ARNOLD

POLICE DEPARTMENT
Serving the community sinc'11972
PERSONAL IDSTORY QUESTIONNAIRE
The Arnold Police Department resolved that subject to all applicable State and Federal statutory or
judicial exemptions, all qualified applicants for employment and/or advancement, whether commissioned
or noncommissioned, shall be given equal opportunity for consideration, selection, appointment and
retention, regardless of race, color, religion, sex, national origin, age, disability or political affiliation.
AN EQUAL OPPORTUNITY EMPLOYER
The City of Arnold
The City of Arnold is located in Jefferson County, Missouri,
approximately 18 miles south of St Louis on interstate 55. The city is
approximately 12 square miles in size with a population of over 20,000.
The City of Arnold Police .!Jepart11JlN1l
.-.-- .-:-}:::};?'':'::-.. }-:==:'
a
variety of watch,
citizens police police
explorers and t > .. . . ........ i ;
::.::.;::::;:,:-.. -=. ,.
.

Dental ......
: i .....
Excellent
Life Insurance
Eleven Paid Holidays
State {)f the Art Police Facility
State of the Art Equipment
The requirements to become a City of Arnold Police Officer are:
21 Years of Age
U.S. Citizen
High school degree or equivalent. Higher education preferred but
not required.
No Criminal Record
Valid Missouri Drivers License
Good Moral Character
Graduate of a 640 Hour Certified Police Academy
Pass the following:
Written Test
Oral Interview
Background Investigation
Polygraph Test
Psychiatric Examination
Medical Examination
To Apply
The City of Arnold Police Department accepts applications at any time.
However, the department will periodically establish an eligibility list on
an as needed basis from which candidates may be selected.
Application are available at the City of Arnold Police Department and
should be returned to:
City of Arnold Police Department
Attn. Ruth Robinson
2101 Jeffco Boulevard
Arnold, MO 63010
For additional information, call Ruth Robinson at
636-296-3204
The City of Arnold is an equal opportunity employer and will not
engage in practices which exclude any person for employment or
employment opportunity on the basis of race, color, religion, age, sex,
national origin, military status, lawful political affiliation or handicap.
ARNOLD
POLICE DEPARTMENT
2101 Jeffco Boulevard
Arnold, Missouri 63010
(636) 296-3204
LAST NAME
SSN
CERTIFICATE OF APPLICANT AND
AUTHORIZATION FOR RELEASE OF INFORMATION
FIRST NAME MIDDLE NAME
DATE OF BIRTH APPLICANT#
I (Print full name), hereby certify that all statements made on or in connection
with this application are true and complete to the best of ml knowledge. I un3erstand and agree that any misstatements or
omissions of material facts will cause forfeiture on my part o all rights to initial employment or continued employment by the
Arnold Police Department
The intent of this authorization is to make available a full and complete disclosure of any and all information pertaining
to my person; therefore, I do hereby authorize all present or past employers, all law enforcement agencies, all military
agencies, the Veterans Administration, the U.S. Army, U.S. Airforce, U.S. Coast Guard, all Federal, State or local
government agencies, State and Federal tax bureaus, credit bureaus, schools and universities to furnish the Arnold
Police Department, with any and all available information regarding my past or present performance, conduct or
behavior. I further authorize the release of any punitive or disciplinary action, or memorandum, to Police Department
in order that the information be evaluated to assist in the determination of my suitability for police work.
I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of
, my personal and business life for the specific purpose of conducting a pre-employment background investigation.
\.1 authorize the Arnold Police Department to make an inquiry and gather any documents of my present and past em-
ployers regarding my character, integrity, reputation and performance.
I authorize the release of any and all of the aforelisted information regarding my person, employment, credit or any other aspect,
whether personal or otherwise, that may or may not be in their written records.
I understand that all materials pertaining to this background investigation become the property of the Arnold Police
Department and will not be made available or returned to me.
I agree to indemnify and hold harmless the person to whom this request is presented, along with the company or organization
therein from any and all claims, damages, losses and expenses, including reasonable attorney's fees arising out of complying with
this request.
