GREENE COUNTY Peace Officer Basic Training...Please feel free to contact the program at Greene...

GREENE COUNTY

Peace Officer Basic Training

Dear Academy Applicant:

Welcome to the field of Law Enforcement! It is our pleasure to provide you with information on the Peace

Office Basic Training course offered through the Greene County Career Center in Xenia, Ohio. We look

forward to traveling with you on your journey into the exciting, yet demanding, arena of police work.

Enclosed please find our information/application packet for the upcoming academy course offerings for

2017-18.

Please feel free to contact the program at Greene County Career Center at 937-372-6941, and speak with

either myself (extension 139) or Becky Bond (extension 204) if you need additional assistance. We

encourage you to visit our website at www.greeneccc.com. You will find academy information, related

law enforcement links and general information on financial aid and other services provided by the Greene

County Career Center.

The Peace Officer Basic Training program is eager to put you on the path to realize your dreams of

becoming an Ohio Peace Officer.

Sincerely,

Michael Hild Sr.

Michael Hild Sr., Commander

Greene County Career Center

http://www.greeneccc.com/

Revised 02/21/17 2

Greene County Peace Officer Basic Training Academy

The Greene County Criminal Justice Training Academy (GCCJTA) strives for professional distinction in

providing state-of-the-art law enforcement training. All training at GCCJTA adheres to the standards set

forth by the Ohio Attorney General’s office and the Ohio Peace Officer Training Commission. Our

instructors come from noted regional law enforcement agencies and provide infinite years of law

enforcement experiences and intuition. Greene County Criminal Justice Training Academy is honored to

be partnered with area law enforcement agencies in the form of an Advisory Board and resource bank of

elite instructors and trainers who lead by example.

Our academy is approximately 750 hours which sets our standards above the minimum state requirement

of 695. Our training offers the Basic Peace Officer course and the following certifications:

Oleoresin Capsicum (OC) Certification

ASP Certification

Taser (User Certification)

Single Officer Response to an Active Shooter

Recruits are responsible to meet all scheduled training hours and provide their own transportation to the

training sites. Attendance is mandatory for all class sessions. The program of training includes

classroom, simulation and field training. The final classroom date is subject to change. The majority of

the training will take place at Greene County Criminal Justice training sites; the rest will be at locations

around Greene County.

Before submitting your application, please evaluate your personal and business commitments and

resources. Compliance with all of the rules and policies set forth by the Academy are mandated. Absence

from classes must be made up at the student’s expense. Attendance and participation in all facets of training

is compulsory and failure to act in accordance with these standards will result in a request for your

resignation or dismissal from the academy.

Revised 02/21/17 3

SWORN OFFICERS:

Persons who hold a current oath of office with any Ohio law enforcement agency are automatically eligible

for the Basic Police Academy.

A physical assessment and oral interview are required.

Verify physical fitness to safely function in all phases of the academy’s strenuous training (verified

by a licensed physician to include disability, chronic illness, pregnancy, etc.)

OPEN ENROLLMENT RECRUITS

Those applicants who are not affiliated with a law enforcement agency must meet the following minimum

standards:

Have a valid Driver’s License

Have NO Felony convictions, warrants or investigations pending

Have NO conviction for any offense stemming from a domestic violence charge, this includes

guilty or no contest pleas to lesser charges when the original charge was domestic violence or drug

charge.

Have NO convictions for any drug offense

Be in violation of Ohio’s Child Support Enforcement Laws

Be certified by a licensed physician as able to participate in all phases of the academy’s strenuous

and stressful training (includes disability, chronic illness, pregnancy, etc.)

Successfully pass the entry level physical fitness assessment at 15% of the OPOTA academy

completion standard

It is strongly recommended that open enrollment applicants have previous knowledge or experience in the

criminal justice field. Applicants will be asked in an oral interview how they have prepared themselves for

entrance into the Basic Police Academy, and preference will be given to candidates who can demonstrate

appropriate preparation.

