• Middlebury Police Department

    Middlebury Police Department

    Robert G. Baker - Town Marshal - 418 N. Main St. Middlebury, IN 46540 Phone: (574) 825-9111

  • APPLICATION FOR EMPLOYMENT

    Reserve Position

  • The Middlebury Police Department is an Equal Employment Opportunity Employer. Federal, State, and Local laws prohibit discrimination in matters affecting employment against any person because of race, religion, ancestry, national origin, age, or sex. If you feel that you have been discriminated against, contact the Town Marshal for assistance and complaint information. Any inquiries will be strictly confidential. This application will be considered for any employment vacancy (vacancies) presently existing within the Middlebury Police Department and will be valid ONLY for any current employment vacancy (vacancies If you should be interested in filling any employment that develops in the future you will be required to reapply at that time. [NOTE! Any intentional misrepresentation of information or failure to: respond completely to any question, provide supplemental documents, or follow instructions, will be cause for rejection of the application!]

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Are you a citizen of the United States?*
  • Can you operate and automobile?*
  • Do you possess a valid drivers license?*
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  • Family background*
  • Have you ever been arrested and/or convicted of a felony?*

  • Education History

  • Do you have a high school diploma or GED?*
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  • Schools Attended*
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  • Employment History

  • Start with the place you are employed now, or where you were last employed, and give a regressing account of your employment history since you first started to work. SHOW ALL PERIODS OF UNEMPLOYMENT! If former employers are out of business, indicate same. *
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  • Do you or your spouse have any other income?*

  • Financial Information

  • Have you ever had property repossessed or turned back to a finance company?*
  • Have your wages ever been garnished?*
  • Present monthly payments, list all debts including personal loans from friends and relatives
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  • References

  • Give the names of three responsible persons, other than relatives or past employers, who know you well enough to give information about you.*
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  • Give the names of three persons whom you consider to be your closest friends, they may ne relatives, with whom you frequently socialize. List your closest friend first.*
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  • Military Record

  • Have you ever served in the U.S. Armed Forces?*
  • Were you ever disciplined while in the Military Service?
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  • Medical History

  • Have you been to a physician for treatment during the past 3 years?*
  • Have you ever been rejected from military service or any employment for physical, mental, or other reasons?*
  • Have you ever been rejected as an applicant for health or life insurance?*
  • Have you ever been under the care of psychiatrist, psychologist, or counselor?*
  • Are you presently taking any prescribed medication?*
  • Have you ever taken any medication or received treatment for a nervous or psychological condition?*
  • Have you ever suffered epileptic seizures?*
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  • I hereby certify that there are no willful misrepresentations or falsifications in any preceding information and answers to questions. I am aware that should investigation disclose any such misrepresentations or falsifications my application will be rejected and that I may be disqualified from applying for any future position in the service of the Middlebury Police Department. I also authorize my former employers to give any information regarding my employment or other pertinent information that they may have. I hereby release them personally and their company from any liability or damage that may result from furnishing same. In addition I authorize any educational institution that I have attended to release copies of transcripts of my grades to the Middlebury Police Department.

     

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Should you become an employee of the Middlebury Police Department, this application and accompanying attached documents will become property in your personnel file.

  • Personal History Questionnaire

  • Instructions

    The Middlebury Police Department considers honesty anessential quality for all employees. Any previous act or previous error injudgment may be disqualifying but will be evaluated on its own merits. Manymore applicants are not accepted because of concealment and omissions thanbecause of previous behavior. This is an official document, and you will beheld accountable for all answers. If you fail to include any pertinentinformation when answering this form, you will forfeit your opportunity to beconsidered for employment.Think carefully before answering the questions period anyfraudulent or intentional misrepresentation or omissions will result indisqualification. Answer the questions as completely as possible. Use the explanation sections for any answers which require additional explanation. The information in this form is needed by the Middlebury Police Department to conduct background investigations into all potential employees to determine their suitability for employment. The contents of this questionnaire will be considered confidential and will be used only for investigation employment suitability with the Middlebury Police Department or another law enforcement agency and possession of notarized permission waiver from you. (Exception, the jurisdictional police agency will be notified if itis discovered you are currently involved in criminal activity or have committed an undiscovered felony.) I acknowledge that all forms in this packet are official documents of the Middlebury Police Department and that all answers I give are accurate to the best of our knowledge. The information in this booklet contains true, complete, and accurate statements. I understand that withholding any information, falsification, or misrepresentation of any information in this booklet will result in the disqualification from the Middlebury Police Department hiring process. Note: Your answers to the following questions and any of the sections or categories may be verified through your school records, former and current employers, IRS tax records, financial institutions, credit reporting agencies, court and legal documents, police agency records, U.S.military records, and through the interviews with persons acquainted with you. You may also be required to submit to a polygraph examination to verify any orall answers given. If you deliberately give false or misleading answers, youmay be disqualified from this or any future employment with this department.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Education