I understand that in the event my application is disapproved, the sources of information obtained are confidential and cannot be
revealed to me.
A photostatic or Zerox copy of this authorization will be considered as effective and valid as the original, even though the copy
does not contain an original writing of my signature.
MUST BE SIGNED IN TIIE PRESENCE OF A NOTARY:
Subscribed and sworn before me this ____ day of----------' 20 __ .
My commission expires-------------'' 20 .
Nmary: _____________________________ ___
Signature (Applicant) Address City/State/Zip
CONFIDENTIAL
APPLICANT PERSONAL IDSTORY QUESTIONNAIRE
PRE-EMPLOYMENT HISTORY FILE ACCESS RESTRICTED BY GENERAL ORDERS
VERIFICATION OF INFORMATION
The information requested on this questionnaire will be used for reference by those who will be considering
your application for employment or training with the Arnold Police Department. An extensive background
investigation will be conducted into your personal history. Applicants for the position of police officer will be
1
required to take a polygraph (lie detector) examination to confirm the information in this questionnaire, and to
determine other items ofbackgronnd information.
ANY FALSE, MISLEADING, OR INCOMPLETE INFORMATION SUBSTITUTED FOR ACCURATE
INFORMATION WILL BE GROUNDS TO DISQUALIFY YOU FROM FURTHER CONSIDERA-
TION IN THE APPLICATION PROCESS WITH THE ARNOLD POLICE DEPARTMENT.
1
I confirm that I have read and that I understand the above and that all statements a ~ d documents pre-
'sented to the Arnold Police Department are true, correct, complete and made in good faith.
'
Signature Date
Please indicate position for which you are applying:
I.
2.
3.
4.
5.
6.
7.
8.
DIRECTIONS
BEFORE YOU BEGIN. read the entire set of directions and listing of documents required for submission.
All applicatiOn checklist is provided on page 13 for your convenience. This is a competitive process, therefore,
applications will no be accepted, processed or evaluated unless complete. All addresses and phone numbers
must include zip codes and area codes.
USE BLACK INK ONLY. Complete this form in your handwriting or printing. If you need any special
accommodation in completing this questionnaire, contact the Commander of Uniform Services
at (636) 296-3204.
Read each question carefully before answering. Be certain that your answers are legible.
Be Certain that each question is answered COMPLETELY and CORRECTLY. Submit all documents as
requested. If a question does not apply to you, write ''N/ A" (not applicable) in the space. Leave no blank space.
Initial EACH page on the bottom right comer.
Additional space is provided on pages 11 and 12 for answers which require clarification or further explanation.
All entries on pages II and 12 will begin with page, section number (Roman numerals I-XIII), and question
(letters A-L) you are explaining or clarifying.
Pursuant to Public Law 93-579, the disclosure of your Social Security Number is completely voluntary. Your
refusal to reveal it will in no way affect applications for any job or consideration provided by this Department.
The Social Security Number assists the Department in differentiating between applicants with similar or
identical names.
Upon completion, the questionnaire must be retorn to the Arnold Police Department, 2101 Jeffco Boulevard,
Arnold Missouri 63010.
INITIALS ---
CONFIDENTIAL
.
FULL NAME LAST
FIRST MIDDLE
lilliE PIKIIIE
ADDRESS Nli!BER STREET CITY STATE ZIP CODE BUS I NESS PIKIIIE/PAGER
PERMANENT I
NUMBER STREET CITY STATE ZIP COOE lllliiE PIKIIIE
ADDRESS
AGE HEIGHT WEIGHT HAIR EYES llATE OF BIRTH PLACE OF BIRTH
SOCIAL SECURITY NUMBER OPERATOR'S LICENSE IIUMBER
STATE ISSUED
A. LIST ANY OTHER NAMES .YOU HAVE EVER USED:
B. ARE YOU A CITIZEN OF THE UNITED STATES? c. WERE YOU NATURALIZED?
Dyes DNo DvEs ONO
D. liST FIRST YOUR PRESENT ADDRESS, THEN LIST ALL ADDRESSES !mERE YOU HAVE LIVED FOR THE PAST TU (10) VEAIIS, INCLUDING
YOUR ADDRESS(ES) IN THE MILITARY SERVICE OR YHilE ATTENDING COLLEGE:
FROM TO STREET ADDRESS CITY /COUNTY STATE ZIP CODE
.