Training Equipment and Uniforms

All police academy recruits will wear the designated uniform of the day. This will consist of a Navy Blue

shirt bearing the Greene County Criminal Justice Academy logo, khaki pants, black shoes, black belt and a

navy blue ball cap bearing the logo, No exceptions. The academy will provide each recruit with instructional

materials, books, two academy shirts, and a ball cap. Recruits are responsible for the following additional

items by the first day of class:

Khaki pants/slacks

Pens, paper and at least four three ring large notebook binder

Duty belt with level two holster and handcuff case with one pair of handcuffs, key, keepers or belt

stays, ammo pouches, ASP baton and holder

Lists of training equipment and suggested types and vendors will be supplied following the physical

assessment, oral review board, and your acceptance into the academy.

Firearms will be a 9mm, or .40 caliber and must be approved by the Academy Commander.

Revised 02/21/17 4

Academy Conduct

All recruits, instructors and persons associated with the Greene County Criminal Justice Academy will

display professional, mature and respectful behavior at all times. The Law Enforcement Code of Ethics

must be adhered to as of Day One of the Academy. Any disruptive, disrespectful or unsafe behavior will

not be tolerated and could result in disciplinary action to include dismissal from the academy with no refund

of monies paid. Academy recruits and personnel shall adhere to the guidelines and policies set forth in the

Student Handbook and will be required to sign a statement of understanding prior to beginning the academy.

Recruits are required to follow standards of personal appearance and hygiene:

o Hair for Men-military or tapered hair, off of the ears and no longer than collar length

o Hair for Women-if longer than shoulder length, must be pinned up or otherwise fastened

securely to head

o No afros, unless short and neatly barbered

o No unusual hair dyes permitted

o No braids, cornrows, etc. in the hair, except where braided in order to fasten securely to

the head (women only)

o No bandanas, hats or do-rags will be worn during classroom instruction

o Men are to be clean-shaven, with no beards, goatees or long sideburns. A mustache may

be worn so long as the ends of the mustache do not extend past the ends of the upper lip.

o No facial jewelry of any kind is permitted, including tongue piercings. No earrings are

permitted for men or women. There are to be no visible body piercings anywhere else on

the body; all jewelry (with the exception of wedding ring) is to be removed before the

physical contact portion of the training begins.

o All tattoos must be covered, particularly those of a vulgar or offensive nature. If the tattoos

are in an area that cannot be covered, it is highly recommended that the individual consider

having them removed.

o Student in the academy must present a clean, neat, professional appearance at all times.

Clothing may not have stains, tears or holes, and will be washed and wrinkle free.

o Students will not wear excessive cologne or perfume.

o Beginning with the first day of class, students will be required to keep a typed notebook,

to be submitted every month for inspection and grading.

Cost and Financial Assistance

Tuition is payable either up front, in a payment plan, through financial aid assistance, or a combination of

self-pay and financial assistance. All financial arrangements and/or fees must take place at least two

weeks prior to the starting date of the academy. Failure to comply with deadlines will prevent

you from participation in the academy. After enrollment and the beginning of the academy, failure to meet

scheduled payment dates will cause you to be terminated from the academy with no refund of monies paid

to date. Recruits sponsored and funded by an agency, must provide a letter of intent or purchase order on

company letterhead. Please contact Mr DeLange, Financial Aid Advisor, at [email protected] with

questions

mailto:[email protected]

Revised 02/21/17 5

Physical Fitness Training

All prospective academy recruits will be required to pass a Pre-Academy Physical Fitness Assessment prior

to beginning academy training. Please review the Pre-Academy Physical Fitness Standards based on the

15th percentile of the Cooper Fitness Standards from the Ohio Peace Officer Training Commission. If

you fail to meet the Pre-Academy Physical Fitness Standards, you will be eliminated from the process.

Physical conditioning and the successful passing of the Final Physical Fitness Assessment at the end of the

academy are compulsory. Please review the Final Physical Fitness Assessment Standards based on the

50th percentile of the Cooper Fitness Standards from the Ohio Peace Officer Training Commission. If

you fail to meet the Final Physical Fitness Standards, you will not be able to sit for the state exam and must

repeat the entire academy. Although academy staff will condition each recruit during the academy, all are

encouraged to begin an exercise regimen prior to, during, and after the academy.

See Fitness Standards Table below.

