INSTRUCTIONS TO APPLICANTS
YARMOUTH POLICE DEPARTMENT
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“EXCELLENCE IN POLICING ”
CANDIDATE INFORMATION FORM AND APPLICATION FOR EMPLOYMENT
________________________________
APPLICANT’S NAME (Please Print: Last, First & Middle Initial)
POLICE: PATROL OFFICER
COMPLETE AND RETURN TO:
YARMOUTH POLICE DEPARTMENT
ONE BRAD ERICKSON WAY
WEST YARMOUTH, MA 02673
ATTN: Lt. Michael Bryant
INSTRUCTIONS TO APPLICANTS
1. READ ALL QUESTIONS CAREFULLY BEFORE ANSWERING.
2. RETURN ONLY A COMPLETE APPLICATION, THAT INCLUDES HAVING THE
APPLICATION NOTARIZED, AND COMPLETING AND RETURNING THIS PAGE.
3. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND MAY BE CAUSE FOR
ELIMINATION FROM THE HIRING PROCESS. .
All applications must include supporting documentation. Use the following checklist to indicate which forms you need to return to us. Check off the documents you are including. Copies and photostats are acceptable with the candidate information form, but you should be prepared to produce the original documents once background investigations are started.
( ) 2 PASSPORT SIZE PHOTOGRAPHS REQUIRED
( ) BIRTH CERTIFICATE
( ) MARRIAGE LICENSE
( ) DIVORCE DECREE
( ) CHILDREN’S BIRTH CERTIFICATES
( ) HIGH SHOOL DIPLOMA / GED CERTIFICATE
( ) HIGH SCHOOL TRANSCRIPT
( ) UNDERGRADUATE DEGREE(S)
( ) PREVIOUS YEARS TAX RETURN
( ) GRADUATE DEGREE(S)
( ) ALL COLLEGE TRANSCRIPTS
( ) AWARDS, HONORS, CITATIONS FROM ALL SCHOOLS
( ) ALL SPECIAL LICENSES (Law, Plumbing, Hairdressing, etc.)
( ) VEHICLE OPERATORS LICENSE
( ) HACKNEY OR CHAUFFEURS LICENSE
( ) FIREARMS LICENSE
( ) FIREARMS IDENTIFICATION CARD
( ) DD214
( ) ARMED FORCES ACTIVE ID
( ) ARMED FORCES DISCHARGE
( ) MEMBERSHIP CARDS, ANY CLUB, GROUP OR CIVIC ORGANIZATION
( ) ALL CERTIFICATES AWARDED FOR ANY SPECIAL SKILLS
( ) ALL CERTIFICATES AWARDED FOR COMPLETION OF PROFESSIONAL TRAINING
(includes but not limited to any certificates from any criminal justice training program, EMT certificates, etc.)
( ) ALL REPORTS RELATED TO ANY EMPLOYMENT DISCIPLINARY ACTION OR INTERNAL AFFAIRS INVESTIGATION INCLUDING CONFIDETIAL AGREEMENTS.
I AM APPLYING FOR THE POSITION OF (a separate application is required for each position)
( ) FULL TIME POLICE OFFICER
I am aware that the completed candidate information form and all supporting documentation will become the property of the Yarmouth Police Department, and will not be returned to me. I am also aware that members of the Yarmouth Police Department will be assigned to conduct a thorough background investigation based upon this candidate information form and also based on information and contacts that the investigators may develop on their own. Once I sign written waivers for the background investigators, I am aware that I must notify the Yarmouth Police Department in writing in order to withdraw my name from further consideration and halt the background investigation. I am also aware that if I fail or refuse to sign the waivers, or cooperate with investigators, or to secure the cooperation of any person or organization named in this form, the Yarmouth Police Department need not continue processing my application, and I will not be considered for employment. I understand that any misrepresentations or false statements can result in immediate disqualification.
____________________________________________ __________________________
Candidate Signature Date
____________________________________________
Candidate Printed Name
YARMOUTH POLICE CANDIDATE INFORMATION FORM
INSTRUCTIONS: Type, or print neatly in black ink. All spaces must be filled. Use N/A where the information called for is not applicable. If more space is needed, attach 8 ½ x 11 inch additional pages.
