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FOR OFFICE USE ONLY Investigation # _______________ Assigned to _________________ O/S _____________ MIL: Y N

EMPLOYMENT APPLICATION HALES CORNERS POLICE DEPARTMENT

Important Instructions: This application must be completely filled out and either typed or 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 Hales Corners Police Department requests this information to complete the employment background verification. Please Note: The Hales Corners Police Department conducts extensive background investigations as outlined in LES 2.01, Wis. Adm. Code. 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.

Legal Name: Last First Middle Social Security Number

Resident Street Address (Where you can be contacted personally) Mailing Address (If Different)

(Area Code) Mobile Telephone Number Email address

(Area Code) Home Telephone Number County of Residence

(Area Code) Work Telephone Number Birth Date (Month/Day/Year) Sex Male Female

List any aliases, nicknames, 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) 2 Asian or Pacific Islander 3 American Indian/Alaskan Native 4 Hispanic (Mexican, Puerto Rican, Cuban, Other) 5 White 6 Multi-Racial (In addition, check any above boxes that apply)

Entrance Requirements No Yes Do you hold a valid Driver’s License?

Driver’s License Number: ____________________________________ State: ___________________

No Yes Do you know any reason why you would not be able to perform any job-related task or function as specified in enclosed the job description? If yes, explain:

No Yes Prior to final appointment, all persons tentatively selected for positions will be required to submit to physical/eyesight/medical/physical-agility testing, psychological and drug screen examinations by physicians and psychologists, of the choice of the Village of Hales Corners and at the expense of the Village of Hales Corners. Will you consent to such examinations?

Certification Statement 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 am applying, and may affect future consideration for other positions in the department.

X______________________________________________ (Applicant Signature) Date

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This page has been intentionally left blank.

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Applicant Name: Last First Middle

Residency History List chronologically, starting with most your recent address, all of your past residences during the past fifteen (15) years. Include addresses while attending school if away from home and all military addresses. (Use additional sheets if necessary.)

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

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Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Dates (Mo/Yr) Street Address (Apt. No.) City, State AND Zip Code

From To

If rented, give name, address and telephone of person responsible for the collection of rent

Please list locations in which you spend a regular part of your free time, example: parent's residence, friend's residence or home town, any location where you would be well known.

What special skills, abilities, experiences, hobbies, etc. do you have which may enhance your qualifications for this position?

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Applicant Name: Last First Middle

Employment History

List all employers beginning with the most recent, and work back. Include all part time employers. Account for all time periods. Make additional copies of this page if necessary.

No Yes Are you presently a permanent, classified state civil service employee? If yes, complete the following: Class Title Agency Pay Range Seniority Date

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

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Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

Employer Name and Address (If unemployed indicate dates) Employment Dates Annual Salary Hours Per Week

Begin End Begin End

Is this business still active? Yes No

Position Held, Duties, Reason for Leaving Supervisor Name and Telephone (Where they can be currently contacted)

May We Contact?

Y N

No Yes Were you ever subjected to disciplinary action, including dismissal, in connection with any employment? If yes, give details:

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Applicant Name: Last First Middle

Peace Officer Licensing List any prior law enforcement/criminal justice employment experience:

No Yes Are you currently or have you ever been certified or licensed as a peace officer (full or part-time):

If yes, please provide the following information: License No. _________________________________ Date Originally Issued:____________________________ Expiration Date: ____________________

Current Status. (Please attach a photocopy of your license certification and current renewal card.) Valid - Active Status Valid - Inactive Status Lapsed Surrendered Suspended Revoked

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 Name AND Address

Military Service No Yes Have you served in the United States Armed Forces? If yes, complete the following: Name Used During Service (Last, First and Middle) Social Security No. Birth Place

Active Service, Past and Present Branch of Service Dates of Active Service Check One Service Number

Date Entered Date Released Officer Enlisted

Reserve, Past and Present Branch of Service Dates of Membership Check One Service Number

From To Officer Enlisted

National Guard Membership (Check One) Army Air Force None State Organization Dates of Membership Check One Service Number

From To Officer Enlisted

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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?

No

No

What was the nature of the change? Changed from ____________________ to ___________________

List all medals and decorations awarded you as a member of the Armed Forces.

Yes Have you ever applied for Department of Defense Security Clearance? If yes, indicate date: _________

Yes 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, how many times? ______

Give Details of charges, agency concerned, dates and descriptions.