Ohio Peace Officer Basic Training Program

Physical Fitness Standards

(50th Percentile*)

Age and Gender Minimum Scores

Pre-Academy

(15th)

Final (50th) Pre-Academy (15th) Final (50th)

Sit-ups (1min)

Push-ups (1 min)

1.5 Mile Run

Males (<-29)

32

19

14:34

Males (<-29)

40

33

11:58

Females (<-29)

23

9

17:49

Females (<-29)

35

18

14:07

Sit-ups (1min)

Push-ups (1 min)

1.5 Mile Run

Males (30-

39)

28

15

15:13

Males (30-39)

36

27

12:25

Females (30-39)

18

7

18:37

Females (30-39)

27

14

14:34

Sit-ups (1min)

Push-ups (1 min)

1.5 Mile Run

Males (40-

49)

22

10

15:58

Males (40-49)

31

21

13:11

Females (40-49)

13

5

19:32

Females (40-49)

22

11

15:24

Sit-ups (1min)

Push-ups (1 min)

1.5 Mile Run

Males (50-

59)

17

7

17:38

Males (50-59)

26

15

14:16

Females (50-59)

7

4* Modified

21:31

Females (50-59)

17

13* Modified

17:13

Sit-ups (1min)

Push-ups (1 min)

1.5 Mile Run

Males (60+)

13

5

20:12

Males (60+)

20

15

15:56

Females (60+)

2

1* Modified

23:32

Females (60+)

8

8* Modified

18:52

Revised 02/21/17 6

*Based on, the Cooper Institute, Physical Fitness Specialist Course and Certification

Our instructors provide individualized support services in the area of fitness, goal setting, nutrition and

exercise so each recruit can focus on meeting personal and OPOTA standards.

Revised 02/21/17 7

Submit the completed notarized application and copy of valid driver’s

license to:

Greene County Criminal Justice Training Academy

c/o Greene County Career Center

Adult Education Building

2960 West Enon Road

Xenia, Ohio 45385-9545

Applicants will receive a letter indicating the location, date and time they

will need to be available for the Physical Assessment entry examination

and oral interview.

.

Revised 02/21/17 8

Greene County Criminal

Justice Training Academy

2960 West Enon Road

Xenia, OH 45385

Adult Education Department


(937) 372-6941 ext. 204

AUTHORIZATION TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

I hereby authorize any commissioned agent or representative of the Greene County Criminal Justice

Training Academy, bearing this release, or a copy thereof, within one (1) year of its date, to obtain any

information in your files pertaining to my employment, credit, support obligation records, or educational

records including, but not limited to, academic achievement, attendance, personal history, disciplinary

records, medical (per HIPPA requirements), fitness reports and military records. I hereby direct you to

release such information upon request to the bearer.

This request is executed with full knowledge and understanding that the information is for the official use

of the Greene County Criminal Justice Training Academy. Consent is granted for the Greene County

Criminal Justice Training Academy to furnish such information, as is described above, to third parties in

the course of fulfilling its official responsibilities.

I hereby release you, as the custodian of such records, and any government agency, school, college,

university, other educational institution, repository of military records, credit bureau, lending institution,

consumer reporting agency, police departments or retail business establishment, including its officers,

employees or related personnel, both individually and collectively, from any liability for damages of

whatever kind, which may at any time result to me, my heirs, family or associates because of compliance

with this authorization and request to release information, or any attempt to comply with it. Should there

be any question as to the validity of this release, you may contact me as indicated below.

FULL NAME___________________________________________________________________

(Signature)

DATE______________________________________________________________________

CURRENT ADDRESS__________________________________________________________

___________________________________________________________________________

TELEPHONE NUMBER________________________________________________________

________________________________________________________________Notary Public In and For

_________________County, Ohio My commission expires ______________________________

Witness ____________________________________ Date __________________

Revised 02/21/17 9



2960 West Enon Road

Xenia, OH 45385



(937) 372-6941 ext 204

MEDIA RELEASE

Date:__________________________ Subject:____________________________

I do hereby grant and give to Greene County Career Center, its successor and assigns (hereinafter referred

to as the school), the right to use, and to permit others to use my name, photograph, testimonial, voice

image, or likeness on printed material, printed film, film recording, video tape, or other sound and/or

visual device, both single and in conjunction with other persons or objects, for any and all purposes

including but not limited to, private or public presentations on the radio, television, in theaters,

newspapers, outdoor, direct mail, promotional literature, point-of-purchase material, signs, publicity, and

promotion related thereto.

I warrant that I have the right to authorize the foregoing uses and to hereby agree to withhold the School

harmless of any and all liability of whatever nature which may arise out of or result from such uses.

