Revised 02 / 2022 CHIEFLAND POLICE DEPARTMENT LAW ENFORCEMENT EMPLOYMENT APPLICATION FORM The Chiefland Police Department is an Equal Employment Opportunity Employer. We consider applicants for all positions without regard to race, color, national origin, sex, age, disability, marital status, religion or any other legally protected status. NOTICE: The following additional documents must be attached to this application: 1 . A certified copy of birth certificate 2. A certified copy of high school diploma or Florida Police Standards approved G.E.D. 3. A copy of military discharge(s). LEVY COUNTY CHIEFLAND, FLORIDA POSITION APPLYING FOR: D Police Officer D Reserve Officer DATE:---------- - --- D Full Time Officer D Part Time Officer INStRUGlit·Q_NS Application must be typewritten or printed legibly in ink. All questions must be answered. Applications which are not complete will not be considered. If space provided is not sufficient for complete answers or you wish to furnish additional information, attach sheets of the same size as this application, and number answers to correspond with questions. I understand that the submission of this application for sponsorship to a law enforcement academy does not constitute an application for employment or appointment with the sponsor-law enforcement agency. Moreover, I understand this law enforcement agency is under no obligation to sponsor me as a candidate for any law enforcement training program. 1. Full Name: Last Name Flrst Middle Abbv. 2. Other: List all other names you have used including circumstances and time periods you used them. (For example: maiden name, former name(s), alias(es), or nickname(s). Dates From Dates To Name Circumstance Mo./Yr. Mo./Yr. I 3. Date and Place of Birth: Date of Birth City 4. Are you a United States citizen? If naturalized, please provide: Court 5. Marital Status: D Married Date D Yes County D D Divorced No D Separated State Country (if not the United States) Place Naluralization No. D Widowed D Never Married 6. Do you have or have you ever applied for a passport? D Yes D No Passport No. ______ _ _ _ 7. Height: _________ Weight: _________ _ Dates Attended High School Mo./Yr. Years Did You Type of 1. Name/Address From To Completed Graduate? Diploma Dates Attended Credit Hours *College/University Mo./Yr. Earned Did You Type of 2. Name/Address From To Qtr. Sem. Graduate? Degree •Attach diploma or official transcript from last institution of higher education attended. Major _ _ ____________ _ __ _ Minor _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ _ 3. Other Schools (Trade, Vocational, Business or Military): Dates Attended Mo./Yr. Name/Address From Credit Hours To Earned Area of Did You Type of Degree Study Graduate? or Certificate .c PERSONAL REFERENCES ·& AC.QUAINTANCES ' ' ' .I 1. Personal References: Give three (3) references (not relatives, former or present empoyers, fellow employees, or school teachers) who are responsible adults of reputable standing in their communities, such as property owners, business or professional men or women, who have known you well for the past five (5) years. If retired, give former occupation. Complete Name Home Address: City & State: (Last, First, Middle) Home Phone: ( ) Yrs. Acq. Occupation Business Address: City & State: Business Phone: ( ) Complete Name Home Address: City & State: (Last, First, Middle) Home Phone: ( ) Yrs. Acq. Occupation Business Address: City & State: Business Phone: ( ) Complete Name Home Address: City & State: (last, First, Middle) Home Phone: ( ) Yrs. Acq. Occupation Business Address: City & State: Business Phone: ( ) Social Acquaintances: Give three (3) social acquaintances in your own age group (including both sexes) who have known you well for the past five (5) years. Complete Name Home Address: City & State: (Last, First, Middle) Home Phone: ( ) Yrs. Acq. Occupation Business Address: City & State: Business Phone: ( ) Complete Name Home Address: City & State: (Last, First, Middle) Home Phone: ( ) Yrs. Acq. Occupation Business Address: City & State: Business Phone: ( ) Complete Name Home Address: City & State: (Last, First, Middle) Home Phone: ( ) Yrs. Acq. Occupation Business Address: City & State: Business Phone: ( ) ORGANIZATION MEMBERSHIP 1 . List all clubs, societies of which you are or have been a member: Present Name City & State Former (list position held & describe activity) 2. Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group or combination of persons which has adopted, or shows a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the constitution of the United States, or which seeks to alter the form of government of the United States by unconstitutional means? D Yes D No 3. Have you ever made a financial or other material contribution to any organization of the type described in question #2 above? D Yes D No If yes to question #2 or #3, answer questions #4 and #5 also. 4. At the time of your membership, participation, or contribution, did you know of any unlawful aims of the organization? D Yes D No 5. Did you intend to promote any unlawful aims of the organization? D Yes D No If yes to question #2, #3, #4, or #5, explain including name of organization and location. 1. Do you or have you ever owned any stock or interest in any firm, partnership or corporation dealing wholly or partly in the sale or distribution of alcoholic beverages? D Yes D No 2·. Are you now issued or have you ever been issued a license to engage in a business or profession? D Yes D No 3. Was license ever cancelled, suspended or revoked? D Yes D No If yes to question #1, #2 or #3, please provide details including the type of license or certificate, the agency that issued the license, effective date of license and license number. z Cl 0 Cl z 0 <( <( Cl ca THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL AND WILL NOT BE MADE AVAILABLE FOR PUBLIC INSPECTION. 1. Applicant's Current Address: Address Cily Telephone Number 2. Applicant's Social Security Number: 3. Spouse's Name and Address (if different): Name Address City 4. Children's Names and Ages: Name 5. Former Spouse(s) Name and Address: Name Address City County State County State Age Address (if different) County State Zip Code Zip Code Zip Code 6. Are you now able to participate with or without accommodation in defensive tactics, firearms or physical training, operation of a motor vehicle, or otherwise perform the duties set forth in the job description or task analysis related to the position for which you applied? D Yes O No 7. This position may require a physical agility test, if such a test or examination is required, would you be able to take this test or examination with or without an accommodation? 0 Yes O No 8. Explain what accommodation(s) you would need to perform these tasks or take the test or examination. f?ERSONA .. LIN'QUIRY WAIVER Authority for Re1ease of lnftJrmation TO: Concerned Person or Authorized Representative of Any Organization, Institution or Repository of Records APPLICANT'S NAME: ________________ DATE OF BIRTH:__ _ ______________ SOCIAL SECURITY NO.: _______________ I respectfully request and authorize you to furnish the Chiefland Police Department any and all information that you may have concerning my work record, school record, military record, reputation, and financial and credit all status. Please include any and all reports including all information of a confidential or privileged nature, and photostats of same, if requested. This information is to be used to assist in determining my qualifications and fitness for the position I am seeking with the Chiefland Police Department. I hereby release you, your organization or others from any liability or damage which may result form furnishing the information requested above. Applicant's Signature Date Address City State Zip Code AFFIDAVIT STATE OF FLORIDA COUNTY OF------- Subscribed and sworn to (or affirmed) before me on _______ (date) by _____________ (name of affiant). He/She is personally known to me or has presented (type of identification) as identification. Signature ---------------------- Name----------------------- Title ------ - ---- - ----------- Commission No.:-------- Expires:--------