Middleton VIPS

VOLUNTEER IN POLICE SERVICE APPLICATION

Middleton Police Department
7341 Donna Drive Middleton, WI 53562 608-824-7300
Todays Date*

MonthDayYear
Date
Position*
Name*

First NameMiddle NameLast Name
List all names other than your present legal name include nicknames and aliases by which you have been known at any time*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Referral Source*
Do you have any special skills abilities experiences hobbies etc. which could be considered in making an appropriate volunteer assignment? *
(Bilingual fast typing mechanical skills organization skills etc.)
RESIDENCE HISTORY
List chronologically, starting with the most recent address, all of your residences for the past five years.*
Include Timeframe(month/year), Street Address (Apt. Number). City, State, and Zip Code. If rented, give name/address of landlord
Briefly describe why you want to volunteer for the Middleton Police Department and what are you hoping to get from the program?*
EMPLOYMENT HISTORY
YesNo
Class Title:
Agency
Pay Range
Seniority Date

MonthDayYear
Date
LIST YOUR CURRENT EMPLOYER(S) (PART OR FULL TIME)
Employer Name/Address*
Supervisor Name and Phone*
Format: (000) 000-0000.
References

Give three references (not relatives, former employers, fellow employees or school teachers) who are responsible adults of reputable standing in their communities. Applicants under the age of 18 may use a current teacher as a reference.
Reference 1*
Include: Name/Address, Home Phone, Work Phone, & Best time to call
Reference 2*
Include: Name/Address, Home Phone, Work Phone, & Best time to call
Reference 3*
Include: Name/Address, Home Phone, Work Phone, & Best time to call
Law Enforcement References

List any persons who are or have been in a law enforcement field that you know (if any)
LE Reference 1
Included: Name, Agency, Work Phone
LE Reference 2
Included: Name, Agency, Work Phone
LE Reference 3
Included: Name, Agency, Work Phone
Professional or Civic Organization Involvement

List all professional or civic organizations that you are a current or previous member of
1.
Include: Name and Type of organization, From (month/year), and To (month/year)
2.
Include: Name and Type of organization, From (month/year), and To (month/year)
3.
Include: Name and Type of organization, From (month/year), and To (month/year)
4.
Include: Name and Type of organization, From (month/year), and To (month/year)
YesNo
**If yes, complete the following
Date of Investigation & Agency
Date of Investigation & Agency
Date of Investigation & Agency
DRIVING HISTORY
YesNo
List driver's license state and number *
Example: WI A123-4567-8910-11
YesNo
If Yes, list states
If you ever had a driver's license suspended, revoked, restricted, or canceled, please provide an explanation in thorough detail*
CERTIFICATION
I certify to the best of my knowledge that this application is true and complete. I understand that any misstatement or omission forfeits my right to the volunteer opportunity at this time for the position for which I am applying, and may affect future consideration for other positions in the department.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Signature of Parent or Guardian If applicant is under 18 years of age

Clear
Date

MonthDayYear
Date
Should be Empty:

VOLUNTEER IN POLICE SERVICE APPLICATION

RESIDENCE HISTORY

EMPLOYMENT HISTORY

LIST YOUR CURRENT EMPLOYER(S) (PART OR FULL TIME)

References

Law Enforcement References

Professional or Civic Organization Involvement

DRIVING HISTORY

CERTIFICATION