PLEASE NOTE: We may reject any application that is incomplete, contains false or misleading information, or is not notarized on the page provided.
PERSONAL HISTORY
|Full Name: DOB: Age: |
|Social Security # |
|Present Address: |
|(number, street name, apartment #,city, state, ZIP code) |
|Mail Address if different: |
|Home Phone: Work Phone: |
|Cell Phone: Email: |
LIST ALL OTHER NAMES YOU HAVE USED, INCLUDING NICKNAMES AND MAIDEN NAME, AND THE CIRCUMSTANCES IN WHICH THE NAME WAS USED.
| Name |Circumstances |
| | |
| | |
CITIZENSHIP U.S.: YES____ NO:____
( ) SINGLE ( ) WIDOWED
( ) MARRIED DATE OF MARRIAGE _______________ PLACE _______________________________________
( ) DIVORCED DATE OF DIVORCE ________________ PLACE _______________________________________
( ) SEPARATED DATE OF SEPARATION ____________PLACE _______________________________________
COURT GRANTING DIVORCE OR SEPARATION ______________________________________________________
CHILDREN
|Name |Date of Birth |
| | |
| | |
| | |
| | |
CURRENT EMPLOYER
|Name of Company: Phone # |
|Address: Start Date: |
|Immediate Supervisor: Phone # |
|Your Title & Duties: |
| |
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EMPLOYMENT HISTORY
List chronologically all employment that you have had for the last fifteen years, or since your sixteenth birthday, whichever is longest. Include all seasonal and part-time employment. Include and explain all periods of unemployment. All the time in questions must be accounted for.
|Employer #1 |Address |Supervisor Name & Phone # |
| | | |
|Job Title: |Responsibilities: |
|Start Date: |Finish Date: |
|Check Reason for leaving: New Job |Terminated |Seasonal |Retired |Other* |
|Were you terminated or subject to an Internal Investigation? Yes( ) No( ) If yes, explain: |
| |
|Employer #2 |Address |Supervisor Name & Phone # |
| | | |
|Job Title: |Responsibilities: |
|Start Date: |Finish Date: |
|Check Reason for leaving: New Job |Terminated |Seasonal |Retired |Other* |
|Were you terminated or subject to an Internal Investigation? Yes( ) No( ) If yes, explain: |
| |
|Employer #3 |Address |Supervisor Name & Phone # |
| | | |
|Job Title: |Responsibilities: |
|Start Date: |Finish Date: |
|Check Reason for leaving: New Job |Terminated |Seasonal |Retired |Other* |
|Were you terminated or subject to an Internal Investigation? Yes( ) No( ) If yes, explain: |
| |
|Employer #4 |Address |Supervisor Name & Phone # |
| | | |
|Job Title: |Responsibilities: |
|Start Date: |Finish Date: |
|Check Reason for leaving: New Job |Terminated |Seasonal |Retired |Other* |
|Were you terminated or subject to an Internal Investigation? Yes( ) No( ) If yes, explain: |
| |
|Employer #5 |Address |Supervisor Name & Phone # |
| | | |
|Job Title: |Responsibilities: |
|Start Date: |Finish Date: |
|Check Reason for leaving: New Job |Terminated |Seasonal |Retired |Other* |
|Were you terminated or subject to an Internal Investigation? Yes( ) No( ) If yes, explain: |
| |
|Employer #6 |Address |Supervisor Name & Phone # |
| | | |
|Job Title: |Responsibilities: |
|Start Date: |Finish Date: |
|Check Reason for leaving: New Job |Terminated |Seasonal |Retired |Other* |
|Were you terminated or subject to an Internal Investigation? Yes( ) No( ) If yes, explain: |
| |
MILITARY BACKGROUND
Have you ever served on active duty or inactive duty for training in the Armed Forces of the United States:
( ) NO ( ) YES Highest rank attained:____________________ Date of Commission:______________ _
Branch of military service:____________________ Service Number :_______________________________
Dates of active duty: From ___________________ To:__________________________________________
Type of Discharge: __________________________ Basis for discharge:_____________________________
Are you now a member of the Reserve Component? ( ) NO ( ) YES Branch:_______________________
Location of drills or meetings:_______________________________________________________________
Location of Annual Training: _______________________________________________________________
Current Rank:_____________________Duty Assignment:________________________________________
Address of unit or armory:__________________________________________________________________
Phone # of unit:_______________________ Unit Commander:____________________________________
While serving as a member of the Active or Reserve Component of the Armed Forces of the United States, were you the subject of any type of disciplinary action, including so-called “non-judicial” or Article 15, UCMJ, actions?
