Personal Data
BACKGROUND EMPLOYMENT PACKET
As an applicant for employment as a Police Officer with the Tomah Police Department, you are being asked to provide information about yourself. The purpose of this request for information is to obtain information about you to permit the Department to thoroughly analyze your qualifications and suitability for employment with us. Attached is an Authorization for Release of Information form. The sources listed will be contacted only for the purposes listed above.
The authorization for information, which you sign, and the data you provide, may be conveyed to a third party. To the extent they disclose private information, they will be disclosed only to the extent that is necessary to complete the employment investigation.
I have read and understand the above.
__________________________________________
Signature Date
PERSONAL DATA
1. What is your full name?
______________________________________________________________________
2. What is your current address (Street, City, State, Zip)?
_____________________________________________________________________
3. What is your telephone number?
_____________________________________________________________________
4. Date of Birth: ___/___/___ Age:______ Sex: _____
Height: ______ Weight: ______ Hair: ______ Eyes:_____
5. Social Security Number: _________________________
6. Where were you born? (City, State, Zip)
_______________________________________________________________________
Updated 2-14-14
RESIDENCE
7. How long have you resided at your current address?
_______________
Do you own or rent? If you rent list the owners name and telephone number.
_______________________________________________________________________
8. Other than your spouse or parents with whom do you reside with? (name, DOB, occupation)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
List his or her place of employment, employment address, and phone number:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
9. In chronological order, state each and every place in which you have lived during the past ten years, beginning with your present address. Include all addresses while you were in school and the military.
Date Address/City/State Owner of Residence Phone Number _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
FAMILY RELATIONSHIPS
10. Were you ever the parent of any children (including deceased children)?
_____Yes ______No
11. List the children below (include adopted and step children):
Name DOB With whom and where does the child reside
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
12. Provide the following for your father, mother, sister, brother, and spouse/significant other:
Type Name DOB Address Phone Number
Father__________________________________________________________________
Mother_________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Additional Information on the above relatives:
Name Occupation Employment Address Employment Phone #
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
KNOWN ASSOCIATES
13. List the names of four Friends and/or associates. Do not include former employers or school teachers.
Name _______________________ Name ____________________________
Address _______________________ Address___________________________
_______________________ __________________________
DOB _________ DOB ____________
Home Phone ___________________ Home Phone _______________________
Occupation_____________________ Occupation ________________________
Employer ______________________ Employer __________________________
Work Phone ____________________ Work Phone ________________________
Name ________________________ Name _____________________________
Address ______________________ Address___________________________
______________________ ___________________________
DOB _________ DOB ____________
Home Phone __________________ Home Phone _______________________
Occupation_____________________ Occupation ________________________
Employer _____________________ Employer __________________________
Work Phone ____________________ Work Phone ________________________
14. List the names of four people with whom you are acquainted who’s employment is affiliated with Law Enforcement. This may include police officers, jailers, dispatchers, judges, attorneys, etc…
Name _______________________ Name __________________________
Address _____________________ Address_________________________
____________________ ________________________
DOB _________ DOB ____________
Home Phone __________________ Home Phone _____________________
Occupation_____________________ Occupation _______________________
Employer _____________________ Employer _______________________
Work Phone ____________________ Work Phone ______________________
Name ________________________ Name _____________________________
Address ______________________ Address____________________________
______________________ ___________________________
DOB _________ DOB ____________
Home Phone __________________ Home Phone _________________________
Occupation______________________ Occupation __________________________
Employer _____________________ Employer ___________________________
Work Phone ____________________ Work Phone _________________________
EDUCATION
15. List chronologically (earliest dates first) all schools and colleges you have attended:
Name of school and address From M/Y to M/Y Type of Degree
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
16. What college degree(s) do you possess:
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Undergraduate Major in __________________________________
Cumulative Grade Point Average ___________________________
Total credits achieved towards degree _______________________
17. Other than English, what languages do you:
Speak _____________ _____________ _____________ ______________
Understand ________________ _______________ ___________ _______________
18. List any problems with school such absenteeism, tardiness, poor grades, or other disciplinary problems.
Date School Problem and Explanation
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
19. It is understood that I will immediately forward transcripts from all high schools and colleges attended to the Tomah Police Department at 805 Superior Ave, Tomah, WI 54660. The applicant must forward the proper fee to the high school or college.