____________________________________________________

Signature

____________________________________________________

Printed Name

____________________________________________________

Street Address

_____________________________________________________

City, State, Zip

Revised 02/21/17 10



2960 West Enon Road

Xenia, OH 45385



(937) 372-6941 ext. 204

DOMESTIC VIOLENCE INFORMATION FORM

Title 18, United States Code, Section 922 (g) (9) makes it illegal for anyone who has been convicted of a

misdemeanor crime of Domestic Violence to possess any firearm or ammunition “Misdemeanor Crime of

Domestic Violence” is generally defined as any offense, whether or not explicitly described in a statute as

a crime of Domestic Violence, which has, as its factual basis, the use or attempted use of physical force, or

the threatened use of a deadly weapon, committed by the victim’s current or former domestic partner, parent

or guardian. The term “convicted” is generally defined in the statute as excluding anyone whose conviction

has been expunged or set aside, or has received a pardon. Any person who has pled guilty or no contest to

a lesser charge when the original charge was domestic violence, ORC 2919.25, is not eligible to apply.

If you are affected by this statute, you may not possess any firearm or ammunition; therefore, you are not

eligible for positions in the uniform forces of the any Police Department. Please answer the following:

1.) Have you ever been convicted of a misdemeanor crime of Domestic Violence

within the meaning of the statute? YES_____ NO _____

2.) If you answered yes to Question 1, provide the following information with

Respect to the conviction:

Court/Jurisdiction: ____________________________________________

Docket/Case Number: _________________________________________

Statute/Charge:_______________________________________________

I hereby certify that, to the best of my knowledge and belief, all of the information provided by me is true,

correct, complete, and made in good faith. I understand that false or fraudulent information provided herein

may be grounds for disqualification for the position of Police Recruit with the Greene County Criminal

Justice Training Academy.

Applicant Name__________________________________________________________ Print or type

Signature____________________________________________Date________________

Witness_____________________________________________Date________________

Revised 02/21/17 11



2960 West Enon Road

Xenia, OH 45385



(937) 372-6941 ext. 204

TO: Child Support Enforcement Agency

RE:

Social Security #

The above named individual is an applicant for the position of police recruit with the Greene County

Criminal Justice Training Academy.

Would you please verify that this individual is current in his/her alimony and/or child support obligations.

If not current, would you please furnish the delinquent amount? A notarized release of information is

enclosed.

The applicant provided the following information concerning his/her obligations.

Obligee:

Children:

Thank you for your assistance.

Sincerely,

Michael Hild Sr.

Michael Hild Sr.

Academy Commander

Revised 02/21/17 12



2960 West Enon Road

Xenia, OH 45385



(937) 372-6941 ext. 204

TO: National Personnel Records Center

(Military Personnel Records)

9700 Page Blvd.

St. Louis Missouri, 63132

FROM: Name:

Date of Birth:

Social Security #:

Branch of Service:

Dates of Service:

The above named individual is an applicant for the position of Police Recruit with the Greene County

Criminal Justice Training Academy, Xenia, Ohio.

Would you please verify the above information and forward his/her complete military history records

(excluding medical). The necessary authorization for the release of this information is enclosed.

Thank you in advance for your assistance.

Sincerely,

Michael Hild Sr.

Michael Hild Sr.

Academy Commander

Type or print all information

GREENE COUNTY PEACE OFFICER BASIC TRAINING

PERSONAL INVESTIGATION WORKSHEET

HOW DID YOU LEARN OF THE CRIMINAL JUSTICE TRAINING ACADEMY? : _________________

INSTRUCTIONS: This application is to be filled out in complete detail. Failure to

provide information or give false information could result in your

rejection. If you need to make any corrections, please initial next

to each.

