               Branch of Service                           Dates            (Check One)                 Service Number
                                                      To           From                                During This Period
                                                                              Officer
                                                                              Enlisted
                                                                              Officer
                                                                              Enlisted
                                                                              Officer
                                                                              Enlisted


                                   National Guard Membership - If “NONE” check here
               Branch of Service                           Dates            (Check One)                 Service Number
                                                      To           From                                During This Period
                                                                              Officer
                                                                              Enlisted
                                                                              Officer
                                                                              Enlisted
                                                                              Officer
                                                                              Enlisted
How many discharges or separations from the service were given to you?
Discharges                                                      Separations




NO       YES
               Has your discharge or separation notice ever been corrected or changed? State nature of change:
               From                                             To




               Have you ever applied for Department of Defense Security Clearance?             Date

               (If yes, indicate date)

               Were you ever court-martialed, tried, or charged, or were you subject of a summary court, deck court,
               captain's mast, company punishment, or any other disciplinary action? If yes, indicate how many times and
               give details of charges, agency concerned, dates, and dispositions.




                                                      Certification

I certify to the best of my knowledge this application is true and complete. I understand that any misstatement forfeits my
right to employment at this time for the position for which I any applying, and may affect future consideration for other
positions in the department.



                                                                       (Applicant Signature)                       (Date)

								
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