( ) NO ( ) YES Describe if yes: ________________________________________________________
______________________________________________________________________________________
Have you ever served in the Armed Forces of another country? ( ) NO ( ) YES
If yes, what country? ________________________________________________
EDUCATIONAL BACKGROUND
ALL ENTRIES HERE MUST BE VERIFIED. YOU MUST INLCUDE WITH THIS FORM ALL DIPLOMAS, TRANSCRIPTS AND ATTENDANCE RECORDS CONCERNING ANY SCHOOL YOU HAVE ATTENDED.
|Name of School | Location | Dates | Courses |Degree/Diploma |GPA |
|High School | | | | | |
| | | | | | |
|College | | | | | |
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|Graduate | | | | | |
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|Miscellaneous | | | | | |
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ARE YOU A MEMBER OF THE BAR? ( ) NO ( ) YES, STATE OF __________ ADMITTED ____________
WERE YOU EVER DISMISSED FROM A SCHOOL, OR WAS ANY DISCIPLINARY ACTION (INCLUDING SCHOLASTIC PROBATION) EVER TAKEN AGAINST YOU AT ANY TIME DURING YOUR SCHOLASTIC CAREER? ( ) YES ( ) NO
IF YES, SCHOOL _________________________DATE ___________ ACTION __________________________
EXPLAINATION:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HAVE YOU BEEN INVOLVED IN ANY CAMPUS POLICE OR SCHOOL SECURITY ISSUE SUCH AS VIOLATION OF SCHOOL RULES & REGULATIONS OR DISTURBANCES? Explain:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LIST AWARDS, HONORS, CITATIONS, POSITIONS HELD IN SCHOOL ORGANIZATIONS, ATHLETIC ENDEAVORS, AND ANY OTHER SPECIAL RECOGNITION YOU RECEIVED WHILE IN SCHOOL.
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RESIDENCES
BEGINNING WITH YOUR CURRENT ADDRESS, LIST IN CHRONOLIGICAL ORDER, ALL OF THE PLACES THAT YOU HAVE RESIDED FOR THE PAST TEN YEARS. INCLUDE ALL RESIDENCES WHILE IN SCHOOL OR THE MILITARY.
| From | From | | | |
|Month Year |Month Year |Apt.# & Street Address |City |State/Country |
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Use additional sheets if necessary, follow the same format as above.
HAVE YOU EVER BEEN EVICTED? YES ( ) NO( ) IF YES PROVIDE A DETAILED EXPLANATION ON A SEPARATE PAGE.
LIST ANY SPECIAL ABILITIES, INTERESTS, SPORTS, OR HOBBIES AND YOUR LEVEL OF ROFICIENCY.
|Subject | Level |
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FOREIGN LANGUAGE
INDICATE YOUR PROFICIENCY IN EACH PHASE OF ANY FOREIGN LANGUAGE. RATE YOURSELF AS
“SLIGHT”, “GOOD”, OR “FLUENT”.
| Language | Speak | Understand | Read |Write |
| | | | | |
| | | | | |
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REFERENCES
List three (3) references. These references can not be former or present employers, fellow employees, school teachers, or school officials. They must be responsible members of good repute in the community. They should be people that have known you personally for at least the last five years. Do not list relatives. If the reference is retired, list their former occupation. Address must include number, street, city, state, and ZIP code.
| |Name: |Home Address: |Home/Cell Phone: |
|1 | | | |
| |Occupation: |Business Address: |Work Phone: |
| | | | |
| | |Email Address: | |
| |Name: |Home Address: |Home/Cell Phone: |
|2 | | | |
| |Occupation: |Business Address: |Work Phone: |
| | | | |
| | |Email Address: | |
| |Name: | |Home /Cell Phone: |
|3 | | | |
| |Occupation: |Business Address: |Work Phone: |
| | | | |
| | |Email Address: | |
SOCIAL REFERENCES
List three (3) social references in your own age group. Include members of both sexes. Do not list relatives, past or current roommates. You should list people that have known you for the past two years or more.