YOUR FULL NAME _______________________________________________________________

(LAST) (FIRST) (MIDDLE)

ANY OTHER NAMES YOU HAVE USED __________________________________________

MAIDEN NAME: ________________________ NICKNAME: __________________________

PRESENT ADDRESS: ___________________________________________________________

(STREET AND APT. #)

______________________________________________________________________________

(CITY) (STATE) (ZIP CODE)

LIST ADDITIONAL ADDRESSES WHERE YOU MAY BE CONTACTED:

______________________________________________________________________________

TELEPHONE NUMBERS: (HOME) _________________ (WORK) _____________________

SOCIAL SECURITY #: _________________________ BIRTHDATE: ____________________

BIRTHPLACE: _________________________________________________________________

ARE YOU A U.S. CITIZEN: _______ YES _______ NO HEIGHT _____ WEIGHT ______

HAIR COLOR ________ EYE COLOR _________

SCARS/MARKS/TATTOOES ___ SPECIFY LOCATION ____________________________

MARITAL STATUS: ____________________________________________________________

(MARRIED, SINGLE, SEPERATED, DIVORCED)

SPOUSE’S FULL NAME: ________________________________________________________

SPOUSE’S SOCIAL SECURITY #: __________________ BIRTHDATE: ________________

SPOUSE’S ADDRESS (IF DIFFERENT): ___________________________________________

(STREET AND APT. #)

______________________________________________________________________________


SPOUSE’S EMPLOYER: ________________________________________________________

(NAME OF COMPANY)

Revised 02/21/17 14

EMERGENCY CONTACT, NAME AND PHONE NUMBER #1 _________________________________

EMERGENCY CONTACT, NAME AND PHONE NUMBER #2 _________________________________

CHILDREN’S NAME(S) AND AGES(S):

NAME AGE

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

IF PREVIOUSLY MARRIED, LIST FORMER SPOUSE’S NAME & ADDRESS

NAME: _______________________________________________________________________


ADDRESS: ____________________________________________________________________

(STREET AND APT. #)

______________________________________________________________________________


WHEN / WHERE DIVORCED? ____________________________________________________

WHAT METHOD OF PAYMENT WILL YOU BE USING FOR YOUR TUITION? CASH _______

THREE PAYMENT PLAN _______ VISA/MASTERCARD _______ FINANCIAL AID: _______

CHECK IF YOU KNOW WHAT PLAN YOU WILL BE USING OR IF YOU HAVE PREVIOUSLY USED ANY

OF THE FOLLOWING:

VA _________ PELL _________ BVR _______ TRA/TAA ________ WIA_______

GREENEWORKS _______ WORKPLUS _______

WHAT DO YOU SEE YOURSELF DOING ONE YEAR FROM NOW? _________________________________

_____________________________________________________________________________________________

WHAT DO YOU SEE YOURSELF DOING FIVE YEARS FROM NOW? ________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

PREVIOUS RESIDENCES

LIST IN CHRONOLOGICAL ORDER ALL PREVIOUS ADDRESSES WITHIN THE PAST 5 YEARS.

DATES (FROM MONTH/YEAR TO MONTH/YEAR) _________________________________

ADDRESS: ____________________________________________________________________

(STREET AND APT. #)

______________________________________________________________________________


OWNED OR RENTED? _________________________________________________________

MORTGAGE HOLDER OR LANDLORD ? _________________________________________


ADDRESS: ____________________________________________________________________

(STREET AND APT. #)

______________________________________________________________________________


OWNED OR RENTED _________________________________________________________



ADDRESS: ____________________________________________________________________

(STREET AND APT. #)

_____________________________________________________________________________


OWNED OR RENTED? _________________________________________________________



ADDRESS: ____________________________________________________________________

(STREET AND APT. #)

______________________________________________________________________________


OWNED OR RENTED? _________________________________________________________


Revised 02/21/17 16

RELATIVES

PARENTS’ NAMES AND ADDRESSES:

MOTHER’S NAME: ____________________________________________________________


ADDRESS: ____________________________________________________________________


FATHER’S NAME: _____________________________________________________________


ADDRESS: ____________________________________________________________________


TELPPHONE NUMBERS: _______________________________________________________

(MOTHER) (FATHER)

DO YOU HAVE ANY RELATIVES CURRENTLY WORKING IN OR RETIRED FROM

LAW ENFORCEMENT ? IF SO, PLEASE LIST THEIR NAME AND DEPARTMENT/AGENCY:

Revised 02/21/17 17

PLEASE LIST SIX REFERENCES INCLUDING NAME, ADDRESS AND TELEPHONE NUMBER:

THREE PERSONAL REFERENCES (NOT RELATIVES)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

THREE PROFESSIONAL REFERENCES

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PHYSICAL AND PSYCHOLOGICAL

DO YOU HAVE ANY PHYSICAL OR PSYCHOLOGICAL LIMITATIONS OR INJURIES (RECENT OR OLD)

THAT MIGHT RESTRICT YOUR FULL PARTICIPATION IN THE ACADEMY? Yes____ No______

ARE YOU DISABLED IN ANYWAY?