20. List all awards received from High School or College:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
21. List any other certificates or training that you have achieved which you feel will assist you in your career (radar, intoximeter, DAAT instructor, EVOC instructor, DARE instructor, etc..).
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MILITARY AND SELECTIVE SERVICE
22. If you are a male and were born after 1960, have you registered with the Selective Service? _____ Yes ______ No
If yes, provide Selective Service Number: ___________________
If no, please explain why: ____________________________________________________________________________________________________________________________________________
23. Have you ever served in an active military organization of the United States (excluding active duty related to training for the Reserves or National Guards)? _____ Yes ____No
If yes, give details:
Branch of Service Military Specialty Rank Held Commanding Officer at Discharge
______________________________________________________________________________________________________________________________________________
24. How many periods of active military service have you had (drafts, enlistments, recalls)?
___________________
25. Give period or periods of active service:
From _______________ To________________
From _______________ To ________________
From _______________ To ________________
26. Are you now or were you ever an active or inactive member of the Reserve or National Guard Forces? ______ Yes _______No
If yes, state which(active or inactive):________________
Branch____________ Regiment _____________ Unit___________________________
Rank______________ Address_____________________________________________
Commanding Officer ______________________ Dates of Service _________________
27. How many discharges or separations from the service were given to you?
Discharges _____________ Separations ____________
28. What is the type of your discharge(s) or separation(s):(honorable, dishonorable, honorable conditions, medical, etc.) Be exact.
Type ____________ Reason_______________________________________________
Type ____________ Reason_______________________________________________
29. Has your discharge or separation notice ever been corrected or changed?
_______Yes ______No
What was the nature of the change? Changed from _________________ to__________
30. Where you ever court marshaled, tried or charged, or were you the subject of a summary court, deck court, captain’s mast, company punishment, or any other disciplinary action?
______Yes _______No
If yes, how many times? ________
Give details of charges, agency concerned, dates, and dispositions.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
31. List all medals and decorations awarded to you as a member of the armed forces:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
32. Have you ever served in any military type organizations or any other associations other than those listed above?
______Yes _______No
Give details:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
EMPLOYMENT HISTORY
33. Present Employer:__________________________________________
Address: ____________________________________Telephone:__________________
Immediate Supervisor:_________________________ Home Phone:________________
Title:__________________________ Job Duties Include:_________________________
______________________________________________________________________________________________________________________________________________
Can your current employer be contacted? ______Yes ______No If no, please explain:
_______________________________________________________________________
34. List below chronologically earliest dates first, each and every place you were previously employed since the age of 16. Omit nothing. Include all full time and part time employment. Include dates of unemployment.
From To Employer/Business Name Job Title
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
35. From the list created in question #34 provide the following information:
Employer: ________________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include:_________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
Employer: _______________________________________ Full/Part Time __________
Address: ____________________________________Telephone: __________________
Immediate Supervisor: _________________________ Home Phone: _______________
Title: __________________________ Job Duties Include: ________________________
_______________________________________________________________________Reason for Leaving: ______________________________________________________
36. Provide the names of four co-workers that you are currently working with. If you are not currently working provide the names of four co-workers from you last employment.
Name _______________________ Name __________________________
Address _____________________ Address_________________________
____________________ ________________________
DOB _________ DOB ____________
Home Phone __________________ Home Phone _____________________
Occupation_____________________ Occupation _______________________
Employer _____________________ Employer _______________________
Work Phone ____________________ Work Phone ______________________
Name ________________________ Name _____________________________
Address ______________________ Address____________________________
______________________ ___________________________
DOB _________ DOB ____________
Home Phone __________________ Home Phone _________________________
Occupation______________________ Occupation __________________________
Employer _____________________ Employer ___________________________
Work Phone ____________________ Work Phone _________________________
37. Were you ever discharged or asked to resign from employment? _____Yes _____No
If yes, please complete the following:
Employer Date Left Reason for Leaving
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
38. Were you ever subjected to disciplinary action in connection with any employment?
______ Yes _______No If yes, give details: ______________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
39. Have you, or any corporation or partnership, of which you were an officer, director, or partner, ever possessed a license or permit (excluding driver’s license or learner’s permit) issued by a governmental agency? ______ Yes ________No If yes, give details:
______________________________________________________________________________________________________________________________________________
40. Have you ever possessed a professional or occupational license, permit, or certificate (including Certified Police Officer)? ______Yes ________No If yes, give details:
______________________________________________________________________________________________________________________________________________
41. Has any license or permit (excluding driver’s license or learner’s permit) issued by any city, state, or federal agency ever been denied, revoked, suspended, or cancelled to you or to any corporation or partnership of which you were an officer, director, or partner?
______ Yes _______No If yes, give details: _________________________________
______________________________________________________________________
42. Are you now engaged in any business as an owner (active or silent, partner, stockholder, or corporate member? _______Yes ______ No If yes, give details:
______________________________________________________________________________________________________________________________________________
43. Have you ever received unemployment insurance or other federal, state, or local benefits or assistance? ______Yes ________No If yes, complete the following:
What kind?_____________________________________________________________
Local Office (include address):______________________________________________
Date from and to that benefits or assistance was received:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
44. Have you made application with this or any other police organization? ____Yes ____No
If yes, complete the following:
When Organization Rejected Y/N Current status
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
45. List below every professional or social organization in which you are or were a member?
From To Organization and Address Type of Organization
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________
MEDICAL HISTORY
46. List below your personal physician, other physician, psychiatrists or psychologists that you have ever consulted:
Name Address Phone Number
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
47. Do you wear contact lenses or glasses? _____ Yes _____No If yes, give details:
______________________________________________________________________________________________________________________________________________
48. Do you currently use, or have you used with in the last 2 years, narcotics, marijuana, barbiturates, sleeping pills, etc..?
______ Yes _______ No If yes, give details: ___________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
49. Do you currently use alcoholic beverages? _____ Yes ______No
If yes, give extent and details: _______________________________________________
______________________________________________________________________________________________________________________________________________
FINANCIAL HISTORY
50. Have you any garnishment, wage assignment or judgments pending against you?
_______ Yes _______No If yes, give details:
Type With whom (Name/Address) When Present Amount Amount in Arrears
_______________________________________________________________________
51. Have you ever received a student loan from a governmental or private agency?
_______Yes ________No If yes, give details: _________________________________
_______________________________________________________________________
Have you ever defaulted on this loan? ______Yes ______No If yes, please explain:
_______________________________________________________________________
52. Have you ever been bonded? ______Yes _______No If yes, with respect to each time bonded state details:
Date By whom (Name/Address) Reason for Bonding
______________________________________________________________________________________________________________________________________________
53. Have you ever been refused a bond? _____Yes ______No If yes, by whom and why?
______________________________________________________________________________________________________________________________________________
54. What is your present salary or wage? _______/hour ________/year
55. Do you have any income from any source other than your principal occupation?
_____Yes ______No If yes, how much? ____________ How often? ______________ Source of that income? ___________________
56. Do you own any real estate? ______Yes _______No
If yes, what is the value? ______________ What is the location?___________________
_______________________________________________________________________
57. Do you own any bonds, governmental or other? _______Yes _______No
If yes, what is the value? ___________________________________________________
58. Do you own any corporate stock? ______Yes ______No Value? _______________
59. Do you have a savings account? ______Yes ______No If yes, complete the following:
Bank/Address Telephone Account # Balance
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
60. Do you have money market accounts? ______Yes ______No If yes, complete the following:
Bank/Address Telephone Account # Balance
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
61. Do you have any checking accounts? _____Yes ______No If yes, complete the following:
Bank/Address Telephone Account # Balance
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
62. Financial Obligations. Give the following information on all 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 any other debts and payments.