  • What is the highest level of education you have completed? (Mark one entry)*
  • Were you ever suspended or expelled from any school for any reason (disciplinary or academic)?*
  • Have you ever entered the Indiana Law Enforcement Academy?*

  • Employment

  • Are you currently employed?*
  • How long have you been working for your current employer? (If you have more than one employer, answer for your main job)*
  • To the best of your knowledge, how does your current employer evaluate your work performance? (If you have received written performance evaluations, base your answers in the most recent one.)*
  • About how often are you tardy or late for work?*
  • During the past year, did you ever miss work and indicate that you were ill when you were not ill?*
  • How long was your longest full-time employment? (Full time means 40 hours per week)*
  • Have you ever resigned from any job under pressure or unfavorable circumstances or to avoid being fired?*
  • Have you ever had a written complaint made against you or your work performance (by a customer, client, etc) on any of your jobs? (Do not include complaints received while working as a law enforcement officer)*
  • Have you ever failed to complete a probationary period for any job?*
  • Have you ever quit a job without giving the notice required by the employer?*
  • Have you ever received a written or oral reprimand or warning at any place of employment?*
  • How many of your former employers would give you a favorable recommendation?*
  • How often have you ever gotten into arguments with co-workers or supervisors at work in which you raised your voice or used insulting language?*
  • Have you ever committed or threatened to commit physical harm against a co-worker or supervisor at any place you were employed?*
  • How many different times in your life have you collected unemployment compensation? (Count each period or time during which you collected unemployment as one time even if you collected a number of separate checks during that time period)*
  • Did you ever work (even on the side) without reporting it while collecting unemployment benefits?*

  • Financial History

  • Are you able to pay all of your monthly bills on time?*

  • Have you ever had any of the following financial problems? If yes, explain below.

  • Chapter 7 bankruptcy (where all your debts were excused)*
  • Chapter 13 consolidation (where you had a payment program to repay your debt)*
  • Been refered to a collection agency*
  • Repossession of property*
  • Had wages garnished*
  • How many times in your life have you had a check returned due to insufficient funds? (that is, had a check bounce)*
  • Have you ever been served an eviction notice by a landlord?*
  • Have you ever had a government subsidized educational loan (school loan) that became delinquent?*
  • Have you ever been delinquent in paying alimony and/or child support?*
  • Have you ever failed to file an income tax return?*
  • Do you have any undocumented loans or debts to non-family members (college roommates, bookies, loan sharks, etc?)*

  • Driving Record

  • Do you currently have a valid Indiana driver's license?*
  • Do you currently have a driver's license issued by another state or country?*
  • Have you ever been refused a driver's license by any state?*
  • Have you ever had your driver's license suspended, revoked, or placed on court probation for any reason?*
  • How many traffic citations (other than parking) have you received? (Include citations that have been cleared by attending traffic school. Include citations received in other states or on a military base)*
  • How many parking citations have you received in the last 12 months?*
  • Do you have any traffic or parking tickets in this state or any other which have NOT been paid?*
  • Have you ever had automobile insurance canceled by the carrier?*
  • Were you under the influence of alcohol or controlled substances in any of the previously listed accidents?*
  • Have you ever been the driver in an automobile accident where an injury or damage occurred in which you failed to report either to the police or to the owner of the property?*
  • Do you carry auto insurance, or have a deposit on file with the Department of Motor Vehicles in lieu of auto insurance, on all of the vehicles that you own and drive?*
  • Have you ever been refused auto insurance for any reason other than failure to pay premium?*
  • Has your auto insurance ever been placed in the assigned risk category as a result of your driving record?*

  • Legal History

  • Have you ever been questioned as a suspect in any crime?*
  • Have you ever been questioned as a witness in any crime?*
  • How many times have you been arrested for any reason?*
  • How many times have you been convicted, pleaded guilty or pleaded no contest to a misdemeanor or felony?*
  • Have you ever been on court probation as an adult (18 or over)?*
  • Have you ever been involved as a plaintiff, defendant, petitioner, or respondent in any civil court action?*
  • Have you ever applied for a permit to carry a concealed weapon?*
  • Have you ever carried on your person or in your vehicle any weapon for protection (other than while employed as a police officer)?*
  • Did you ever buy anything that you suspected was stolen?*
  • Did you ever sell anything that you thought was stolen?*

  • Arrest/Undetected Crimes

    The next block of questions ask about specific criminal offenses. Respond to each criminal offense as it applies to you. For each criminal offense, mark all answers that apply. Be sure to mark at least one response for each offense. If none of the first answers apply, mark the response labeled "None of the above." Please explain any responses other than "None of the above" at the bottom of this section.
  • Arson (Intentionally setting a fire)*
  • Forgery (Signing another person's name to a document without permission or authorization)*
  • Embezzlement/Frauds (Theft of money or other valuables entrusted to you, fraudulent credit card purchases)*
  • A forcible sex act or rape*
  • Sexually abusing or molesting a child*
  • Causing harm to others (such as battery or resisting arrest)*
  • Theft of property (such as burglary, stealing, breaking into coin operated device or breaking and entering)*
  • Vandalism or criminal mischief*
  • A sexual crime, other than rape or child molesting (such as self-exposure, obscene phone calls, "peeping tom", etc)*
  • Driving under the influence of alcohol or drugs*
  • Causing an injury or death while driving recklessly or under the influence of alcohol or drugs*
  • Act involving being in possession of stolen property*
  • Act of abducting another person*
  • Act of soliciting sex from a child less than 13 years of age*
  • Act of taking a child (under the age of 18) out of the state in which the child resides in violation of a judgement or court as result of a child custody suit*
  • Act of sex with a person less than 16 years of age when you were four plus years older than the person*
  • Act of producing, purchasing, selling, viewing, or possessing child pornography through either printed material or computer (digital)*
  • Act of harassment and/or stalking*
  • Any sexual contact with an animal*
  • Act of manufacturing explosives or devices or causing an explosion*
  • Participated in Gang Activity or have been a member of a Gang*
  • Act of filing a fraudulent insurance claim*
  • Act of filing a false report to any police officer*
  • Act of impersonating a police officer or law enforcement officer*
  • Act involving resisting arrest, evading, or fleeing from a police officer*
  • Act of prostitution/solicitation*
  • Act involving illegal gambling*
  • Act involving theft, use of vehicle without the consent of the owner, or joyriding in a stolen vehicle*
  • Any other acts you may believe to have been illegal or immoral which were not listed previously*

  • Substance Abuse

    The questions about drugs do not refer to prescribed drugs or treatment legally prescribed to you by a physician or other authorized medical professional
  • Indicate Usage of Each Drug Listed. Write N/A to indicate never used.*
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  • How many times in your life have you driven after using illegal or controlled substances/drugs?*
  • Have you ever provided any illegal or controlled substances to friends or others in exchange for money or in trade for goods?*
  • When is the last time you ever provided any illegal or controlled drugs to friends or others, in exchange for money or in the trade for goods?*
  • To the best of your knowledge, has your spouse, romantic partner, or roommate ever been involved in the use of any illegal or controlled substances during the past three years?*
  • Have you ever grown or cultivated marijuana?*
  • Have you ever participated in the manufacture of Methamphetamine or Amphetamine?*
  • Have you ever purchased items knowing that the items would be used in the manufacture of Methamphetamine or Amphetamine?*
  • Have you ever used another chemical or substance, i.e. household cleaner, computer cleaner, glue, spray paint, etc., for any other purpose than it was intended, to unduce mind altering affects?*

  • Military Experience

  • Have you ever registered for Selective Service (the draft)?*
  • How long did you serve in the military on active duty? (Include National Guard and Reserves duty)*

  • If you did not serve in the military, skip to the next section (law enforcement experience). If you did serve in the military, continue with the next questions.

  • In which branch of the military did you serve? (mark all that apply)
  • What is the highest rank you attained?
  • Were you personally involved in combat?
  • Did you fail to complete any term enlistment for any reason?
  • Were you eligible to re-enlist?
  • What type of military discharge did you receive?
  • How many times did you receive any disciplinary actions in the military (such as court material, Article 15, or Captain's Mast)?
  • While in the service, were you ever absent without leave (AWOL, missed formation, etc.)?
  • While in the military, were you ever incarcerated (brig time)?
  • While in the military, were you ever reduced in rank as a punishment?

  • Law Enforcement Experience

  • To how many different law enforcement agencies have you ever applied for employment? (Count ALL applications including applications currently in progress even if you only went through the initial stages of submitting an application)*
  • Do you have any law enforcement experience?*

  • Answer the following law enforcement questions only if you have law enforcement experience. If you have no law enforcement experience, skip to the next section.

    Indicate whether you have each of the following types of law enforcement experience:
  • Sworn, weapon carrying officer (police officer, sheriff's deputy)
  • Sworn, weapon carrying reserve officer
  • Military police officer
  • Correction officer
  • Probation officer
  • Other law enforcement job (park ranger, police community service officer)
  • During the time you have been a law enforcement officer, how many citizen's complaints were formally filed against you?
  • How many of those citizen's complaints were sustained (found to be true)?
  • How many reprimands (written or oral) have you received while a law enforcement officer?
  • Were you ever the subject of a civil suit of criminal prosecution because of your actions as a law enforcement officer?
  • Have you ever had any unsatisfactory personnel ratings as a law enforcement officer (including ratings of improvement needed)? Do not include ratings during the probationary period.
  • Since becoming an officer, have you ever used illegal drugs?
  • Did you ever drink while on duty and in uniform?
  • Did you ever lie or seriously distort the facts in an official report?
  • Did you ever lie or commit perjury in court or any other official proceeding?
  • Did you ever cover up a serious incident for a fellow officer?
  • Have you ever been terminated or forced to resign from a law enforcement position during the probationary period?
  • Have you ever been terminated or forced to resign from a law enforcement position after the probationary period?
  • Have you ever been the subject of an internal affairs investigation while an officer? Do not count citizen's complaints.
  • Have you ever damaged departmental property, equipment, or vehicles and failed to report it, or falsified the report?
  • As a law enforcement officer, how many times (separate incidents) have you personally shot at someone, whether you hit the or not?
  • As a law enforcement officer, how many on-duty traffic accidents have you been involved in where you were the driver? (regardless of who was at fault)

  • End of Law Enforcement Questions

  • General Information

  • Have you ever used or been known by any name other than the one you used on this questionnaire?*
  • Have you ever had or used a social security number other than the one you used on this application?*
  • How many physical fights have you been in since the age of 18 (other than as part of your job as a law enforcement officer)?*
  • Have you ever physically assaulted (hit, slapped, choked, etc.) your spouse or romantic partner?*
  • Have you ever been a subject of a Protection from Abuse Order?*
  • How many handguns do you own?*
  • How many combat or assault type firearms do you own?*
  • Have you ever been a member of, or supported financially or otherwise, any organization which advocates, advises, or supports the use of force or other unlawful means to deny other persons their rights under the Constitution of the United States?*
  • If it became necessary to shoot at another human being in the course of carrying out your law enforcement duties, would you be willing to do so?*
  • If it became necessary to inflict serious physical injury on another human being in the course of your law enforcement duties, would you be willing to do so?*
  • Did you in any way cheat, lie, or commit fraud during the application or evaluation process for this agency?*

  • Have you ever been rejected as a job applicant for any of the following reasons?

  • issues raised by a background investigation?*
  • issues raised by a polygraph examination?*
  • issues raised by an oral interview?*
  • issues raised by a physical ability test?*

  • This completes the personal history questionnaire. Please review your answers throughout this questionnaire making certain each question is answered thoroughly, completely, and honestly.

  • End of Application

  • Please click the continue button which will take you to a final signature button. Your application will be screened by the Middlebury Police Department. All applicants that pass the initial screening phase may be contacted for an initial interview. During the initial interview you may be asked to sign authorization forms which will allow the Middlebury Police Department to initiate a background investigation for your employment. After the background investigation is complete, you may be contacted for a second interview. During the application process, if the position is filled, you will be contacted via the email provided notifying you that the position is filled. Your application will remain on file with the Middlebury Police Department for one year. 

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