__________________________________________________________________________________________

HAVE YOU EVER RECEIVED MENTAL HEALTH TREATMENT? Yes______ No______

IF YES, PLEASE EXPLAIN:___________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

DO YOU SUFFER FROM POST TRAUMATCI STRESS DISORDER (PTSD)?

_____________________________________________________________________________________________

Revised 02/21/17 18

EDUCATION

IF YOU PROGRESS TO THE NEXT STEP OF THE HIRING PROCESS, COPIES OF YOUR HIGH SCHOOL

TRANSCRIPTS OR GED CERTIFICATE AND COLLEGE TRANSCRIPTS WILL BE REQUIRED.

LAST HIGH SCHOOL ATTENDED: _______________________________________________

ADDRESS: ____________________________________________________________________

(STREET) (CITY) (ZIP CODE)

DATE OF GRADUATION (MONTH/YEAR): ________________________________________

IF YOU DID NOT GRADUATE AND OBTAINED A GED PLEASE FURNISH THE FOLLOWING

INFORMATION:

DATE RECEIVED: _________________________ STATE RECEIVED: __________________

COLLEGES ATTENDED:

NAME: _______________________________________________________________________

ADDRESS: ____________________________________________________________________

(CITY) (STATE)

DATES ENROLLED: ___________________________________________________________

GRADE POINT AVERAGE: ______________ CREDIT HOURS EARNED: _______________

MAJOR: ________________________________ DEGREE: _____________________________


NAME: _______________________________________________________________________

ADDRESS: ____________________________________________________________________

(CITY) (STATE)

DATES ENROLLED: ___________________________________________________________

GRADE POINT AVERAGE: ______________ CREDIT HOURS EARNED: _______________

MAJOR: ________________________________ DEGREE: _____________________________


LIST ANY ADDITIONAL POST HIGH SCHOOL TRAINING: ___________________________

_________________________________________________________________________________

Revised 02/21/17 19

EMPLOYMENT

LIST CHRONOLOGICALLY ALL EMPLOYMENT FOR THE PAST 5 YEARS INCLUDING PART-TIME AND

TEMPORARY EMPLOYMENT. ALL TIME MUST BE ACCOUNTED FOR. IF UNEMPLOYED, LIST DATES.

ALL ADDRESSES MUST BE COMPLETE, INCLUDING ZIP CODES. PLEASE LIST PRESENT EMPLOYER

FIRST.

EMPLOYER: __________________________________________________________________

ADDRESS: ____________________________________________________________________

(#) (STREET) (CITY) (STATE) (ZIP CODE)

DATES OF EMPLOYMENT: _____________________________________________________

TYPE OF WORK: _________________________ SUPERVISOR: ________________________

REASON FOR LEAVING: _______________________________________________________

EMPLOYER: __________________________________________________________________

ADDRESS: ____________________________________________________________________





EMPLOYER: __________________________________________________________________

ADDRESS: ____________________________________________________________________





Revised 02/21/17 20

EMPLOYER: __________________________________________________________________

ADDRESS: ____________________________________________________________________





EMPLOYER: __________________________________________________________________

ADDRESS: ____________________________________________________________________





HAVE YOU APPLIED FOR EMPLOYMENT WITH A POLICE DEPARTMENT?

____________ IF YES, LIST NAME OF DEPARTMENT AND DATE OF APPLICATION:

DEPARTMENT DATE OF APPLICATION

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

HAVE YOU EVER BEEN DENIED EMPLOYEMENT ANYWHERE ?____________________

FROM WHERE ? ___________________________________

PLEASE EXPLAIN: ________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Revised 02/21/17 21

MILITARY (ACTIVE DUTY ONLY)

BRANCH: ___________________ DATES OF ACTIVE SERVICE: ______________________

LAST DUTY STATION: _________________________________________________________

(NAME) (CITY) (STATE)

SERIAL #: ________________________ HIGHEST RANK ATTAINED: __________________

DISCIPLINARY ACTION / TYPE: ________________________________________________

______________________________________________________________________________

IF YOU ARE A FORMER OR CURRENT MEMBER OF THE RESERVES OR NATIONAL GUARD PLEASE

ANSWER THE FOLLOWING:

BRANCH: ___________________ HIGHEST RANK ATTAINED: _______________________

PRESENT DUTY STATION: _____________________________________________________

DATES OF SERVICE: ___________________________________________________________

ARE YOU REGISTERED WITH SELECTIVE SERVICE ? _____________________________

IF YOU ARE A MILITARY VETERAN AND PROGRESS TO THE NEXT STEP IN THE HIRING PROCESS, A

COPY OF YOUR DD214 WILL BE REQUIRED. ALSO, PERSONS REQUIRED TO BE REGISTERED WITH

SELECTIVE SERVICE WILL BE REQUIRED TO FURNISH PROOF OF REGISTRATION.

Revised 02/21/17 22

FINANCIAL HISTORY STATEMENTS

YES

NO

1. HAVE YOU EVER HAD YOUR WAGES ATTACHED OR GARNISHED?

2. HAVE YOU EVER BEEN A DEFENDANT IN SMALL CLAIMS OR OTHER

CIVIL ACTION?

3. DO YOU HAVE ANY CIVIL ACTION PENDING AGAINST YOU?

4. HAVE YOU EVER HAD A JUDGEMENT RENDERED AGAINST YOU?

5. HAVE YOU EVER BEEN REFUSED AN INSURANCE POLICY?

6. HAVE YOU EVER HAD AN INSURANCE POLICY CANCELLED?

7. HAVE YOU EVER BEEN REFUSED CREDIT?

8. HAVE YOU EVER HAD ANY PROPERTY REPOSSESSED?

9. DO YOU CURRENTLY HAVE ANY ACCOUNTS UP FOR COLLECTION?

10. IF YOU ARE OBLIGATED TO PAY CHILD SUPPORT AND/OR ALIMONY,

ARE YOU CURRENT IN YOUR PAYMENT?

IF YOU ANSWERED YES TO ANY OF THE PREVIOUS QUESTIONS (1-10) OR NO TO #10 PLEASE EXPLAIN

BELOW:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Revised 02/21/17 23

TRAFFIC RECORD

INCLUDE A LEGIBLE COPY OF YOUR DRIVER’S LICENSE

DRIVERS LICENSE # __________________________ STATE ISSUED __________________

LIST ALL TRAFFIC VIOLATIONS (EXCEPT PARKING TICKETS) FOR WHICH YOU HAVE BEEN

CONVICTED IN THE PAST 10 YEARS:

DATE POLICE AGENCY CHARGE COURT OF

DISPOSITION

HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED? ____________________

IF YES, PLEASE EXPLAIN: ______________________________________________________

DO YOU OWN AN AUTOMOBILE, OR HAVE ONE AT YOUR DISPOSAL? _____________

IF YES, PLEASE ANSWER THE FOLLOWNG QUESTIONS:

YEAR ___________ MAKE ___________________ MODEL _________________________

INSURANCE COMPANY/AGENT ________________________________________________

TYPE OF COVERAGE ___________________________ HIGH RISK? ___________________

CRIMINAL RECORD

HAVE YOU EVER BEEN ARRESTED? ______________ DATE OF ARREST______________

REASON FOR ARREST? __________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

LIST ALL CRIMINAL VIOLATIONS FOR WHICH YOU HAVE BEEN CONVICTED OR ADJUDICATED:

DATE POLICE AGENCY CHARGE COURT OF

DISPOSITION

Revised 02/21/17 24

DRUG HISTORY

EXAMINE THE FOLLOWING LIST OF DRUGS AND SUBSTANCES TO DETERMINE YOUR ILLEGAL

USAGE, IF ANY, IN EACH PARTICULAR CATEGORY. PLEASE CHECK APPROPRIATE RESPONSE TO

EACH QUESTION:

Drug Type Yes No

HALLUCINOGENIC DRUGS

MARIJUANA

HASHISH/HASH OIL

THC

LSD

PCP

DMT

PEYOTE

MESCALINE

STIMULANTS

COCAINE (ALL FORMS)

AMPHET AMINES

DEPRESSANTS

BARBITURATES

TRANQUILIZERS

OTHER NARCOTIC SUBSTANCES

OPIUM

MORPHINE

HERION

CODEINE

METHODONE

DILUDID

DEMEROL

HARMFUL INTOXICANTS

ORGANIC SOLVENTS

(THINNER, CLEANING FLUID,

GASOLINE, PLASTIC CEMENT,

ETC.)