| |Name: |Home Address: |Home/Cell Phone: |
|1 | | | |
| |Occupation: |Business Address: |Work Phone: |
| | | | |
| | |Email Address: | |
| |Name: |Home Address: |Home/Cell Phone: |
|2 | | | |
| |Occupation: |Business Address: |Work Phone: |
| | | | |
| | |Email Address: | |
| |Name: |Home Address: |Home/Cell Phone: |
|3 | | | |
| |Occupation: |Business Address: |Work Phone: |
| | | | |
| | |Email Address: | |
FOREIGN TRAVEL
Have you ever visited or resided in any foreign country, including any travel in the Armed Forces? ( ) NO ( ) YES
Passport number: _____________________Date Issued: __________________________________
Place passport issued:_______________________________________________________________
|Country Visited | From | To | Reason |
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CREDIT REPORT
|Has your credit record ever been considered unsatisfactory, or has your application for credit ever been refused? |
|Yes ( ) No ( ) If yes , explain: |
|Are you indebted to anyone? | | |
|Creditor | Amount Borrowed | Balance |
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CRIMINAL RECORD
Have you ever been convicted as an adult of a misdemeanor within the last five (5) years?
No ( ) Yes ( ) If Yes explain:_________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been convicted as an adult of a felony offense? No ( ) Yes ( ) Explain if yes:_________________ ____________________________________________________________________________________________
Has any member of your family (including in-laws) or a close relative ever been convicted of any offense other than traffic violations? No ( ) Yes ( ) Explain if yes:______________________________________ __________________________________________________________________________
ORGANIZATIONAL MEMBERSHIP
List below your memberships, past and present, in any club, society, or organization.
|Name of Organization |City, State |Position in Organization |
| | | |
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Are you now, or have you ever been, a member of any organization advocating the overthrow of our democracy? No( ) Yes ( ) Explain if yes: ________________________________________________________________________
______________________________________________________________________________________________
Are you now, or have you ever been, a member of any club, society, or organization that advocated the denial of any rights group based on that groups race, color, creed, sex, or national origin? No( ) Yes ( ) Explain if yes:__________________________________________________________________________________________
RELATIVES
|Father: |Occupation: |
|Address: |DOB: |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Mother: |Occupation: |
|Address: |DOB: |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Sibling: |Occupation: |
|Address: |DOB: |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Sibling: |Occupation: |
|Address: |DOB: |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Sibling: |Occupation: |
|Address: |DOB: |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Sibling: |Occupation: |
|Address: |DOB: |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
Current/Former Significant Other
Go back ten years and include all marriages regardless of time:
|Name: |Occupation: |
|Relationship: Former Spouse( ) |Current Girl/Boyfriend ( ) Former Girl/Boyfriend ( ) |
|Maiden Name: |Dates of Relationship: From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Name: |Occupation: |
|Relationship: Former Spouse( ) |Current Girl/Boyfriend ( ) Former Girl/Boyfriend ( ) |
|Maiden Name: |Dates of Relationship: From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Name: |Occupation: |
|Relationship: Former Spouse( ) |Current Girl/Boyfriend ( ) Former Girl/Boyfriend ( ) |
|Maiden Name: |Dates of Relationship: From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Name: |Occupation: |
|Relationship: Former Spouse( ) |Current Girl/Boyfriend ( ) Former Girl/Boyfriend ( ) |
|Maiden Name: |Dates of Relationship: From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
Other relatives or persons with whom you have resided for more than thirty days.
|Name: |Occupation: |
|Relationship: | Dates Lived Together: |
|Maiden Name: |From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Name: |Occupation: |
|Relationship: | Dates Lived Together: |
|Maiden Name: |From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
|Name: |Occupation: |
|Relationship: | Dates Lived Together: |
|Maiden Name: |From: To: |
|Address: |DOB: SS# |
| |Birth Place: |
|Phone: Cell Phone: |Email: |
**Add pages for additional persons in all categories.
LICENSES
Have you ever been issued any of the following types of licenses?
❑ License to Carry State: ________ Number: ___________________
❑ Firearms Identification Card State: _________ Number: ___________________
❑ Drivers License State: ________ Number: ___________________
❑ Private Investigator State: ________ Number: ___________________
❑ Hackney State: ________ Type: ___________________
Have any of these licenses ever been suspended or revoked in this or any other State?
