MIDDLEBURY POLICE APPLICATON

Middlebury Police Department

Robert G. Baker - Town Marshal - 418 N. Main St. Middlebury, IN 46540 Phone: (574) 825-9111
APPLICATION FOR EMPLOYMENT
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
Which position are you applying for?*
Name*

First NameMiddle NameLast Name
Social Security*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address*
Are you a citizen of the United States?*

YesNo
Can you operate and automobile?*

YesNo
Do you possess a valid drivers license?*

YesNo
Driver's License Number*
Driver's License State*
Please upload a COLOR copy of your driver's license*

Cancelof
Other addresses for past ten years
How long?
Family background*

SingleMarriedDivorcedWidowedIn a Relationship
Spouses Name
Children, how many? *
Are there any children by former marriage(s) or past relationships? How many? Are you responsible for child support payments? If yes, indicate monthly payment: Are you responsible for paying alimony? If yes, indicate monthly payment: If you are responsible for making child payments or paying alimony, has legal action ever been taken against you for either failing to make payment or delaying payments? Are you current in support payments?
Explain all that apply above
Have you ever been arrested and/or convicted of a felony?*

YesNo
If so explain below, date, charges, outcome...
Education History
Do you have a high school diploma or GED?*

High School DiplomaGEDNo
Please Upload a copy of your diploma or GED

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Schools Attended*

	School name, location	From Month & Year	To Month & Year	Highest Grade Completed
Middle School
High School
Post High School/College

Are you bilingual? Speak other languages?
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. *

	Name and Address	From Month & Year	To Month & Year	Position Held	Nature of Duties	Reason for Leaving
Current Employer
Employer 1
Employer 2
Employer 3
Employer 4
Employer 5
Employer 6
Employer 7
Employer 8

What is your present annual salary*
Do you or your spouse have any other income?*

YesNo
If yes, give total amount and source:
Financial Information
Have you ever had property repossessed or turned back to a finance company?*

YesNo
If yes, explain:
Have your wages ever been garnished?*

YesNo
If yes explain

Present monthly payments, list all debts including personal loans from friends and relatives

	Lender	Address	Reason for loan	Monthly payment	Balance
Debt
Debt
Debt
Debt
Debt
Debt
Debt
Debt
Debt
Debt
Debt

References

Give the names of three responsible persons, other than relatives or past employers, who know you well enough to give information about you.*

	Name	Address & phone number	Occupation	How long acquainted?
Person 1
Person 2
Person 3

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.*

	Name	Address & phone number	Occupation	How long acquainted?
Person 1
Person 2
Person 3

Military Record
Have you ever served in the U.S. Armed Forces?*

YesNo
If so, which branch?
Were you ever disciplined while in the Military Service?

YesNo
If so, explain:
If discharge is other than honorable, give complete details:
Please upload DD214 if applicable

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Medical History
Name of family physician*
Address of family physician
Have you been to a physician for treatment during the past 3 years?*

YesNo
If yes, explain:
Have you ever been rejected from military service or any employment for physical, mental, or other reasons?*

YesNo
If yes, explain:
Have you ever been rejected as an applicant for health or life insurance?*

YesNo
If yes, explain:
Have you ever been under the care of psychiatrist, psychologist, or counselor?*

YesNo
If yes, explain:
Are you presently taking any prescribed medication?*

YesNo
If yes, explain:
Have you ever taken any medication or received treatment for a nervous or psychological condition?*

YesNo
If yes, explain:
Have you ever suffered epileptic seizures?*

YesNo
If yes, explain:
Indicate type and approximate dates of any major surgery during your lifetime:
List any tattoos, scars, and/or distinguishing marks:
Please upload an individual COLOR photograph of yourself, not in a group, which has been taken in the last two years*

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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*

MonthDayYear
Date
Signature*

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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*

MonthDayYear
Date
Signature*

Powered by Jotform SignClear
Education
What is the highest level of education you have completed? (Mark one entry)*

GEDGraduated High School1-2 years college3-4 years collegeGraduated from four year college (BA or BS)Post-Grad Degree
What was your major in college? (If applicable)
Were you ever suspended or expelled from any school for any reason (disciplinary or academic)?*

NoYes, one timeYes, two or more times
Have you ever entered the Indiana Law Enforcement Academy?*

NoYes and graduatedYes, but did not graduate
Have you ever successfully completed a Law Enforcement training academy in another State? If so, what State?
Explanations:
Employment
Are you currently employed?*

NoYes, full timeYes, part time
How long have you been working for your current employer? (If you have more than one employer, answer for your main job)*

Not currently employedLess than one yearOne to two yearsThree to five yearsSix or more years
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.)*

Does not apply, not currently employedMuch above averageSomewhat above averageAbout averageSomewhat below averageMuch below average
About how often are you tardy or late for work?*

NeverA few times per year, or lessAbout every other monthAbout 1-3 time per weekAbout once a weekA few times a weekAlmost everyday
During the past year, did you ever miss work and indicate that you were ill when you were not ill?*

Does not apply, not employed during the past yearNoYes, 1-2 timesYes, 3-4 timesYes 5 or more times
How long was your longest full-time employment? (Full time means 40 hours per week)*

Never had a full-time jobless than 1 year1 to 2 years3 to 5 years6 or more years
List any employer(s) who terminated your services and/or those who you would not expect to give you a positive reference. Also state reason for termination or negative reference.
Have you ever resigned from any job under pressure or unfavorable circumstances or to avoid being fired?*

YesNo
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)*

YesNo
Have you ever failed to complete a probationary period for any job?*

YesNo
Have you ever quit a job without giving the notice required by the employer?*

YesNo
Have you ever received a written or oral reprimand or warning at any place of employment?*

YesNo
If yes, how many times?
How many of your former employers would give you a favorable recommendation?*

All wouldMost wouldHalf would, half wound notMost would notNone would
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?*

Never1 time2 times3 or more times
Have you ever committed or threatened to commit physical harm against a co-worker or supervisor at any place you were employed?*

YesNo
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)*

Never1 time2 times3 or more times
Did you ever work (even on the side) without reporting it while collecting unemployment benefits?*

NoYes, 1 timeYes, 2 timesYes, 3 or more times
Explanations
Financial History
Are you able to pay all of your monthly bills on time?*

Yes, alwaysMost of the timeSome of the timeAlmost never
Have you ever had any of the following financial problems? If yes, explain below.
Chapter 7 bankruptcy (where all your debts were excused)*

YesNo
Chapter 13 consolidation (where you had a payment program to repay your debt)*

YesNo
Been refered to a collection agency*

YesNo
Repossession of property*

YesNo
Had wages garnished*

YesNo
How many times in your life have you had a check returned due to insufficient funds? (that is, had a check bounce)*

Never1-5 times6-10 times11-20 timesmore than 20 times
Have you ever been served an eviction notice by a landlord?*

YesNo
Have you ever had a government subsidized educational loan (school loan) that became delinquent?*

YesNo
Have you ever been delinquent in paying alimony and/or child support?*

YesNo
Have you ever failed to file an income tax return?*

YesNo
Do you have any undocumented loans or debts to non-family members (college roommates, bookies, loan sharks, etc?)*

YesNo
Explanations
Driving Record
Do you currently have a valid Indiana driver's license?*

YesNo
Do you currently have a driver's license issued by another state or country?*

YesNo
If so, what state or country?
Have you ever been refused a driver's license by any state?*

YesNo
If yes, what state and why?
How long have you been a licensed driver?*
Have you ever had your driver's license suspended, revoked, or placed on court probation for any reason?*

YesNo
If yes, explain
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)*

None123-45-78-1011 or more
If received citations, list year and jurisdiction where the citations were issued
How many parking citations have you received in the last 12 months?*

None1-23-45 or more
Do you have any traffic or parking tickets in this state or any other which have NOT been paid?*

YesNo
If yes, where?
Have you ever had automobile insurance canceled by the carrier?*

YesNo
If yes, list name of company and agent
List ALL automobile accidents you have ever been involved in which you were the operator of the vehicle, regardless of fault or if it was reportable, including approximate dates, citations issued, and if it was investigated by a police agency. If none, put none.*
Were you under the influence of alcohol or controlled substances in any of the previously listed accidents?*

YesNo
If so, explain
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?*

YesNo
If so, explain
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?*

YesNo
Have you ever been refused auto insurance for any reason other than failure to pay premium?*

YesNo
Has your auto insurance ever been placed in the assigned risk category as a result of your driving record?*

YesNo
Legal History
Have you ever been questioned as a suspect in any crime?*

YesNo
If yes, explain
Have you ever been questioned as a witness in any crime?*

YesNo
If yes, explain
How many times have you been arrested for any reason?*

Never123 or more
If so, explain
How many times have you been convicted, pleaded guilty or pleaded no contest to a misdemeanor or felony?*

Never12 or more
If so, explain
Have you ever been on court probation as an adult (18 or over)?*

YesNo
If so, explain
Have you ever been involved as a plaintiff, defendant, petitioner, or respondent in any civil court action?*

YesNo
If so, explain
Have you ever applied for a permit to carry a concealed weapon?*

YesNo
Have you ever carried on your person or in your vehicle any weapon for protection (other than while employed as a police officer)?*

YesNo
Did you ever buy anything that you suspected was stolen?*

YesNo
If yes, explain
Did you ever sell anything that you thought was stolen?*

YesNo
If yes, explain
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)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Forgery (Signing another person's name to a document without permission or authorization)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Embezzlement/Frauds (Theft of money or other valuables entrusted to you, fraudulent credit card purchases)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
A forcible sex act or rape*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Sexually abusing or molesting a child*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Causing harm to others (such as battery or resisting arrest)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Theft of property (such as burglary, stealing, breaking into coin operated device or breaking and entering)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Vandalism or criminal mischief*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
A sexual crime, other than rape or child molesting (such as self-exposure, obscene phone calls, "peeping tom", etc)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Driving under the influence of alcohol or drugs*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Causing an injury or death while driving recklessly or under the influence of alcohol or drugs*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act involving being in possession of stolen property*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of abducting another person*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of soliciting sex from a child less than 13 years of age*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
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*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of sex with a person less than 16 years of age when you were four plus years older than the person*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of producing, purchasing, selling, viewing, or possessing child pornography through either printed material or computer (digital)*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of harassment and/or stalking*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Any sexual contact with an animal*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of manufacturing explosives or devices or causing an explosion*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Participated in Gang Activity or have been a member of a Gang*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of filing a fraudulent insurance claim*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of filing a false report to any police officer*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of impersonating a police officer or law enforcement officer*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act involving resisting arrest, evading, or fleeing from a police officer*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act of prostitution/solicitation*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act involving illegal gambling*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Act involving theft, use of vehicle without the consent of the owner, or joyriding in a stolen vehicle*

I have committed itI have been arrested for itI have been tried in court for itI have been convicted of it, or pleaded guilty or no contestNone of the above
Any other acts you may believe to have been illegal or immoral which were not listed previously*

I have committed itI am unsureI have not committed this
Explain any above
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.*

	Date of most recent usage
Marijuana
Hashish
Cocaine
Heroin
LSD
PCP
Speed
Mushrooms
Anabolic Steriods
Meth/Amphetamines
Ecstasy
Prescription Drugs (not prescribed to you)
Synthetic Drugs (K2, Delta-9)
Other illegal drugs/substances

How many times in your life have you driven after using illegal or controlled substances/drugs?*

Never1-2 times3 or more times
Have you ever provided any illegal or controlled substances to friends or others in exchange for money or in trade for goods?*

YesNo
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?*

Doesn't apply, I have never done thisIn the last month1-12 months ago1-2 years ago3 or more years ago
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?*

Not applicable, I live aloneNoYes
Have you ever grown or cultivated marijuana?*

YesNo
Have you ever participated in the manufacture of Methamphetamine or Amphetamine?*

YesNo
Have you ever purchased items knowing that the items would be used in the manufacture of Methamphetamine or Amphetamine?*

YesNo
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?*

YesNo
Explain any drug use from above if applicable
Military Experience
Have you ever registered for Selective Service (the draft)?*

No, although I was legally required to do soNo, because I was not legally required to do soYes
How long did you serve in the military on active duty? (Include National Guard and Reserves duty)*

Did not serve in the militaryLess than one year1-4 yearsMore than 4 years, but less than 20 years20 years or more
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)

ArmyNavyAir ForceMarinesCoast GuardNational GuardOther
What is the highest rank you attained?

Enlisted (E1 through E9)Commissioned Officer
Were you personally involved in combat?

YesNo
Did you fail to complete any term enlistment for any reason?

YesNo
Were you eligible to re-enlist?

YesNoNot applicable, still on fulltime active duty
What type of military discharge did you receive?

HonorableHonorable with hardship reasonsGeneralLess than honorableStill on fulltime active dutyStill on reserve statusother
How many times did you receive any disciplinary actions in the military (such as court material, Article 15, or Captain's Mast)?

Never123 or more
While in the service, were you ever absent without leave (AWOL, missed formation, etc.)?

YesNo
While in the military, were you ever incarcerated (brig time)?

YesNo
While in the military, were you ever reduced in rank as a punishment?

YesNo
Explain further on above questions
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)*

None1-23-45 or more
Do you have any law enforcement experience?*

YesNo
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)

YesNo
Sworn, weapon carrying reserve officer

YesNo
Military police officer

YesNo
Correction officer

YesNo
Probation officer

YesNo
Other law enforcement job (park ranger, police community service officer)

YesNo
How many years of experience do you have as a sworn, weapon carrying, law enforcement officer? Total for all agencies combined.
During the time you have been a law enforcement officer, how many citizen's complaints were formally filed against you?

None123-56 or more
How many of those citizen's complaints were sustained (found to be true)?

None123 or more
How many reprimands (written or oral) have you received while a law enforcement officer?

None123 or more
Were you ever the subject of a civil suit of criminal prosecution because of your actions as a law enforcement officer?

NoYes, but charges were dropped and no settlements were madeYes, and charges were upheld or settlements were made
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.

YesNo
Since becoming an officer, have you ever used illegal drugs?

YesNo
Did you ever drink while on duty and in uniform?

YesNo
Did you ever lie or seriously distort the facts in an official report?

YesNo
Did you ever lie or commit perjury in court or any other official proceeding?

YesNo
Did you ever cover up a serious incident for a fellow officer?

YesNo
Have you ever been terminated or forced to resign from a law enforcement position during the probationary period?

YesNo
Have you ever been terminated or forced to resign from a law enforcement position after the probationary period?

YesNo
Have you ever been the subject of an internal affairs investigation while an officer? Do not count citizen's complaints.

YesNo
Have you ever damaged departmental property, equipment, or vehicles and failed to report it, or falsified the report?

YesNo
As a law enforcement officer, how many times (separate incidents) have you personally shot at someone, whether you hit the or not?

None1234 or more
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)

None1234 or more
Explain any questions from above
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?*

YesNo
If yes, explain
Have you ever had or used a social security number other than the one you used on this application?*

YesNo
If yes, explain
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)?*

None123 or more
Have you ever physically assaulted (hit, slapped, choked, etc.) your spouse or romantic partner?*

NoYes, on one occasionYes, on 2 or 3 occasionsYes, on 4 or more occasions
Have you ever been a subject of a Protection from Abuse Order?*

YesNo
If yes, explain, city, state
How many handguns do you own?*

None123 or more
How many combat or assault type firearms do you own?*

None123 or more
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?*

YesNo
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?*

YesNo
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?*

YesNo
Did you in any way cheat, lie, or commit fraud during the application or evaluation process for this agency?*

YesNo
Have you ever been rejected as a job applicant for any of the following reasons?
issues raised by a background investigation?*

YesNo
issues raised by a polygraph examination?*

YesNo
issues raised by an oral interview?*

YesNo
issues raised by a physical ability test?*

YesNo
Explanations for questions above
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.
Should be Empty:

Middlebury Police Department

APPLICATION FOR EMPLOYMENT

Personal Information

Education History

Employment History

Financial Information

References

Military Record

Medical History

Personal History Questionnaire

Instructions

Education

Employment

Financial History

Driving Record

Legal History

Arrest/Undetected Crimes

Substance Abuse

Military Experience

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.

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.

End of Law Enforcement Questions

General Information

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

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