Type Name/Address Account # Balance Monthly payment
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Type Name/Address Account # Balance Monthly payment ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LITIGATION HISTORY
63. Were you ever a party to a civil action or proceeding in this state or elsewhere, or have you been named in a notice of claim that you may be a defendant in a civil action or proceeding? ______ Yes ________No If yes, indicate below every civil action, excluding civil law violations.
Date Type Plaintiff, Respondent, or Defendant Disposition
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
64. Have you ever been named as a defendant in a criminal proceeding?
_____Yes ______No If yes, give details?
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
65. Have you ever been arrested, convicted, or adjudicated for any violation of criminal law or civil law excluding traffic or parking tickets? ______Yes ______No If yes, provide the following information:
Date Violation Location Disposition Age Police Agency
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
66. Have you ever been fingerprinted (exclude only the present application process with this department)? ______Yes _______No If yes, provide the following:
When Where Reason
______________________________________________________________________________________________________________________________________________
MOTOR VEHICLE & DRIVERS LICENSE HISTORY
67. Have you ever received a summons for a violation of the traffic laws in this state or any other state (exclude parking violations)? ______Yes _______No
If yes, please provide the following information:
Date Offense Disposition Age Police Agency/Location
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
68. Do you or have you ever possessed a Wisconsin Driver’s License? _____Yes _____No
Driver’s License Number:__________________ Type ___________________________
69. Do you or have you ever possessed a Driver’s License issued by another state?
_______Yes _______No
Name of State:_____________________
Type:_____________________ Drivers License Number: ___________________
70. Was your current driver’s license or any other driver’s license ever revoked?
________Yes _______No Suspended? _______Yes _______No
If you answered yes to either one of the above, complete the following:
Which license? ____________________________ When?_________________
Where?___________________________
Why?__________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
71. Have you ever been involved in a motor vehicle accident? _____Yes ______No
If yes, state details:______________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
72. List all motor vehicles which you own, jointly own, or which you drive on a regular basis.
License Plate Number State Where Vehicle is Registered
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
73. List the name and address of your auto Insurance Company:
Name:________________________________________
Address: _________________________________________________
74. Has your auto insurance ever been cancelled or have you ever been refused auto insurance? ______Yes _______No If yes, give details: ______________________
______________________________________________________________________________________________________________________________________________
75. Enclose a certified copy of your birth certificate.
76. Enclose a recent, colored, photograph of yourself.
I certify that all of the statements by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that any false information or omission of information from this application may be cause for rejection, or later dismissal if I am later employed.
_________________________________________ __________________
Signature of Applicant Date
TOMAH POLICE DEPARTMENT
CHIEF MARK D. NICHOLSON
805 Superior Avenue
Tomah, Wisconsin 54660
[pic]
Telephone (608)374-7400
Fax (608)374-7413
Authorization for Release of Information
EMPLOYING AGENCY
(For official use only, not to be released to unauthorized person)
I hereby empower an employee of the Tomah Police Department or other authorized representative bearing this release to, within one year of its date, obtain information and records pertaining to me from any or all of the following sources:
1. Selective Service System or any branch of the Military Service
2. Any banking institution
3. Any place of business (for purposes of obtaining credit or employment data)
4. Credit rating bureaus or institutions maintaining individual credit rating files
5. Any previous employer (for the purpose of obtaining personnel file, evaluation file, hiring file, disciplinary file or any other file related to employment or dismissal of employment)
6. Present employer (for the purpose of obtaining personnel file, evaluation file, hiring file, disciplinary file or any other files related to employment)
7. Any business or institution which possess documents related to past employment or hiring processes
8. Any school, college, university or other educational institution
9. Any office, clinic, sanatorium, or hospital where illnesses, injuries, and/or deterioration (physical and/or mental in nature) are diagnosed and treated
10. Any person the Department chooses to interview concerning my reputation
I hereby release any individual or institution, including its officers, employees, or related personnel, both individually and collectively, from any and all 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.
I understand that a failure to sign this form will result in my exclusion from this hiring process. I further understand that the background investigation completed on me will not be made available to me for any reason.
A photocopy of this release will be as valid as an original.
________________ __________________________________________
Date Signature
__________________________________________
Printed Name
__________________________________________
Address
________________ __________________________________________
Date Witness
................
................
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