No ( ) Yes ( ) If yes, explain. _____________________________________
CIVIL INVOLVEMENTS
Have you ever been sued or had your wages garnished? No ( ) Yes ( ) If yes, explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you now, or have you ever been, a party in a civil or equity lawsuit? No ( ) Yes ( )
If yes, please explain, including the name of the suit, the court in which it is/was heard, and the outcome.
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
Have you ever witnessed a crime, been a suspect in a crime or testified in court? No ( ) Yes ( ) If yes , explain:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
POLICE TRAINING
|TRAINING |LOCATION |DATE |
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POLICE EMPLOYMENT & TESTING
Are you now or ever been an applicant for any other police/investigative position? ( ) NO ( ) YES If yes, where have you applied and what is the status of that application?
| Organization | Date | Status |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
| | |Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ |
| | |Expired List:___ Did not make list:___ Application completed:___ |
POLICE OFFICER DISCIPLINE
Have you ever been subject to an internal investigation or received any type of discipline from your current department or any department in the past? YES: ( ) NO: ( )
If yes, please provide a brief description of the event or events and attach any related documents, whether or not there has been any confidential settlement:
1.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please produce any documentation related to the investigation or discipline.
I, ___________________, understand that all appointments are probationary for a period of twelve months following my successful completion of an approved police academy. I understand that during that twelve month period, I must demonstrate my fitness for continued employment by the Yarmouth Police Department. I understand that I will be required to complete an employment contract with the Yarmouth Police Department that will require me to reimburse the Police Department for the expenses of my hiring and training if I terminate my employment within three years of my initial appointment. I also understand that it has been necessary to establish regular night and midnight shifts and that I must be available for these shifts as the department’s needs might require. I understand that I may be compelled to work beyond my regular work schedule if the departments needs require. I further understand that any appointment tendered me will be contingent upon the complete evaluation of my character and fitness, and an investigation of my background.
I understand that willfully withholding information, or making false statements on this application will be the basis for my dismissal from the Yarmouth Police Department hiring process and future employment. I agree to these conditions and I hereby certify that all statements made by me on this application are true and complete, to the best of my knowledge. I am further aware that I will not be tenured in my position until I have completed three years of service, and have been recommended for it. I understand that I must reside within 15 miles of the town of Yarmouth or I can be terminated at any time.
_______________________________________ ________________
Signature Date
AUTHORITY FOR RELEASE OF INFORMATION
I, __________________________________, born on ________________________, and having filed an application for employment with the Yarmouth Police Department, consent to having an investigation made as to my moral character, reputation, and fitness for the position for which I have applied, and such information as may be received by or reported to the Yarmouth Police Department, the Yarmouth Town Administrator, or the Yarmouth Board of Selectmen. I agree to give any further information that may be required in reference to my past record.
I also authorize and request every person, firm, company, corporation, governmental agency, court, association or institution having control of any documents, records, and any other information pertaining to me to furnish to the Yarmouth Police Department any such information, including but not limited to, consumer credit investigative reports, documents, records, files regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, and to permit the Yarmouth Police Department or any of its agents or representatives to inspect and make copies of such documents, records, and other information. I also authorize the release of any internal investigations and results said investigations regardless of any confidential agreements I have entered into with any employer, past or present.
I hereby release, discharge, and exonerate the Yarmouth Police Department, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information during the investigations made by or on the behalf of the Yarmouth Police Department.
A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature.
This authority shall continue for three years from the date indicated under my signature unless sooner revoked in writing by me.
__________________________________ ________________________________
Applicant Signature Witness
__________________________________
Date
__________________________________
Social Security Number
Notary Public’s Seal
Commonwealth of Massachusetts: County of _________________
I, _________________________, being duly sworn, depose and say I am the above named person. I signed the foregoing statement. Personally read and typed or printed by hand the answers to each and every question therein and I do solemnly swear that each and every answer is full, true, and correct in every respect.
___________________________
Candidate Signature
Sworn to before me, this _____ day of _________________, 20__
_________________________________________
Notary Public or Commissioner of Deeds
Seal
Do not sign below until directed by Notary
______________________________
Candidate Sign Here
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