-.. ------
E. HAVE YOU EVER APPLIED FOR A POSITiON IIITH THIS DEPARTMENT BEFORE?
Dves ONO
IF
11
YES,'' DATE OF APPLICATION
F. HAVE YOU Fl LED AN EMPLOYMENT APPLICATION WITH ANY OTHER SOURCES
Dves ONO RECENTLY? IF "YES,
11
LIST BELOW:
DATE ORGANIZATION/FIRM NAME
II,,
ADDRESS/ZIP CODE POSITION APPLIED FOR DISPOSITION
.
G. ARE YOU ACQUAINTED WITH ANY Arnold Police Department
EMPLOYEES? IF
11
YES,
11
PLEASE LIST: Dves ONO
.
M. BASED ON THE ESSENTIAL FUNCTIC*S OF THE POSITION FOR WHICH YOU APPLIED, DESCRIBED IN THE IIRITTEN JOB DESCRIPTION
THAT ACCOMPANIED THIS APPLICATION, ARE YOU ABLE TO PERFORM THESE FUNCTIONS?
DYEs DNo
PAGE 2
INITIALS-'----
CONFIDENTIAL
LIST fCUR (4) CHARACTER REFERENCES, TWO OF IIIIlCH ARE NEAR YCU!l SilllE AGE AND AilE NOT RELATIVES, !M-WIS OR Po\ST
YOO HAVE KIICW YCU IIEll llURING THE PAST THREE YEARS OR IIORE:

P!KiiiE lll.llliiER YEARS ACSUAINTED
RESIDENCE ADDRESS
CITY
STATE ZIP OODE
BUSINESS NAME AND ADDRESS
OCCUPATION
_!j NAME
P!KiiiE NlmBER YEARS ACQUAINTED
RESIDENCE ADDRESS
CITY STATE ZIP OODE
BUSINESS ADDRESS
DCCUPATIOII
.

PHONE NlmBER YEARS ACCIWU NYED
RESIDENCE ADDRESS
CITY STATE ZIP OODE
BUSINESS ADDRESS
OCCUPATION

PHONE NlmBER YEARS ACQUAINTED
RESIDENCE ADDRESS CITY STATE ZIP IXlDE
BUSINESS ADDRESS OCCUPATION
A. OTHER THAN TRAFFIC CITATIONS, HAVE YCU, AS AN ADULT OR JUVENILE, BEEN ARRESTED, CONVICTED, CHARGED, QUESTIONED,
ACCUSBl OR DETAINED FOR ANY REASON BY AMY POLICE, SECURITY OFFICER OR MILITARY POLICE AUTHORITY, EITHER IN THE UNITED
STATES OF AMERICA OR IN AMY FOREIGN COUNTRY?
Dves DNO IF ."YES, DESCRIBE BELOY AND EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
DATE CHARGE DEPARTMENT/AGENCY LOCATION (CITY, CCUNTY, STATE) DISPOSITION
B. llERE YCU EllER SERVED WITH A CRIMINAL OR CIVIL SUBPOENA OR SUMMONS OTNER THAN TRAFFIC?
Dyes DNo IF "YES, EXPLAIN IN FULL DETAil ON PAGES 11 AND 12.
c. HAVE THE POLICE EVER BEEN CALLED TO ANY OF YOUR FORMER OR CURRENT RESIDENCES FOR ANY REASON?
Dns DNO
IF "YES, EXPLAIN INFULL DETAIL ON PAGES 11 AND 12.
D. HAVE YOU EVER BEEN INVOLVED IN ANY UNDETECTED CRIME, INCLUDING THE BUYING OR SELLING OF ILLICIT DRUGS?
Dves DNa
If "YES, EXPLAIN IN FULL DETAil ON PAGES 11 AND 12.
E. ARE YOU !roll UNDER CHARGES FOR ANY VIOLATION Of LAII?
Dus DNo IF "YES, EXPLA!M IN FULL DETAIL ON PAGES 11 AND 12.