ANY AEROSOL PROPELLANT

ANY FLUOROCARBON

REFRIDGERANT

ANY ANESTHETIC GAS

OTHER SUBSTANCES NOT PREVIOUSLY SPECIFIED

______________________________________________________________________________

[TYPE(S)]

Revised 02/21/17 25

PLEASE ANSWER THE FOLLOWING QUESTIONS CONCERNING YOUR ILLEGAL DRUG ACTIVITIES. IF

YOU HAVE NEVER USED DRUGS ILLEGALLY, GO DIRECTLY TO QUESTION #11. (IF A QUESTION

DOES NOT APPLY, INSERT DNA):

1. AT WHAT AGE DID YOU FIRST USE DRUGS/TYPE(S)?__________________________

2. DATE (MONTH/YEAR) YOU LAST USED DRUGS/TYPE(S)? _____________________

3. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER PURCHASED/

TYPE(S)? ___________________________________________________________________

4. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER SOLD/

TYPE(S)? ___________________________________________________________________

5. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER TRANSPORTED/

TYPE(S)? _____________________________ WHEN? _____________________________

6. HAVE YOU EVER CULTIVATED MARIJUANA? _________________________________

AMOUNT? ____________________________ WHEN? _____________________________

7. HAVE YOU EVER ILLEGALLY OBTAINED ANY PRESCRIPTION DRUG AND IF SO,

LIST TYPE AND HOW OBTAINED? ____________________________________________

____________________________________________________________________________

8. HOW MANY CLOSE FRIENDS DO YOU KNOW WHO USE DRUGS AND WHAT

TYPES OF DRUGS DO THEY USE? ____________________________________________

____________________________________________________________________________

9. HOW MANY TIMES HAVE YOU GIVEN OTHERS MONEY TO BUY DRUGS?

WHAT TYPE(S)? ___________________________________________________________________

Revised 02/21/17 26

10. EXTENT OF ILLEGAL DRUG USAGE (List specific drug at the bottom of this page):

Drug Category

More

than 50

times

20 to

50

times

10 to 20

times

2 to 10

times

One

time

HALLUCINOGENIC DRUGS

STIMULANTS

DEPRESSANTS

OTHER NARCOTIC SUBSTANCES

HARMFUL INTOXICANTS

11. DO YOU CONSUME ALCOHOLIC BEVERAGES? _______________________________

12. IF YOU ANSWERED YES TO #11, WHAT IS YOUR CONSUMPTION?:

PER WEEK ___________ TYPE(S)? ____________________________________________

13. HAVE YOU EVER SUCCESSFULLY COMPLETED A SUPERVISED DRUG AND/OR

ALCOHOL REHABILITATION PROGRAM? (IF YES, YOU WILL BE REQUIRED TO

FURNISH PROOF OF SUCCESSFUL COMPLETION UPON REQUEST) _____________

14. IF YOU ANSWERED YES TO #13, HAVE YOU REMAINED ALCOHOL AND/OR DRUG

FREE SINCE THE COMPLETION DATE OF YOUR PROGRAM: ___________________

IF NO, PLEASE EXPLAIN: ___________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF NECESSARY, USE THE FOLLOWING SPACE TO EXPLAIN OR ADD TO YOUR ANSWERS. MAKE

REFERENCE TO THE PARTICULAR PAGE NUMBER, SECTION, AND QUESTION:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Revised 02/21/17 27

CERTIFICATION

I CERTIFY THAT THE STATEMENTS HEREIN CONTAINED ARE TRUE TO THE BEST OF MY

KNOWLEDGE AND UNDERSTAND THAT ANY FALSE STATEMENTS OR OMISSIONS OF INFORMATION

MADE IN THIS APPLICATION MAY BE CAUSE FOR DISAPPROVAL OF MY APPOINTMENT OR FOR

DISCHARGE AFTER APPOINTMENT.

___________________________________ _______________________________

(SIGNATURE) (DATE)

____________________________, appeared before me on the day of year .

____________________________________

(NOTARY)

Notary Public in and for County, Ohio. My commission expires ____________________

GREENE COUNTY Peace Officer Basic Training...Please feel free to contact the program at Greene...

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