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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