PAGE 3
INITIALS----
CONFiD!ENTiAL
A. DO YOU HAVE: (CHECK APPROPRIATE BOXES)
OGED/HIGH SCHOOl
03-31 COlLEGE CREDIT HOURS
03263 COllEGE CREDIT HOURS
064119 COLLEGE CREDITS
DsACHELOR'S DEGREE
OPOST GAAOOATE DEGREE
B. STARTING YITH THE MOST RECENT, LIST ALL ELEMENTARY,
HIGH SCHOOl, COLLEGES Allll UNIVERSITIES YOU NAVE ATTENDED:
MONTH & YEAR ATTENDED NAI!E AND LOCATION
# CREDITS
YEAR OF
FROM TO (STREET, CITY STATE, ZIP) COMPLETED TYPE OF DEGREE MAJOR DEGREE
c. STUDENT ASSOCIATIONS/ACTIVITIES:
D. HAVE YOU EVER BEEN SUSPENDED, EXPELLED OR ASKED TO LEAVE ANY SCHOOL FOR DISCIPLINARY REASONS?
Dves DNo IF "YEs, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
E. HAVE YOU EVER BEEN PLACED ON ACADEMIC PROBATION?
DvEs DNo IF Yes, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12e
F. ARE YOU A GRADUATE OF A CERTIFIED POLICE ACADEMY OR LAW ENFORCEMENT TRAINING PROGIWI"I
Dyes DNa IF "YES," EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
G. INDICATE LANGUAGES YOU SPEAK, READ AIID/OR WRITE OTHER THAN ENGLISH:"
==-..
FLUENT ABOVE AVERAGE FAIR
SPEAK
READ
11,
WRITE
H. SPECIAL SKILLS, QUALIFICATIONS AND AWARDS SUMMAKIZE SPECIAL SKILLS, QUALIFICATIONS AND ACCOMPLISHMENTS (INCLUDING
CLERICAL SKILLS) THAT YOU WISH TO BE CONSIDERED:
PAGE 4
INITIALS---
V. IEIMIPlOYIMIIENT
CONFIDENTIAL
START WITH TCUR PRESENT OR LAST JOB AND LIST ALL OF THE PLACI:S YOO HAVE WORKED FOR THE PAST TEN YEARS.
LIST ANT
A.
ADDITIONAL EMPLOYERS ON PAGES 11 AND .1Z. IF Y00 ME PIIESEIITLY m>I.O'IBI, IIAY liE t:llBTliCT 111111 EII'UIIE!l?
Dves oliO

ADDRESS
CITY I STATE
ZIP CODE
PHONE IIUMBER
DATES EMPLOYEO I
HCURLY OR ANNUAL SALARY I
JOB TITLE
FROM
TO
START
FINAL
WORK PERFORMED
SUPERVISOR
CO WORKER
REASON FOR LEAVING

ADDRESS
CITY I STATE
ZIP CODE PHONE IIUMBER
DATES EMPLOTEO I
HCURLY OR ANNUAL SALARY . f JOB TITLE
FRCII TO
START FINAL
WORK PERFORMED
SUPERVISOR co-WORKER
REASON FOR LEAVING
_:j EMPLOYER
ADDRESS
CITY
I STATE
ZIP CODE PHONE IIUMBER
DATES EMPLOYEO I
HCURLY OR ANNUAL SALARY I JOB TITLE
FRCII TO START FINAL
WORK PERFORMED
SUPERVISOR CO WORKER
REASON FOR LEAVING

ADDRESS
CITY
I STATE
ZIP CODE PHONE IIUMBER
DATES .EMPLOYEO J HOURLY OR ANNUAL SALARY I JOB TITLE
FRCII TO START FINAL
WORK PERFORMED SUPERVISOR CO WORKER
REASON FOR LEAVING
B. HAVE YOU EVER BEEN DISMISSED, FIRED OR ASKED TO RESIGN FRCII ANY EMPLOYMENT?
Ores DNO IF "YES, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 1Z.
c. HAVE YOU EVER STOLEN ANY MONEY OR MERCHANDISE FROM A(IY PLACE OF EMPLOYMENT?
