Gillespie Police Department

Employment Application

Gillespie Police Department

Personal History Form 109 W. Pine Street Gillespie, IL 62033

Warning Any misrepresentation, falsification, omission or concealment of a material fact will subject the applicant to disqualification and may subject the applicant to discharge if discovered subsequent to employment. 1. Are you willing to submit to an Administrative Interview and/or a polygraph examination to verify all information supplied in this Personal History Form?

Full Name

First

Middle

Last

Date of Birth

Social Security Number

Home Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Present Height

Weight

Eye Color

Hair Color

Place of Birth

City

County

State

Country

List all other names used (adoption, legal name change, alias, maiden, nickname, etc).

Residence History

List each and every place you have resided since your first year of high school, including all college, military, or other temporary address. Begin with your present address and work back. Please add the full address and dates of residency.

Are you, currently or formerly, related to or associated with any individual who has a criminal history?

Employment History

List each and every place you have been employed since you began working, including full and part time jobs, internships, and military service. Start with your present job and work back. Omit none. For some applicants this is not difficult. For those with long employment histories, more effort is required, such as taking time to draft a list from memory, ask help from family members, obtain copies of previous applications on which you have listed prior appointments, etc. Some applicants may be tempted to skip employment for which they have difficulty in recalling dates and addresses. This is a big mistake. The background investigation includes review of Social Security records, which are very complete. Law enforcement employers are particularly interested in hiring people who are capable of making honest, accurate and complete disclosures –and avoiding those who are not capable of doing so. Omissions are grounds for disqualification. You must provide the full, accurate, current address for each employer, and show any dates of unemployment or military service within the sequence. Please do not use vague terms such as “Personal Reasons” when giving your reasons for leaving a job. Use more specific terms such as “Fired, Asked to Resign, Voluntarily Resigned, Laid Off, Better Pay etc.”

Employer 1

Employer Name

Hire Date

End Date

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor Name

First

Last

Supervisor Email

Phone

Position

Reason for Leaving

Employer 2

Employer Name

Hire date

End Date

Employer Address (copy)

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor Name

First

Last

Supervisor Email

Position

Reason for Leaving

Employer 3

Employer Name

First

Last

Hire Date

End Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor Name

First

Last

Supervisor Email

Position

Reason for Leaving

Employer 4

Employer Name

First

Last

Hire Date

End Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor Name

First

Last

Supervisor Email

Position

Reason for Leaving

Employer 5

Employer Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Hire date

End Date

Supervisor Name

First

Last

Phone

Supervisor Email

Reason for Leaving

Position

Employer 6

Employer Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Hire date

End date

Supervisor Name

First

Last

Phone

Supervisor Email

Reason for Leaving

Position

If you have a longer employment history, please use the file attachment option to attach any additional page with the information following the same format.

Drag & Drop Files, Choose Files to Upload

Military Information

Have you ever served in the Armed Forces of the Untied State or a foreign military service?

Service Record 1

From

Service Number

Branch

Last Rank

Discharge Type

Service Record 2

From

Service Number

Branch

Last Rank

Discharge Type

Service Record 3

From

Service Number

Branch

Last Rank

Discharge Type

If you did serve in the military, were you ever court-martialed, tried on charges, given a Captain’s Mast, punished under Article 15, or the subject of a summary court or other military discipline?

Have you ever been discharged or asked to resign from employment or the military?

Employment Discipline History

Were you ever the subject of any disciplinary action or inquiry of any kind by an employer (including verbal counseling, written warning, reprimand, suspension, or loss of pay) or the subject of an Internal Affairs investigation for violation of a rule?

Applicant History

Have you ever been arrested, issued a summons or Notice to Appear (other than traffic), taken into custody, questioned or investigated concerning any criminal violation (felony or misdemeanor)?

List ALL drivers’ licenses you have held in any state. Start with the current license and work back, include the State, License Number, Date Issued & if Still Valid?

List ALL traffic violations in any state at any age, include the Date, City & State, Police Agency, Charge/Violation & Disposition

Have you ever tried, used, or experimented with Marijuana, Hashish, or THC?

Have you ever illegally tried, used, possessed, sold, delivered, transported or experimented with ANY illegal drug including: Methamphetamine, Cocaine, Crack, Heroin, Methadone, Inhalants, LSD, Ecstasy, Codeine, Morphine, Painkillers, PCP, Steroids, etc.?

Have you ever applied for any other law enforcement position?

Please indicate whether you Graduated High School or obtained a GED

Please indicate the date & Name/Address of Institution which provided Diploma or GED

Do you speak any language in addition to English?

List all colleges or universities you have attended, please list all Dates, Institution Name, Graduate, & Degree

List any professional licenses or certifications, please list all Dates, Institution Name & Type of License or Certification

Please list ALL debts that you currently owe (credit cards, charge accounts, mortgages, loans, etc.), please list all Creditor Name(s), Present Balance, Monthly Payment & Number of Payments Behind

Are you or have you ever been subject to a civil or small claims court action?

Are you now, or have you ever been, a member of any foreign or domestic organization, association, group, militia, movement, part or other combination of persons which has adopted, advocated or approved the use of force or violence to oppose the government or deny other person their rights under the Constitution of the United States, or which to seek or alter the form of the United States government by unconstitutional means?

Do you have any knowledge or information, in addition to that specifically called for in the preceding questions, which is or which may be relevant, directly or indirectly, to the investigation of your eligibility or fitness for a law enforcement position?

of Agency, employment.

Personal References

List three personal references that have known you for at least one year, and are not your relatives. Use only one member in a household or family. Provide full accurate addresses and telephone numbers.

Personal Reference 1

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Years Known

Personal Reference 2

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Years Known

Personal Reference 3

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Years Known

Why do you want to be a police officer for the City of Gillespie?

Applicant Signature

Applicant Signature and Acknowledgements I herby swear or affirm that this Personal History form contains no misrepresentations, falsifications, omissions or concealment of material fact, and that all information and statements contained therein are true and complete to the best of my knowledge and belief. I am aware that all information and statements contained herein are subject to investigations: and, should investigation disclose any misrepresentation, falsification, omissions or concealment of material fact, my application may be rejected, my name removed from eligibility for law enforcement employed in Gillespie, Illinois and I may be subject to discharge from any employment based all or in part on such information and statements. I also acknowledge that records established and maintained pursuant to public expenditures may be classified a public record and may be released to parties requesting them. As an applicant for a law enforcement position in Gillespie, Illinois, I hereby release the Gillespie Police Department and the City of Gillespie from any liability or damages which may result from the release of any record pertaining to my application. I also hereby authorize the release of my criminal conviction record and any other background information to the City of Gillespie Police Department.

Signature

Clear Signature

Date / Time