Explorer Preliminary Questionnaire

Form
Tomball Police Department

Explorer Program
Preliminary Questionnaire

The purpose of this questionnaire is to assist in determining if you meet the minimum standards set by the Tomball Police Department, Learning for Life, Boy Scouts of America, and the Texas Law Enforcement Explorer Advisory Association (T.L.E.E.A.A.).

This questionanaire is designed to save you time and money by allowing us to determine if you qualify to continue processing with the Explorer Program and the Tomball Police Department.

Read each question carefully. These questions will be asked again during a detailed interview with an Explorer Advisor and then verified. Knowingly giving any false answers is just cause for denying or terminating your application.

If you have any questions, email us at explorerpost5451@tomballtx.gov.
Today's Date *

Month Day Year
Name *

Last First Middle
Date of Birth *

Month Day Year
Age *
Social Security # *
Address *

Street Address

Apt #

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Email
example@example.com
Adult T-Shirt Size *
Height *
Weight *
Known Allergies
If this does not apply to you, put N/A.
Medical Conditions
If this does not apply to you, put N/A.
EDUCATION
Do you have a High School Diploma? *

Yes No
If NO, do you have a GED?

Yes No
If NO to both questions above, what High School are you attending?
If this does not apply to you, put N/A.
Grade Level
If this does not apply to you, put N/A.
Counselor
If this does not apply to you, put N/A.
Do you have any college credit(s)? *

Yes No
If YES, how many hours/credits?
If this does not apply to you, put N/A.
DRIVING RECORD
Do you have a valid Driver's License? *

Yes No
Driver's License #
If this does not apply to you, put N/A.
Have you ever had any traffic tickets (regardless of outcome)? *

Yes No
If YES, how many?
If this does not apply to you, put N/A.
How many traffic tickets in the last 12 months?
If this does not apply to you, put N/A.
ARREST RECORD
Have you ever been arrested as a juvenile? *

Yes No
Have you ever been arrested as an adult? *

Yes No This does not apply to me.
List all arrest (to include M.I.P., Littering, etc.) regardless of outcome. This should include the date of offense, name of offense and the disposition (jail time, not guilty, fine, etc.).
If this does not apply to you, put N/A
DRUG USE

Have you ever intentionally or knowingly used, experimented with, or tried any of the following illegal drugs or substances? *

	Yes	No	Month & Year of Last Use	Age?
Marijuana
Hashish
Steroids
Inhalants
Ecstasy (XTC)
Meth (Speed)
LSD
Heroin
Cocaine
Crack
P.C.P
Quaaludes
Psilocybin
Tranquilizers

Name any other designer drug(s) you have used.
If this does not apply to you, put N/A.
Have you ever taken prescription drugs NOT prescribed to you? *

Yes No
If YES, please explain:
If this does not apply to you, put N/A
JOB HISTORY
Are you currently employed? *

Yes No
How many jobs have you held, including your present job? *
If this does not apply to you, put N/A.
Have you ever been fired from a job? *

Yes No This does not apply to me.
If YES, please explain when and why you were fired. Include the name of the employer that fired you.
If this does not apply to you, put N/A
Have you ever been asked to resign from a job? *

Yes No This does not apply to me.
If YES, please explain:
If this does not apply to you, put N/A

List the jobs you have held, starting with your current job:

	Name of Business	Immediate Supervisor	Position	Duties	Dates Employed
1
2
3
4
5
6

I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to the above questions. I fully understand that any such willful misrepresentations, omission, or falsification will deem me permanently unsuitable, or if accepted, will terminate my application.
Print Full Name *
Signature *

Clear
Date *

Month Day Year
Date
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Form

Tomball Police Department

EDUCATION

DRIVING RECORD

ARREST RECORD

DRUG USE

JOB HISTORY