INCLUDE FINAL DISPOSITION DF ALL !TENS
(I.E., SOLD, RETAINED FOR PERSONAL USE, RETURNED, ETC.)
Ores DNO
IF "YES," EXPLAIN IN FULL DETAil. Clll PAGES 11 AND 1Z.
D. HAVE YOU EVER BEEN UNEMPLOYED FOR A PERIOD DF TIME IN EXCESS DF SIX MONTHS?
DYEs DHO IF "YES, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 1Z.
PAGE 5
INITIALS---
CONFiDENTIAL
A. LIST ALL CIVIC OR SOCIAL ORGANIZATIONS, FRATERNITIES, CLUBS, BROTHERHOODS,
SOCIETIES 1m GROOPS OF IIIIlCH YOU ARE, Oft
HAVli BEEN, A MEMBER OR ASSOCIATE. ALSO FURNISH THEIR LOCATIONS.
NME Of ORGANIZATION ADDRESS
OFFICE HELD
B.
ARE YOU Hal, OR HAVE YOU BEEN, A MEMBER OF ANY FOREIGN OR DOMESTIC SUBVERSIVE ORGANIZATION, ASSOCIATION, MOVEMENT
1
GROUP OR CLUB IIHICH HAS ADOPTED OR SHDIIS A POLICT Of ADIIIJCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOL
ENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES OR THE STATE OF MISSOURI, BY ANY
UNLAWFUL OR UNCONSTITUTIONAL MEANS?
DYES
DNO IF "YES, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
A. ARE YOU REGISTERED WITH THE SELECTIVE SERVICE? B. REGISTRATION NUMBER c. LOCATION WHERE REGISTERED
Dyes DNO
D. DO YOU HAVE A CURRENT OBLIGATION WITH THE UNIT ADDRESS/PHONE COMMANDER
MILITARY SERVICE?
DYES DNo
E. HAVE YOU EVER SERVED IN THE ARMY NAVY, MARINE CORPS, AIR FORCE, COAST GUARD, ROTC, OR ANY OTHER MILITARY OR SEMI
MILITARY ORGANIZATION? (IF THERE IS MORE THAN ONE PERIOD, LIST THE SEPARATE PERIODS)
Dyes DNo
MONTH/YEAR ENTERED BRANCH/ORGANIZATION DISCHARGE DATE TYPE Of DISCHARGE RANK OCCUPATIONAL SPECIALTY
..
,
F. WERE YOU EVER REDUCED IN RANK IN THE MILITARY?
Dves o.o !F
0
l'ES,
11
EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
REDUCED FROM TO
G. WERE YOU EVER COURT MARTIALED?
Dves DNo IF
11
YEtJ', n EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
TYPE OF COURT MARTIAL: DSUMMARY DsPECIAL DGENERAL
SENTENCE RECEIVED:
HAVE YOU EVER RECEIVED A CAPTAIN'S MAST, COMPANY PUNISHMENT OR ART! CLE 15?
DYEs DNo
IF
11
YES," EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
H. HAVE YOU EVER SERVED IN A MILITARY OR NAVAL ORGANIZATION OF ANY FOREIGN GOVERNMENT?
.
DYES DNo IF
11
YES
11
, EXPLAIN:
PAGE 6 INITIALS __ _
CONFIDENTIAL
A. LIST THE
OF-All YOUR INCCIIE AT TIME.
TYPE OF I NCOIIE
FIRM OR SWRC NAME
IIOIITHLY.o\MCMIT
YOUR SALARY
OTHER EMPLOYMENT
DIVIDENDS/INTEREST
MILITARY
OTHER (specify)
TOTAL
B. IF YOUR SPOUSE IS EMPLOYED,
PLEASE COMPLETE THE cno' nutur..
BUSINESS NAME
BUSINESS ADDRESS ZIP CODE
TELEPHONE NUMBER
I
JOB TITLE MONTHLY AMOUNT
c. LIST ALL DEBTS AND OBLIGATIONS WHICH YOU NOW OWE, AND THE INDIVIDUALS OR FIRMS WITH WHOM YOU HAVE CREDIT DEALINGS.
