Civil-Service-Application-for-Patrolman

HONESDALE BOROUGH POLICE DEPARTMENT
Enter your full name here
1.The information you provide in this Application for Employment will be used to assist your qualifications for the position of Police Officer, in accordance with applicable regulations. 2.Respond to all items and questions. If a question does not apply to you, write "N/A" (not applicable) in the space provided for your response. If you cannot obtain or remember certain information, indicate so in your response. 3.If you need more space for any response, use the space at the end of the application and identify the additional information by the question number. 4.If you need additional space for an answer, use a piece of white 8.5x11 inch paper indicating the question number and

5. All pages of this document must be initialed at the bottom indicating you have read and understand each and every page. Also, every page must be submitted to be considered for employment. You may make a copy for your own

6. Application must be returned on or before the due date.
The information you include in this application will be used to determine your qualifications for employment. It is therefore important that you supply all information and material requested and that you answer all questions fully and accurately. Failure to do so may cause a rejection of your application and a loss of employment opportunity.
Applicants for positions on the Honesdale Borough police force must have, and may be required to substantiate, or provide documentation establishing the fact that they possess the following qualifications:
1.Citizenship. Must be a citizen of the United States of America. 2. Age. No person shall be eligible to apply for examination unless he/she is at least 20 years of age. 3.High school diploma or equivalent. 4.Character. Must be of good moral character. The applicant must provide separate references from three citizens of the United States. Such references must contain original signatures of individual providing the reference. Electronic signatures will not be accepted. Immediate family member's fathers, mothers, brothers, and sisters are not eligible references. 5.Applicants must have successfully completed the Municipal Police Officers' Education and Training requirements known as Act 120. The certificate of completion and grade sheet must be provided with the application. 6. The applicant must have a valid motor vehicle operating license issued by the Commonwealth of Pennsylvania. 7.Applicants for employment to the Honesdale Borough police force must complete an agility test that is job-related and consistent with business necessity required to perform the duties and responsibilities outlined in the job description of a Honesdale Borough police officer prior to taking any of the required examinations for employment. Upon compliance with the above requirements, an individual will become a "Candidate for Conditional Employment."

The statements made by the applicant in his/her application and all other documents submitted therewith shall contain no falsification, omission, or concealment of material fact. Should investigation disclose any material misstatement, falsification, omission, or concealment, the Commission shall disqualify the applicant from further consideration for the position or any future position with the Police Department. Any material misstatement, falsification, omission, or concealment that is not discovered until after appointment shall constitute grounds for dismissal from the Police Department.

The Borough is an equal opportunity employer. It is the Borough's and the commission's policy to grant equal employment opportunities to qualified persons without regard to race, religion, color, national origin, gender, age, veteran status, marital status or non-job- related physical or mental handicap or disability. The Borough and the commission will provide equal opportunities in employment and promotion.
Employment Application - POLICE OFFICER Page 2 of 15

SECTION 1: PERSONAL 1. YOUR FULL NAME

LAST FIRST 2. OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOWN BY
LAST
FIRST
MIDDLE
NUMBERSTREET
APT UNIT
4.° MAILING ADDRESS, IF DIFFERENT FROM ABOVE
STATE
ZIP
WORK ( )
EXT
OTHER ( )
HOME
BUSINESS
7. If you were born outside of the United States, are you a U.S. citizen? If no, are you a lawfully authorized to work in the United States?
8 BIRTH PLACE CITYCOUNTYSTATECOUNTRY
9 AGE 20 OR OVER YN
9. AGE 20 OR OVER (Y/N)10. SOCIAL SECURITY NUMBER
NO
STATE
EXP
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
List 4 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.
A NAME
HOME ADDRESS (NUMBER /STREET / APT)
HOME PHONE
Address

HOME ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
WORK ADDRESS (NUMBER/STREET / APT)CITY
Address

WORK ADDRESS NUMBERSTREET APT

Street Address Line 2

CITYSTATE

ZIP
WORK PHONE
Please enter a valid phone number.
CELL PHONE
Please enter a valid phone number.
EMAIL
example@example.com
HOW DO YOU KNOW THIS PERSON FOR EXAMPLE FRIEND TEACHER FAMILY FRIEND CO WORKER
HOW LONG HAVE YOU KNOWN THIS PERSON
NAME
B NAME
HOME ADDRESS (NUMBER /STREET / APT)CITY
Address

HOME ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
HOME PHONE
Please enter a valid phone number.
WORK ADDRESS (NUMBER /STREET / APT)CITY
Address

HOME ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
WORK PHONE
Please enter a valid phone number.
Address

WORK ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
CELL PHONE
Please enter a valid phone number.
EMAIL
example@example.com
HOW DO YOU KNOW THIS PERSON FOR EXAMPLE FRIEND TEACHER FAMILY FRIEND CO WORKER
HOW LONG HAVE YOU KNOWN THIS PERSON
NAME
C NAME
HOME ADDRESS (NUMBER /STREET /APT)
Address

HOME ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
HOME PHONE
Please enter a valid phone number.
WORK ADDRESS (NUMBER / STREET / APT)CITY
Address

WORK ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
WORK PHONE
Please enter a valid phone number.
CELL PHONE
Please enter a valid phone number.
EMAIL
example@example.com
HOW DO YOU KNOW THIS PERSON FOR EXAMPLE FRIEND TEACHER FAMILY FRIEND CO WORKER
HOW LONG HAVE YOU KNOWN THIS PERSON
NAME
D NAME
HOME ADDRESS
Address

HOME ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
HOME PHONE
Please enter a valid phone number.
WORK ADDRESS (NUMBER /STREET / APT)CITY
Employment Application - POLICE OFFICER Page 3 of 15
Address

WORK ADDRESS NUMBER STREET APT

Street Address Line 2

CITYSTATE

ZIP
WORK PHONE
Please enter a valid phone number.
CELL PHONE
Please enter a valid phone number.
EMAIL
example@example.com
HOW DO YOU KNOW THIS PERSON FOR EXAMPLE FRIEND TEACHER FAMILY FRIEND CO WORKER
HOW LONG HAVE YOU KNOWN THIS PERSON
SECTION 2: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.

High School Diploma from an accredited U.S. institution
GED
15. List high schools attended:
A NAME
FROM
TO
DID YOU GRADUATE?
CITY
STATE
B NAME
FROM
TO
DID YOU GRADUATE?
CITY
STATE
16. List all colleges or universities attended:
NAME
A NAME
FROM
TO
TOTAL UNITS EARNED
TYPE OF DEGREE TOTAL UNITS EARNED EARNED
CITY
STATE
TYPE OF DEGREE EARNED
B NAME
FROM
TO
TOTAL UNITS EARNED
TYPE OF DEGREE TOTAL UNITS EARNED EARNED
CITY
STATE
TYPE OF DEGREE EARNED
C NAME
FROM
TO
TOTAL UNITS EARNED
TYPE OF DEGREE TOTAL UNITS EARNED EARNED
CITY
STATE
TYPE OF DEGREE EARNED
17 List any trade, vocational, or business schools/institutes attended:
A NAME
DID YOU COMPLETE THE COURSE?
TYPE OF SCHOOL OR TRAINING
FROM
TO
CITY
STATE
B NAME
FROM
TO
DID YOU COMPLETE THE COURSE?
TYPE OF SCHOOL OR TRAINING
CITY
STATE
C NAME
FROM
TO
DID YOU COMPLETE THE COURSE?
TYPE OF SCHOOL OR TRAINING
CITY
STATE
18. Have you ever attended an Act 120 Training Academy? If yes, provide the following information:
A ACADEMY NAME
FROM
TO
DID YOU GRADUATE? YN
LOCATION CITYSTATE
NAME OF TRAINING OFFICER ACADEMY COORDINATOR
B ACADEMY NAME
FROM
TO
DID YOU GRADUATE? N Y
Employment Application - POLICE OFFICER Page 4 of 15
LOCATION CITYSTATE
NAME OF TRAINING OFFICER ACADEMY COORDINATOR
CONTACT NUMBER
SECTION 3: RESIDENCE
19 LIST OF RESIDENCES
List all residences. Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit or apartment number Do not use P.O. Boxes. If the residence Is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LIST military barracks mates unless you shared individual quarters. If more space is needed continue the last page of the application.
A ADDRESS WHERE YOU NOW LIVE NUMBER/STREET /AT
FROM
CITY
STATE
ZIP
IF RENTING PROPERTY MANAGER RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER RENT COLLECTOR OR OWNER NUMBER STREET APT
CONTACT NUMBER
CITY
Names of those with whom you live
STATE
ZIP
EMAIL
example@example.com
B FORMER ADDRESS NUMBER /STREET /APT
FROM
TO
CITY
STATE
ZIP
IF RENTING PROPERTY MANAGER RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER RENT COLLECTOR OR OWNER NUMBER STREETAPT
CONTACT NUMBER
CITY
STATE
Names of those with whom you lived
ZIP
EMAIL
example@example.com
C FORMER ADDRESS NUMBER/STREET /APT
Reason for moving
FROM
TO
CITY
STATE
ZIP
IF RENTING PROPERTY MANAGER RENT COLLECTOR OR OWNER
ADDRESS OF PROPERTY MANAGER RENT COLLECTOR OR OWNER NUMBER STREET APT
CONTACT NUMBER
CITY
Names of those with whom you lived
STATE
ZIP
EMAIL
example@example.com
Reason for moving
SECTION 4: EXPERIENCE AND EMPLOYMENT
List ALL jobs you have had, including part-time, temporary, self-employment and volunteer. (Begin with your most current. If more space is needed continue your response on the last page of the application If you have military experience, including reserve duty, enter your military base, assignments, or unit of assignment. List ALL periods of unemployment in excess of 30 days.
A NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBERSTREET OR BASE
SUPERVISOR
Employment Application - POLICE OFFICER Page 5 of 15
STATEZIP
CONTACT NUMBER
CITY
STATE
ZIP
EXT
JOB TITLE
EMAIL
example@example.com
DUTIES ASSIGNMENTS
NAMES OF COWORKERS
2
REASON FOR WANTING TO LEAVE
F-T
P-T
Would there be a problem if we contact your current employer? No Yes
IF YES EXPLAIN
B PERIOD OF UNEMPLOYMENT
FROM
TO
C NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBERSTREET OR BASE
SUPERVISOR
CITY
STATE
STATEZIP
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
example@example.com
DUTIES ASSIGNMENTS
F-T
P-T
NAMES OF COWORKERS
1
2
REASON FOR LEAVING
D PERIOD OF UNEMPLOYMENT
FROM
TO
E NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBERSTREET OR BASE
SUPERVISOR
CITY
STATE
STATEZIP
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
example@example.com
DUTIES ASSIGNMENTS
F-T
P-T
NAMES OF COWORKERS
2
REASON FOR LEAVING
F PERIOD OF UNEMPLOYMENT
FROM
TO
G NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBERSTREETOR BASE
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
example@example.com
Employment Application - POLICE OFFICER Page 6 of 15
DUTIES ASSIGNMENTS
F-T
P-T
NAMES OF COWORKERS
2
REASON FOR LEAVING
H PERIOD OF UNEMPLOYMENT
FROM
TO
1 NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBER STREETOR BASE
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
example@example.com
DUTIES ASSIGNMENTS
F-T
P-T
NAMES OF COWORKERS
2
REASON FOR LEAVING
J PERIOD OF UNEMPLOYMENT
FROM
TO
K NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBER STREET OR BASE
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
example@example.com
DUTIESASSIGNMENTS
F-T
P-T
2
REASON FOR LEAVING
L PERIOD OF UNEMPLOYMENT
FROM
TO
M NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS NUMBER STREET OR BASE
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE
EMAIL
example@example.com
F-T
P-T
2
REASON FOR LEAVING
Employment Application - POLICE OFFICER

21. Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling, reprimands, suspensions, reductions in pay, reassignments or demotions) 22. Have ever you ever been fired, released from probation, or asked to resign from any place of employment? 23. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer?

24. Have you ever quit without giving proper notice?

25. Have you ever resigned in lieu of termination? 26. Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc by a co-worker, superior, subordinate or customer? 27. Were you ever the subject of a written complaint at work?

28. Have you ever been counseled at work due to lateness or absences?

29. Did you ever receive an unsatisfactory performance review?

30. Have you ever sold, released, or given away legally confidential information? 31. Have you ever called in sick when you were neither sick nor caring for a sick family member? If yes, how many sick days have you used in the past five years which were not due to illness?
If you answered yes to any of Questions 2131 explain include when where and circumstances indicate corresponding number
SECTION 5: MILITARY EXPERIENCE
32. Are you required to register for the Selective Service? If yes, have you registered? If no, explain:
If no explain
33 BRANCH OF SERVICE
From
To
Reentry Code 14 if applicable refer to your DD214
35. Are you currently participating in one of the following?
If checked date obligation ends

MonthDayYear
Date
36. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain's mast, office hours, company punishment)? 37. Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded?
Employment Application - POLICE OFFICER Page 8 of 15
If you answered yes to Questions 36 andor 37 explain include dates and circumstances
Employment Application - POLICE OFFICER Page 9 of 15
SECTION 6: LEGAL
Disclosure of Arrests and Convictions

This section requires you to report convictions, including diversion programs that were not successfully completed. As a police officer applicant, you are required to disclose this information, unless specifically exempted by state or federal law. In responding to the following criminal history question do not disclose any information concerning (I) any conviction or plea that has been pardoned, sealed, or expunged by court order, or which has been dismissed pursuant to a pre-trial diversion or accelerated rehabilitative disposition program (ARD), (ii) any summary offense, or (iii) any offense committed while you were a juvenile. It is strongly recommended that you consult with an attorney before omitting any information.

38. Have you ever been convicted of any misdemeanor or felony offense in this state or in any other legal jurisdiction (including offenses punishable under the Uniform Code of Military Justice)?YesNo

If yes, explain each incident: If more space is needed, continue in the space provided.
A APPROXIMATE DATE

MonthDayYear
Date
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
B APPROXIMATE DATE

MonthDayYear
Date
ARRESTING OR DETAINING AGENCY
CHARGE
APPROXIMATE DATE

MonthDayYear
Date
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
39. Have you ever been placed on court probation as an adult? 40. Were you ever required to appear before a juvenile court for an act which would have been a crime if committed as an adult? 41. Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity, support, etc? 42. Have the police ever been called to your home for any reason?

43. Have you or your spouse/partner ever been referred to Child Protective Services?
Employment Application - POLICE OFFICER Page 10 of 15

SECTION 6: LEGAL continued 44. Have you ever been the subject of an emergency protective order/restraining order/stay-away/Protection from abuse order? 45. Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf was required to make payment to the other party?Yes 46. Have you ever fraudulently received welfare, unemployment compensation, workers' compensation, or other state-orfederalassistance? Yes

47. Have you ever filed a false insurance or workers' compensation claim?
If you answered yes to any of Questions 4047 explain include court case or document dates and circumstances indicate corresponding number
SECTION 7: MOTOR VEHICLE OPERATION
48 CURRENT DRIVERS LICENSE NUMBER
STATE OF ISSUE
EXPIRATION DATE

MonthDayYear
Date
NAME UNDER WHICH LICENSE WAS GRANTED
49. LIST OTHER STATES WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE:

Name under which license was granted and license number, If known
Use this space to provide information that does not fit elsewhere on this form eg additional family members schools residences employers explanations to questions etc Identify the corresponding question and specific item being referenced
Employment Application - POLICE OFFICER

Page 11 of 15 SECTION 8: Waiver and Release for Background Investigation

am presently applying for employment with Honesdale Borough, which I acknowledge and understand, must thoroughly investigate my employment background, criminal history, personal background, education and references in order to evaluate my qualifications for a position with the police department. | understand that it is in the public's interest that all relevant information in this regard, including my personal and employment history with my current and former employers, be disclosed to the Honesdale Borough. By this release, I hereby authorize any representative of all of my former employers, which have been fully disclosed and identified in my employment application, to divulge any information in its files pertaining to my employment records and history, and I further authorize the release of such information upon request to any representative of Honesdale Borough. I also authorize all former employers identified in my employment application to permit a review and full disclosure of all records, and or any part thereof, concerning myself and my employment with those former employers, by and to any duly authorized agents of Honesdale Borough Police Departments., whether said records are of public, private, or confidential nature. The intent of this authorization is to permit all former employers identified in my employment application to provide, and for Honesdale Borough to obtain, full and free access to the background and history of my personal life and my employment history and performance, for the specific purpose of permitting the Honesdale Borough Police Department to conduct a thorough background investigation regarding me that will provide pertinent data for consideration by Honesdale Borough in determining my suitability for employment in the police department. It is my specific intent to provide Honesdale Borough with access to personnel information, however personal or confidential it may appear to be. I authorize all former employers, which have been fully disclosed and identified in my employment application, to release any and all public and private information that it may have concerning me, my work, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including my arrest record(s) and records compiled during or as a result of a criminal investigation(s) of me, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have or have had, an interest, attendance records, polygraph examinations, and internal affairs investigations and discipline, including any files which are deemed to be confidential and/or sealed.

I hereby release all former employers which have been fully disclosed and identified in my employment application and, if applicable, their elected and appointed officials, employees and agents and all others from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I hereby release all former employers which have been fully disclosed and identified in my employment application and, if applicable, its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct all former employers identified in my employment application to release such information upon request of the duly accredited representative of the Honesdale Borough Police Department, regardless of any agreement I may have made with the former employer to the contrary. In addition, I also give Honesdale Borough the right to thoroughly investigate my background, previous employment, education and references in order to ascertain my suitability for service as a Honesdale Borough employee. I release and hold harmless Honesdale Borough, the Honesdale Borough Police Department, its elected officials, agents and employees from and against any and all liability which might result from conducting such an investigation, including any damages of whatever kind which may at any time result to me, my heirs, family or associates because of such investigation. I recognize and understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and disclosure of records, and I waive those rights with the understanding that information furnished by any former employer will be used by Honesdale Borough and the Honesdale Borough Police Department in conjunction with employment procedures. A photocopy or facsimile of this release form will be valid as an original thereof, even though said photocopy or facsimile does not contain an original writing of my signature.
This waiver is valid for a period of one year from the date of my signature

Should there be any questions as to the validity of this release, you may contact me at the address listed on my employment application.
Employment Application - POLICE OFFICER Page 12 of 15

I agree to indemnify and hold harmless the person to whom this request is presented, as well as his agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request.

SECTION 8: Waiver and Release for Background Investigation (continued)
First and Middle
Last
Street
Cell
Employment Application - POLICE OFFICER Page 13 of 15 SECTION 9: Consent to Obtain Consumer Report

I, the undersigned, an applicant for employment with Honesdale Borough, hereby acknowledge that I have received a separate Notice informing me that Honesdale Borough may obtain one or more Consumer Reports about me for employment purposes; in connection with my application for employment and/or subsequent periods of employment should I be hired by Honesdale Borough. I further acknowledge that I have carefully read and fully understand the contents of that Notice, and that I understand that an analysis of any such report by Honesdale Borough may affect its decision whether or not to offer employment to me. I hereby authorize Honesdale Borough and give it my consent to order a Consumer Report about me from one or more consumer reporting agencies. I further authorize and consent to Honesdale Borough's use of the Consumer Report in evaluating my application for employment and, if hired, in connection with any future decisions regarding my employment with Honesdale Borough. Finally, should I become an employee of Honesdale Borough; I authorize Honesdale Borough to obtain Consumer Reports at any time during my term of employment with Honesdale Borough. I authorize and consent to Honesdale Borough's use of these Consumer Reports as factor Honesdale Borough may rely upon when making future decisions regarding my employment status with Honesdale Borough.
Last
First and Middle
Signature: Social Security Number:
Street
Cell
Employment Application - POLICE OFFICER Page 14 of 15

(PLEASE READ BEFORE INITIALING AND SIGNING)

I swear or affirm that the information provided in this Employment Application true and accurate to the best of my knowledge, and that I have not provided any false or misleading information, nor have I made any omissions. I understand that I am subject to the penalties of 18 Pa. C.S.A. § 4904 relating to unsworn falsification to authorities for any false or misleading information provided in this Employment Application. I acknowledge and understand that falsification or misrepresentation of the information requested on this Employment Application or with respect to any other information provided in the hiring process will be sufficient cause for the denial or termination of employment, regardless of when such fact may be discovered.

I acknowledge that completion of this Employment Application does not constitute a guarantee of eventual employment with Honesdale Borough and that nothing in this employment application gives rise to a contract of employment. If employed, unless my employment is governed by a written agreement to the contrary, my employment will be of an at-will nature, and both Honesdale Borough and I have the right to terminate the employment relationship at any time, with or without cause.
APPLICANTS SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

WORK ( )

OTHER ( )

List 4 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.

A NAME

HOME ADDRESS (NUMBER /STREET / APT)

HOME PHONE

WORK ADDRESS (NUMBER/STREET / APT)CITY

B NAME

HOME ADDRESS (NUMBER /STREET / APT)CITY

WORK ADDRESS (NUMBER /STREET / APT)CITY

C NAME

HOME ADDRESS (NUMBER /STREET /APT)

WORK ADDRESS (NUMBER / STREET / APT)CITY

D NAME

HOME ADDRESS

WORK ADDRESS (NUMBER /STREET / APT)CITY

SECTION 2: EDUCATION

GED

DID YOU GRADUATE?

DID YOU GRADUATE?

A NAME

TYPE OF DEGREE TOTAL UNITS EARNED EARNED

C NAME

TYPE OF DEGREE TOTAL UNITS EARNED EARNED

A NAME

DID YOU COMPLETE THE COURSE?

B NAME

DID YOU COMPLETE THE COURSE?

C NAME

DID YOU COMPLETE THE COURSE?

DID YOU GRADUATE? YN

DID YOU GRADUATE? N Y

CONTACT NUMBER

SECTION 3: RESIDENCE

19 LIST OF RESIDENCES

A ADDRESS WHERE YOU NOW LIVE NUMBER/STREET /AT

CONTACT NUMBER

B FORMER ADDRESS NUMBER /STREET /APT

CONTACT NUMBER

C FORMER ADDRESS NUMBER/STREET /APT

CONTACT NUMBER

SECTION 4: EXPERIENCE AND EMPLOYMENT

STATEZIP

CONTACT NUMBER

F-T

P-T

B PERIOD OF UNEMPLOYMENT

STATEZIP

CONTACT NUMBER

F-T

P-T

D PERIOD OF UNEMPLOYMENT

STATEZIP

CONTACT NUMBER

F-T

P-T

F PERIOD OF UNEMPLOYMENT

CONTACT NUMBER

F-T

P-T

H PERIOD OF UNEMPLOYMENT

CONTACT NUMBER

F-T

P-T

J PERIOD OF UNEMPLOYMENT

CONTACT NUMBER

F-T

P-T

L PERIOD OF UNEMPLOYMENT

CONTACT NUMBER

F-T

P-T

SECTION 5: MILITARY EXPERIENCE

SECTION 6: LEGAL