City of Raceland Kentucky

City of Raceland Kentucky
Police Department

711 Chinn St., Raceland, KY 41169
Phone (606)836-8621 Fax (606)836-7161

Application for Employment
Each question must be answered truthfully, false statements or answers will be cause for disapproving your application, or for discharge after employment. When providing an address, give complete details. If a post office box is used also provide a valid home address.
Date*

MonthDayYear
Date
Applying for:*

Full TimePart Time
Name*

First NameMiddle NameLast Name
Social Security Number:*
Date of Birth:*

MonthDayYear
Date
Drivers License Number:*
Drivers License State:*
Is your license suspended or revoked?*
Are you 21 years of age?*
Marital Status:*

Family History (For mother list maiden name)
Father:

First NameLast Name
Mother:

First NameLast Name
Brother and/or Sisters Names: (List oldest to youngest if multiple)

First NameLast Name
Second Sibling

First NameLast Name
Third Sibling

First NameLast Name

References
List at least 5 personal references who are NOT relatives or employers. Provide name, address, phone number, and years known. (Each reference should start on a new line)

Military

Skip if you do not have any military experience.
Military Branch:
Date Served From:

MonthDayYear
Date
Date Served To:

MonthDayYear
Date
Highest Rank:
MOS and Position Held:
Type of Discharge Received: (also explain why if other than honorable discharge)

Criminal and Driving History
Have you ever been indicted or convicted of a felony and/or misdemeanor?

YesNo
If yes explain in detail:
Have you ever been charged with a traffic violation and/or other offense?

YesNo
If yes list and explain in detail:
List any collisions you have had (date, location, and details):
Have you ever been Bonded?

YesNo
If yes, was your bond ever cancelled and for what reason:

Other
List any qualifications, skills or abilities that you possess that will be helpful in doing the job as a police officer.
Explain why you desire to be a member of the Raceland Police Department (Minimum 25 words)
I certify that the answers given herein are true and correct to the best of my knowledge. I authorize an investigation of all statements contained in this employment application as may be neccesary in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulationsfor the employer. I understand that neither this document nor any verbal promises made by the employer or representative employee may be constituted as an employment contract. I understand that this application is the property of the police department. This application must be signed and dated below before I will receive consideration for employment. Applications are kept on file for six (6) months.
Signature*

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Date*

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Date
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Address & Contact Information