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
Are you a U.S. Citizen?
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
Are you presently a permanent, classified state civil service employee? If yes, complete the following:
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)
Have you ever been the subject of a background investigation by a law enforcement agency?
**If yes, complete the following
Date of Investigation & Agency
Date of Investigation & Agency
Date of Investigation & Agency
DRIVING HISTORY
Do you have a valid driver's license?
List driver's license state and number
Example: WI A123-4567-8910-11
Do you now, or have you ever had a license from a state other than listed above?
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
Date

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