USE PAGES 11 AND 12 IF ADDITIONAL SPACE IS NEEDED.
OBLIGATION NAME, ZIP CODE
NUMBER
UNPAID -TUIY
AMY PAST DUE
DMORTGAGE DRENT
AUTO PAYMENT
PERSONAL LOANS
SCHOOL LOANS
CREDIT CARD
CREDIT CARD
CREDIT CARD
OTHER (specify)
OTHER (specify)
--==
.::::::s.;--

TOTALS La:
IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS "YES," WRITE DETAILS ON PAGES 11 AND 12.
MARK
11
YES
11
IF THE QUESTION
INVOLVES YOU, YOUR SPOUSE OR ANY EXSPOUSE.
D. HAVE YOU EVER BEEN DELINQUENT IN ANY OF
DYES DNa
J. HAVE YOU EVER FILED A LAWSUIT OR HAD A
YOUR FINANCIAL OBLIGATIONS?
REPRESENTATIVE FILE A LAWSUIT
ON YOUR BEHALF?
E. HAVE YOU EVER BEEN REFUSED CREDIT? DYES ONO
DvEs DNo
F. HAVE YOU EVER HAD ANY OF YOUR
DYEs DNo
K. HAS YCUR TAX RETURN EVEN BEEN AUDITED
PROPERTY REPOSSESSED?
BY THE IRS FOR ANY REASON OTHER THAN
A RANDOM AUDIT?
G. HAVE YOU EVER FILED BANKRUPTCY? DYES DNo
Dves ONO
Dyes DNa
L. HAVE YOU EVER FAILED TO FILE
H. HAVE YOU EVER BEEN SUED IN COURT?
OR BEEN DELINQUENT IN
F-ILING YOUR TAX RETURN?
I. HAVE YOU EVER REC1VED A SETTLEMENT IN
PAYMENT FOR DAMAGES, INJURY, LIBEL, ETC. 0
EITHER WITH OR WITHOUT COURT ACTION? YES DNo
DvEs 0110
PAGE 7
INITIALS
CONFIDENTIAl
A. WITHIN THE LAST SiX IIOIITHS,
HAVE YOU CONSUMED ANY AlCOIKli.IC BE\IEIIAGES BECAUSE OF AN ADOICTION TO AlCOHOl?
DvEs DNo
IF "YES, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
B. VITHIN THE LAST SIX IIOIITHS, HAVE YOU USED A CONTROLLED SUBSTANCE WITHDUJ A PRESCRIPTION?
DvEs DNO IF "YES," EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
A. CHECX YOUR CURRENT MARITAL STATUS. USE ADDITICIIAL SPACE ON PAGES 11 AND 12 IF EXPLANATION IS NECESSARY.
DsiNGLE DeNGAGED DMARRIED DsEPARATED DDIVORCED DwiD<llo0
IF ENGAGED OR MARRIED, INDICATE THE FOLLOVING INFORMATION RELATIVE TO FIANCE(E) OR SPOUSE:
NAME (include .. ; den name> DATE OF BIRTH ADDRESS
CITY STATE ZIP CODE PHONE NUIIBER ANTICIPATED DATE OF MARRIAGE
IF SEPARATED OR DIVORCED, INDICATE THE FOLLOVING INFORMATION RELATIVE TO EXSPOUSE:
NAME (MAIDEN) DATE OF BIRTH ADDRESS
CITY STATE ZIP CODE PHONE NUMBER DATE OF SEPARATION/DIVORCE
CAUSE #
IF SPOUSe IS DECEASED, INDICATE THE FOLLOWING INFORNATION:
NAME (MAIDEN) DATE DECEASED
B. LIST ALL CHILDREN AND/OR DEPENDENTS. USE ADDITIONAL SPACE ON PAGES 11 AND 12 IF NECESSARY.
NAME DATE OF PLACE Of WITH WIKlll X suPPORT
BIRTH BIRTH RELATIONSHIP ADORESS RESIDING PROVIDED
;
.
r,.
c. DO YOU NOW SUPPORT ALL CHILDREN BORN. TO YOU?
DYES DNo IF
11
NO, EXPLAIN:
D.
ALL EMPLOYEES OF TIDS DEPARTMENT WORK A MlNIMUM EIGHT-HOUR DAY, FIVE DAYS PER WEEK, 50
WEEKS PER YEAIL ARE YOU ABLE TO MEET THESE REQUIREMENTS WITH OUT EXCESSIVE ABSENCES ?
Ores DNO
PAGE 8 INITIALS---
X. MA!Rlrir Al ST AT!UJS/fAMDl Y lflJ1liEMI!:iliEIRlS icontl
CONFIDENTIAL
E.
ARE YOU PRESENTLY LIVING WITH ANYONE ELSE (fRIEND OR RELATiVE)?
Dns
DNO
IF YES, El!PLAIM IN FULL DETAIL Gl PAGES 11 lliiD 12.
F.
HAVE YOU HAD ANY SERillUS PROBLEMS !liTH YOUR RELATIVES DR IHLAWS?
Dns
DNO
If "YES, EXPLAIN IN FULL DETAIL ON PAGES 11 AND 12.
G.
LIST FUll ~ ( S ) Of YOUR IMMEDIATE FAIIIlY, SUCH AS FATHER, PIOTHER (!lA! D E ~ -E) BIIOTHERS MD SISTERS.
NAME
DATE OF BIRTH
RELATIONSHIP ADDRESS
ZIP CODE PHONE IIIJMBER OCCUPATION
A.
IF THE NECESSITY AROSE FOR Yllll TO SHOOT A PERSOII IN TKE COURSE OF YllUR DUTIES i\S AN OFFICER, llllULD Yllll HAVE ANY
RELUCTMCE TO DO SO?
DYEs otiC IF
11
YES, EXPLAUl IN DETAIL:
B.
HAVE Yllll EVER USED A IIEi\PON TO DEFEND YOURSELF DR OTHERS? IF "YES, EXPLAIN IN DETAIL:
Dves DNo
c.
AS THE NEED TO DO SO MAY ARISE AT AllY TIME, ARE YllU PHYSICALLY CAPABLE OF MAICING A FORCEFUL ARREST REQUIRING
PHYSICAL STRENGTH AND EXERTION?
Dyes DNO
IN 25 TO 50 WORDS, EXPLAIN WHY YOU WISH TO BE A POLICE OFFICER
COINFIDiEIIiTIAL
A.
LiST ALL DRIVER'S OR CHAUffEUR'S LICENSES YOO OR P!!EV!OOSLY MEW, EITNER iN MlSSCIJRl 011 MY
STATE OR COONTY
STATE TYPE OF Ll CENSE Ll tENSE MllfilfR
EXPIRATION DATE
.
B. HAVE AllY OF THE ABOVE LICENSES EVER BEEN SUSPENDED OR RE\IOICED?
Dvts DNO IF yes, EXPLAIN:
c.
LIST All DRIVING CITATIONS/TICKETS OR SUMMOilSES YOU HAVE RECEIVED AS All ADULT OR JUVENILE, BEGINNING IIITH THE NOST
RECENT. IF YOU CANNOT REMEMBER EXACT DATES OR LOCATIONS, GIVE APPROXIMATE DATES AND LOCATIONS.
MONTH/YEAR CHARGE CITY/STATE ISSUING AGENCY/DEPARTMENT D I SPDSITIOII
D. LIST ALL VEHICLES WHICH YOU OWN, LEASE OR HAVE FOR YOUR PERSOIIAL USE (INCLUDE MOTORCYCLES).
YEAR MAKE MODEL L1 CENSE NI.I4BER STATE
E. 1100 MANY TRAFFIC ACCIDENTS YOU BEEN INVOLVED IN DURING THE PAST FIVE YEARS? EXPLAIN CIRCUMSTANCES OF EACH
.
F. LIST ALL INFORMATION RELATIVE TO YOUR CURRENT AUTONOBILE INSURANCE:
NAME OF CONPANY ADDRESS CITY STATE ZIP CODE
PHONE NUMBER NAME OF AGENT
i,
POLICY NUMBER EXPIRATION DATE.
G. HAVE YOU EVER BEEN DENIED AUTONOBILE INSURANCE OR HAD INSURANCE CANCELLED?
Dves DNo IF "YES," EXPLAIN Uf DETAIL:
H. HAVE YOU RECENTLY CHANGED AUTONOBILE INSURANCE COMPANIES?
Dves DNo IF "YES," INDICATE THE FOLLOI/ING INFO!OO\TION RELATIVE TO YOUR PREVIOUS INSURANCE COMPANY.
NAME OF COMPANY ADDRESS ZIP CODE PHONE NUMBER DATE DISCONTINUED
PAGE 10 INITiALS __ _
USE THIS PAGE FOR AHY ADDITIONAL JNFCI!IIATION.
LIST QUESTION NIIIIBER TO IIlliCH THE ADDITIONAL IMFCI!IIATION APPLIES.
PUT
YOUR lli!TIALS AT THE ENO OF EACH ITEH ANO AT THE BOTTOM OF THIS PAGE .
QUESTION IIUMBER
ADDITIONAL INFORHATIOM
PAGE SECTION
LETTER
(111) (IXIII)
(AL)
.
PAGE 11
INITIALS---
USE THIS PAGE FOR ANY ADDITIONAL INFORMATION.
LIST QUESTION NUMBER TO WHICH THE ADDITIONAL
YOUR INITIALS AT THE END OF EACH ITEM AND AT THE BOTTON OF THIS PAGE.
INFORMATION ~ P L i E S . PUT
QUEST I OJrl NUMBER
ADDITIOIIAL INFORMATION
PAGE SECTION LETTER
(111) (lXllll (A-Ll
1 .
PAGE 12
INITIALS----
The foll()wing documents must be in.cluded with this application, or explain why
they are not included. All documents submitted become the property of the Arnold
Police Department and will no be returned.
1. Completed Certificate of Applicant and Authorization for release of
Information.
2. Certified copy of birth certificate ( state issued with raised impression,
certified or notarized copy). If you are applying for a noncommissioned
(civilian) position, a photo copy is acceptable.
3. Copies of all educational transcripts, (including police academy records)
High School and College must have a raised seal aff"IXed. If you are applying
for a noncommissioned (civilian) position, a photo copy is acceptable.
4. Copy of military discharge papers- DD From 214.
5. Two recent facial photographs. Polaroid, passport or photo booth
photographs are acceptable.
6. Special Awards
7. Naturalization papers (if applicable).
8. Copy of your Social Security card.
9. Copy of any license, including state issued motor vehicle operator's
license, pilot's license, radio operator's If you are applying for
a noncommissioned (civilian) position, you need not submit this item.
i!YES i!NO
i!YES i!NO
IF UNABLE TO FURNISH ANY OF THESE DOCUMENTS, PLEASE EXPLAIN:
DOCUMENT REASON FOR EXCLUSION
I,,
'
REV. ll/02/01
PAGE 13 INITIALS __ _
\\ ulrh
( UIIIII1111HICI'
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2 Dispatchers
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Jail
Public
Information
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ARNOLD POLICE DEPARTMENT
ORGANIZATION CHART
2007
D.A.JU./ S.R.O
Youth Officer
Special
Operations
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Assignment
Detectives
Narcotics
1 Detective
Crime Prevention
&
Evidence Detective
Internal
Affairs

..
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LAST NAME FIRST NAME MIDDLE INITIAL
DATE:
lf>OSITION APPLIED FOR:
DATE OF BIRTH:
:SOCIAL SECURITY #:
REMARKS: --------------
EMPLOYEE REFERRAL
EMPLOYEE NAME: DSN:
PRIOR MILITARY: o YES o NO
BRANCH:
POST CERTIFIED: o YES o NO
AGENCY:
EDUCATION:
HIGH SCHOOL
Bl HRS
32-63 HRS ________ _
-;,,_
SIGNATURE:
64+ HRS ---------
BS
MS
DATE: