VIPS Application

Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth

MonthDayYear

Social Security No:

YesNoNo Answer

Driver's License No:

You must be able to provide a copy of your valid driver's license

Driver's License State

If your license has ever been suspended - why. Explain any citations.

YesNo

Current Auto Insurance Company

Home Number

Area CodePhone Number

Mobile Number

Area CodePhone Number

Work Number

Area CodePhone Number

E-mail

List and explain any other names you have used

List any languages, other than English, which you speak fluently

List any special skills, training, interests or hobbies you have that may be useful to the Police Department

High School or GED

Name of School

College information (if applicable): Name of School, Dates Attended, Degree Received

Volunteer Experience

Preferred time of day (Hours)

ie. 5pm - 10pm

Military Service Branch (if applicable)

Date Entered

MonthDayYear

Date Separated

MonthDayYear

Type of Discharge

Work Experience (most recent first)

Rows	Employer Name	Address	Duties	Dates Worked
1
2
3

I heard about the VIPS program through

YesNo

If "yes" explain

YesNo

If "yes" explain

YesNo

If "yes" explain

YesNo

If "yes" explain

IN CASE OF EMERGENCY, PLEASE CONTACT:

Name & Relationship

First NameLast NameRelationship to Volunteer

Phone Number

Area CodePhone Number

YesNo

Insurance Company Name:

Group / ID Number

By submitting this form, I aknowlege the following:

As a candidate for a volunteer position with the Tomball Police Department, I am willing to furnish any information necessary for determining my qualifications. In this regard, I authorize release of any and all information that you may have concerning me, including information of a confidential or privileged nature, as is necessary to evaluate my qualifications for the volunteer position. I hereby release you, your organization, or others from liability or damage, which may result from furnishing the information requested.

I understand that for security reasons a background investigation, including polygraph, will be conducted, and I will be fingerprinted. I understand that this information will be used for the specific purpose of evaluating my qualifications for a volunteer position. I understand that falsifying statements on this application or during the interview process is cause for my immediate dismissal from the volunteer program.

I understand that information I provide in this application may be verified on the polygraph examination.

Date

DateHourMinutesAM/PM Option