Personal Information

List the required information for your father, mother, sisters, brothers: Relationship Name Address Occupation Telephone

List all persons who live in the same household with you (if not listed above or under references). Name Relationship Occupation Place of Employment

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Applicant Name: Last First Middle

Personal References

Give three references (not relatives, fellow employees or school teachers) who are responsible adults of reputable standing in their communities. DO NOT LIST LAW ENFORCEMENT REFERENCES.

Name AND COMPLETE Address (Area Code) Home Telephone

(Area Code) Work Telephone

Occupation Best Time To Contact

Social References Give three social references, not in law enforcement or not listed in personal reference.

Name AND COMPLETE Address (Area Code) Home Telephone

(Area Code) Work Telephone

Occupation Best Time To Contact

Law Enforcement References List the names of all agency officers you know personally and that would have personal knowledge of you.

Name Name

List the names of other law enforcement officers you know personally and that would have personal knowledge of you. Name Department Address (If Known) Telephone

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List all professional or civic organizations that you are a member or have been a member of, example: American Legion, Optimists, Kiwanis, etc.

Membership Dates Organization Name Type of Organization From To

Driving History

No

No

Use of Alcohol or Drugs as an Adult

No

No

No

Yes Have you ever had a Driver’s License suspended, revoked or restricted? If yes, please explain:

Yes Do you hold a valid Driver’s License from any state other than those listed on page 1? If yes, list those states:

Yes Do you currently drink alcoholic beverages? If yes, to what degree?

Yes Do you currently use marijuana? If yes, to what degree?

Yes Do you currently use nonprescription illegal drugs, such as opiates, LSD, cocaine, etc. If yes, please explain:

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Applicant Name: Last First Middle

Judicial Action No Yes Have you ever been charged or convicted of ANY law violation including traffic law, other than

parking tickets? Include traffic violations as a juvenile. If yes, complete the following. Date

(Mo/Day/Year) Location Charge/Violation Final Disposition Comments

(Agency and Court)

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

No Yes 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 Location Offense Age Then Police Agency Involved

State County

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

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Financial History Provide the names and address of the individuals, companies or others to whom you are indebted and the extent of your debt. Include rent, mortgages, vehicle payments, charge accounts, credit cards, loans, and other debts and payments. Include account numbers where applicable.

Type of Account Name AND Address of Creditor Account Number Total Balance Monthly Payment

No Yes Do you have a savings, checking, or money market account? If yes, complete the following: Name of Institution AND Address Account Number Type of Account

No

No

No Yes Have you ever been declared delinquent in child support payments ordered by the court? If yes, give details:

Yes Have you ever filed for bankruptcy or been declared bankrupt? If yes, give details:

Yes Have you ever had any garnishment, wage attachment, or civil judgment against you? If yes, give details:

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Applicant Name: Last First Middle

Education History

The Hales Corners Police Department requires an applicant for employment as a law enforcement officer possess either a 2 year associate degree or a minimum of 60 fully accredited college-level credits. This policy does not apply to applicants employed as law enforcement officers prior to February 1, 1993.

No Yes I was employed as a law enforcement officer prior to 2/1/93. Dates of Employment: _______________ Check appropriate box if you were not employed as an officer prior to February 1, 1993: Check highest level of education attained:

I currently hold a 2 Yr. Associate Degree 05 - Associate Degree 07 - Bachelor of Arts I have 60 fully accredited college-level credits 08 - Bachelor of Science 09 - Masters Degree I do not have 60 fully accredited college-level credits 10 - PHD, JD, et al

For those applicants not meeting the educational requirements, please complete the following: _____ Number of college-level credits currently complete _____ Number of credits anticipated by the start of Academy class

No Yes I have applied to Department of Justice for a waiver Application Date for Waiver (Mo/Day/Yr): ________________________

High School - Give Name AND Address Date (Mo/Yr) Major Field of Study Diploma/Degree Granted (Mo/Yr)

Credits

From To

Colleges/Universities

Give Name AND Address Date (Mo/Yr) Major Field of Study Diploma/Degree

Granted (Mo/Yr) Credits

From To

Graduate School - Give Name AND Address Date (Mo/Yr) Major Field of Study Diploma/Degree

Granted (Mo/Yr) Credits

From To

Education History - Continued

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Voc/Tech/Trade/Business School Give Name AND Address

Date (Mo/Yr) Major Field of Study Diploma/Degree Granted (Mo/Yr)

Credits

From To

Miscellaneous Education Give Name AND Address

Date (Mo/Yr) Major Field of Study Diploma/Degree Granted (Mo/Yr)

Credits

From To

List all Law Enforcement intern programs you have been a part of (high school and college) Date School Department Involved Advisor and Telephone Number

Attach copies of all diplomas and transcripts.

List all awards received from high school and college:

List any problems with school (absenteeism, tardiness, poor grades, other disciplinary problems), including college. (Be very specific.)

Date School Problem Brief Explanation

· INFORMATION RELEASE AUTHORIZATIONFor Official Use By Authorized Persons

HALES CORNERS POLICE DEPARTMENT

Agency4109 0197 s.230.16(11, Wis. Stats. and LES 2.01, Wis. Adm. Code

INSTRUCTIONS TO APPLICANT: Complete this release and return with employment application. Hales Corners Police Department requests this information to complete the employment background verification. The information obtained is used exclusively for the purpose of employment consideration. Note: This release must be signed by a witness. Failure to complete will result in delayed processing of your application.

Legal Name: Last I Date of Birth

Re�ident Street Address, City, State, Zip code

{Area Code) Home Telephone I (Area Code) Work Telephone

Former Name (If Applicable)

To Whom It May Concern: I authorize any official representative of Hales Corners Police Department bearing or presenting this release, to obtain information and records pertaining to rne and my personal background whether such information and records are public, private, favorable, unfavorable, or confidential in nature from any or all of the following sources:

1. Military Record Centers2. Any place of business3. Any Court, Police Agency or other location where criminal and misdemeanor records are kept4. Former Employer(s)5. Present Employer(s)6. Any School, College, University or other educational institution including peace officer records7. Credit Bureau(s)8. Any Banking Institution9. Any Local, State, or Federal Governmental Agency10. Any private citizen who has knowledge of individual

understand that any information obtained by the personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by Hales Corners Police Department. I fully understand that the refusal to grant this authorization will not, of itself, constitute a basis for rejection of my application. I hereby release any individual or institution, including it's officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, including actions brought under s. 895.50, Wisconsin Statutes (the Privacy Act) 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.

Exceptions to this blanket authorization.

A photocopy of this release will be as valid as an original,

Applicant Signature Witness Signature

First Middle

(Area Code) Mobile Telephone

X X

Date Date

An Applicant and witness signature is required

FOR OFFICE USE ONLY: Investigation: Assigned to: Social Security Number: Mailing Address If Different: Email address: County of Residence: Sex: OffList any aliases nicknames maiden name of your present legal name: 1 Black Not Hispanic: Off2 Asian or Pacific Islander: Off3 American IndianAlaskan Native: Off4 Hispanic Mexican Puerto Rican Cuban Other: Off5 White: Off6 MultiRacial In addition check any above boxes that apply: Offspecified in enclosed the job description If yes explain: From: To: If rented give name address and telephone of person responsible for the collection of rent: From_2: To_2: If rented give name address and telephone of person responsible for the collection of rent_2: From_3: To_3: If rented give name address and telephone of person responsible for the collection of rent_3: From_4: To_4: If rented give name address and telephone of person responsible for the collection of rent_4: From_5: To_5: If rented give name address and telephone of person responsible for the collection of rent_5: From_6: To_6: If rented give name address and telephone of person responsible for the collection of rent_6: From_7: To_7: If rented give name address and telephone of person responsible for the collection of rent_7: From_8: To_8: If rented give name address and telephone of person responsible for the collection of rent_8: From_9: To_9: If rented give name address and telephone of person responsible for the collection of rent_9: From_10: To_10: If rented give name address and telephone of person responsible for the collection of rent_10: From_11: To_11: If rented give name address and telephone of person responsible for the collection of rent_11: From_12: To_12: If rented give name address and telephone of person responsible for the collection of rent_12: From_13: To_13: If rented give name address and telephone of person responsible for the collection of rent_13: From_14: To_14: If rented give name address and telephone of person responsible for the collection of rent_14: Please list locations in which you spend a regular part of your free time example parent: What special skills abilities experiences hobbies etc do you have which may enhance your qualifications for this position: Class Title: Agency: Pay Range: Seniority Date: Begin: End: Begin_2: End_2: Is this business still active: OffBegin_3: End_3: Begin_4: End_4: Is this business still active_2: OffEmployer Name and Address If unemployed indicate dates_3: Begin_5: End_5: Begin_6: End_6: Is this business still active_3: OffPosition Held Duties Reason for Leaving_3: Supervisor Name and Telephone Where they can be currently contacted_3: Employer Name and Address If unemployed indicate dates_4: Begin_7: End_7: Begin_8: End_8: Is this business still active_4: OffHours Per WeekRow1_3: Position Held Duties Reason for Leaving_4: Supervisor Name and Telephone Where they can be currently contacted_4: Employer Name and Address If unemployed indicate dates_5: Begin_9: End_9: Begin_10: End_10: Is this business still active_5: OffHours Per WeekRow1_4: Position Held Duties Reason for Leaving_5: Supervisor Name and Telephone Where they can be currently contacted_5: Employer Name and Address If unemployed indicate dates_6: Begin_11: End_11: Begin_12: End_12: Is this business still active_6: OffHours Per WeekRow1_5: Position Held Duties Reason for Leaving_6: Supervisor Name and Telephone Where they can be currently contacted_6: Employer Name and Address If unemployed indicate dates_7: Begin_13: End_13: Begin_14: End_14: Is this business still active_7: OffHours Per WeekRow1_6: Position Held Duties Reason for Leaving_7: Supervisor Name and Telephone Where they can be currently contacted_7: Employer Name and Address If unemployed indicate dates_8: Begin_15: End_15: Begin_16: End_16: Is this business still active_8: OffHours Per WeekRow1_7: Position Held Duties Reason for Leaving_8: Supervisor Name and Telephone Where they can be currently contacted_8: Employer Name and Address If unemployed indicate dates_9: Begin_17: End_17: Begin_18: End_18: Is this business still active_9: OffHours Per WeekRow1_8: Position Held Duties Reason for Leaving_9: Supervisor Name and Telephone Where they can be currently contacted_9: employment If yes give details 1: List any prior law enforcementcriminal justice employment experience 1: If yes please provide the following information License No: Date Originally Issued: Expiration Date: DateRow1: DateRow2: Name Used During Service Last First and MiddleRow1: Date EnteredRow1: Date ReleasedRow1: Date EnteredRow2: Date ReleasedRow2: Date EnteredRow3: Date ReleasedRow3: FromRow1: ToRow1: FromRow2: ToRow2: FromRow3: ToRow3: FromRow1_2: ToRow1_2: FromRow2_2: ToRow2_2: FromRow3_2: ToRow3_2: Discharges: Separations: What was the nature of the change Changed from: to: List all medals and decorations awarded you as a member of the Armed Forces 1: undefined_7: captains mast company punishment or any other disciplinary action If yes how many times: Give details of charges agency concerned dates and dispositions 1: RelationshipRow2: RelationshipRow3: RelationshipRow4: RelationshipRow5: RelationshipRow6: Name AND COMPLETE AddressRow1: Name AND COMPLETE AddressRow2: Name AND COMPLETE AddressRow3: Name AND COMPLETE AddressRow1_2: Name AND COMPLETE AddressRow2_2: Name AND COMPLETE AddressRow3_2: NameRow3_2: NameRow4_2: NameRow5_2: FromRow1_3: ToRow1_3: FromRow2_3: ToRow2_3: FromRow3_3: ToRow3_3: FromRow4: ToRow4: FromRow5: ToRow5: 1_2: 2_2: 1_3: Date MoDayYearRow1: Date MoDayYearRow2: Date MoDayYearRow3: Date MoDayYearRow4: Date MoDayYearRow5: Date MoDayYearRow6: Date MoDayYearRow7: Date MoDayYearRow8: Date MoDayYearRow9: respondent of any civil court action If yes explain include when where name and location of: DateRow1_2: DateRow2_2: DateRow2_3: StateRow1_2: DateRow1_4: DateRow2_4: DateRow3: Type of AccountRow1: Type of AccountRow2: Type of AccountRow3: Type of AccountRow4: Type of AccountRow5: Type of AccountRow6: Type of AccountRow7: Type of AccountRow8: Type of AccountRow9: Name of Institution AND AddressRow1: Name of Institution AND AddressRow2: Name of Institution AND AddressRow3: 1_5: 2_5: details 1: No_35: OffYes I was employed as a law enforcement officer prior to 2193 Dates of Employment: Offundefined_16: 05 Associate Degree: Off08 Bachelor of Science: OffI currently hold a 2 Yr Associate Degree: OffI have 60 fully accredited collegelevel credits: OffI do not have 60 fully accredited collegelevel credits: Off07 Bachelor of Arts: Off09 Masters Degree: Off10 PHD JD et al: OffNumber of collegelevel credits currently complete: Number of credits anticipated by the start of Academy class: No_36: OffYes I have applied to Department of Justice for a waiver: OffApplication Date for Waiver MoDayYr: FromRow1_4: ToRow1_4: FromRow2_4: ToRow2_4: High School Give Name AND AddressRow3: FromRow3_4: ToRow3_4: High School Give Name AND AddressRow4: FromRow4_2: ToRow4_2: CollegesUniversities Give Name AND AddressRow2: FromRow1_5: ToRow1_5: CollegesUniversities Give Name AND AddressRow3: FromRow2_5: ToRow2_5: CollegesUniversities Give Name AND AddressRow4: FromRow3_5: ToRow3_5: CollegesUniversities Give Name AND AddressRow5: FromRow4_3: ToRow4_3: Graduate School Give Name AND AddressRow2: FromRow1_6: ToRow1_6: Graduate School Give Name AND AddressRow3: FromRow2_6: ToRow2_6: Graduate School Give Name AND AddressRow4: FromRow3_6: ToRow3_6: Graduate School Give Name AND AddressRow5: FromRow4_4: ToRow4_4: FromRow1_7: ToRow1_7: FromRow2_7: ToRow2_7: FromRow3_7: ToRow3_7: FromRow4_5: ToRow4_5: FromRow1_8: ToRow1_8: Miscellaneous Education Give Name AND AddressRow3: FromRow2_8: ToRow2_8: Miscellaneous Education Give Name AND AddressRow4: FromRow3_8: ToRow3_8: Miscellaneous Education Give Name AND AddressRow5: FromRow4_6: ToRow4_6: DateRow1_5: DateRow2_5: DateRow3_2: List all awards received from high school and college 1: DateRow1_6: DateRow2_6: DateRow3_3: Entrance: OffState: DL Number: First: Middle: Address 1: AgencyName1: AgencyName2: SocialSecurity#: BirthPlace: Branch of ServiceRow1: Branch of ServiceRow2: Branch of ServiceRow3: Branch of ServiceRow1_2: Branch of ServiceRow2_2: Branch of ServiceRow3_2: ServiceNumer1_2: ServiceNumer2_2: ServiceNumer3_2: ServiceNumer1: ServiceNumber2: ServiceNumber3: ServiceNumer1_3: ServiceNumer3_3: ServiceNumer2_3: StateRow1: StateRow3: StateRow2: RelationshipRow1: NameRow1: NameRow3: NameRow4: NameRow5: NameRow6: Occupation2: Occupation3: Occupation4: Occupation5: Occupation6: Telephone6: Applicant Name Last: Entrance2: OffEntrance3: OffRelationship1: Relationship2: Relationship3: Relationship4: Relationship5: Relationship6: NameRow2: Occupation7: Occupation8: Occupation9: Occupation10: Place1: Occupation11: Occupation12: Place2: Place3: Place4: Place5: Place6: Home1: Work1: Work2: Occupation1: Occupation13: Occupation14: Contact1: Contact2: Home2: Home3: Work3: Occupation15: Contact3: Contact4: Contact5: Contact6: Occupation16: Occupation17: Occupation18: Work4: Work5: Work6: Home4: Home5: Home6: NameRow2_2: NameRow2_3: NameRow1_2: NameRow3_3: NameRow1_3: NameRow4_3: NameRow5_3: NameRow1_4: NameRow2_4: NameRow3_4: NameRow4_4: NameRow5_4: Department4: Department5: Telephone1: Telephone2: Telephone3: Telephone5: Telephone4: Organization1: Organization2: Organization3: Driving History: OffDL Suspension: OffDrug Use: OffMarijuana: OffIllegal Drugs: OffDiscipline: OffCertified: OffBackground: OffMilitary Service: OffDischarge: OffSecurity Clearance: OffCourt-martialed: OffCharge1: Charge2: Charge3: Charge4: Charge5: Charge6: Charge7: Charge8: Charge9: Final1: Final2: Final3: Final4: Final5: Final6: Final7: Final8: Final9: Comments2: Comments3: Comments4: Comments5: Comments6: Comments7: Comments8: Comments9: Comments1: Location3: Location4: Location5: Circumstances1: Circumstances2: Circumstances3: Account4: Account5: Account6: Account7: Account8: Account9: Total1: Total2: Total3: Total4: Total5: Total6: Total7: Total8: Total9: Monthly1: Monthly2: Monthly4: Monthly3: Monthly5: Monthly6: Monthly7: Monthly8: Monthly9: Account2: Account3: Major1: Major2: Major3: Credits2: Credits3: Credits4: Credits5: Credits6: Credits8: Credits7: Credits9: Credits10: Credits11: Credits12: Credits13: Credits14: Credits15: Credits16: Credits1: Credits17: Credits18: Credits19: Credits20: Diploma5: Diploma6: Diploma7: Diploma8: Diploma9: Diploma10: Diploma11: Diploma12: Diploma13: Diploma14: Diploma15: Diploma16: Diploma17: Diploma18: Diploma19: Diploma20: Major5: Major6: Major7: Major8: Major4: Major9: Major10: Major11: Major12: Major13: Major16: Major14: Major15: Major17: Major20: Major18: Major19: Department1: Department3: Advisor1: Advisor2: Advisor3: School1: School2: School3: Judicial Action: OffCourt Action: OffFingerprinted: OffPardon: OffContact: OffDeclared: OffGarnishment: OffBankruptcy: OffSavings: OffFormer Name If Applicable: Exceptions to this blanket authorization 1: Exceptions to this blanket authorization 2: 1: 2: Area Code Mobile Telephone: Area Code Home Telephone: Area Code Work Telephone: Birth Date MonthDayYear: CLEAR FORM: Signature Date: Signature Date_2: Signature Date_3: Telephone11: Address7: Address8: Address9: Address10: Address11: NameRow7: NameRow8: NameRow9: NameRow10: NameRow11: NameRow12: State civil service: OffMay We Contact9?: OffMay We Contact8?: OffMay We Contact7?: OffMay We Contact6?: OffMay We Contact?: OffMay We Contact2?: OffMay We Contact3?: OffMay We Contact4?: OffHours Per WeekRow1_2: Hours Per WeekRow1_1: Hours Per WeekRow: DL Status: OffDLH1: DLH2: ChargeLoc1: ChargeLoc2: ChargeLoc3: ChargeLoc4: ChargeLoc5: ChargeLoc6: ChargeLoc7: ChargeLoc8: ChargeLoc9: FamAddress1: FamAddress2: FamAddress3: FamAddress4: FamAddress5: FamAddress6: Diploma1: Diploma2: Diploma3: High School Give Name AND AddressRow1: High School Give Name AND AddressRow2: Address 2: Address 3: Address 4: Address 5: Address 6: Address 7: Address 8: Address 9: Address 10: Address 11: Address 12: Address 13: Address 14: Employer Name and Address If unemployed indicate dates: Supervisor Name and Telephone Where they can be currently contacted: Position Held Duties Reason for Leaving: Employer Name and Address If unemployed indicate dates_2: Supervisor Name and Telephone Where they can be currently contacted_2: Position Held Duties Reason for Leaving_2: Active service: OffActive service2: OffActive service3: OffReserve1: OffReserve2: OffReserve3: OffNGuard1: OffNGuard2: OffNGuard3: OffNGuardMem: OffTelephone7: Telephone8: Telephone9: Telephone10: Department2: InternDept1: InternDept2: InternDept3: ProblemSchool1: Type5: Type4: Org10: 1: 2: 3: 4: 5:

Type10: 1: 2: 3: 4: 5:

Offense1: Age1: Police1: CountyRow1: Police4: Police3: Police2: FPlocation1: Reason1: Reason2: FPLocation2: NameAndAddress1: NameAndAddress2: NameAndAddress3: NameAndAddress4: NameAndAddress5: NameAndAddress6: NameAndAddress7: NameAndAddress8: NameAndAddress9: Account1: Account10: Account11: Account12: AccountType3: AccountType2: AccountType1: Diploma4: VocTechTradeBusiness School Give Name AND AddressRow2: VocTechTradeBusiness School Give Name AND AddressRow3: VocTechTradeBusiness School Give Name AND AddressRow4: VocTechTradeBusiness School Give Name AND AddressRow5: Miscellaneous Education Give Name AND AddressRow2: Brief3: Brief2: Brief1: Problem1: Problem2: Problem3: ProblemSchool3: ProblemSchool2: Resident Street Address Where you can be contacted personally: 2_3: undefined_9: