Police Service Commission Form - Michigan - Edit, Fill, Sign Online

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100 E. Michigan Blvd. * Michigan City, IN 46 360 * Telephone: (219) 87 3-1570 *

Emergency: Dial 911

email: [email protected]

Dear Applicant:

Enclosed is the Michigan City Police Department application, which must be completed and

may be returned in the self-addressed envelope. It is your responsibility to affix the postage.

The additional attachment of five sheets, listing instructions and the basic functions of a

police officer, may be retained for your reference.

BEFORE RETURNING, PLEASE RE-CHECK. THE INFORMATION MUST BE

TRUTHFUL, NEAT AND COMPLETED IN FULL. We will not return incomplete

applications and failure to follow instructions may disqualify you.

PLEASE NOTE, ON PAGE 9, TH AT A NOTARY IS REQUIRED.

Make sure the following items are included with your application:

1. Authenticated copy of a birth certificate.

2. Copy of a high school diploma or certified copy of a G.E. D. certificate .

(On-line high school diploma will not be accepted.)

3. Copy of your valid state driver’s license.

4. Copy of y our social security card.

5. Certified copy of a transcript issued by an accredited high school or a

certified achieve ment test certificate from an accredited high school or

State Board of Education. (On-line high school transcripts will not be

accepted.)

6. Copy of your DD 214 (If applicable).

If you have any questions please contact our office at 873-1570.

Sincerely,

Michael D. Palmer

Commissioner

1

DATE_______________________ PLEASE PRINT ALL INFORMATION

NAME ______________________________________________________________________

LAST FIRST MIDDLE MAIDEN (IF APPLICABLE)

PERMANENT ADDRESS _______________________________________________________

STREET APT. NO.

____________________________________________________________________________

CITY COUNTY STATE ZIP

TELEPHONE: HOME ( )_________________ WORK ( )___________________

AREA CODE AREA CODE

Cell Phone: ( ) ______________ Email Address: _____________________________

AREA CODE

NOTE: All information must be truthful and all documents must be attached. Application must

be completed neatly if it is to be processed.

MERIT COMMISSION RULE #3 , Article XVI-A: Any applicant who personally, or through

another person, solicits a member of the Commission to favor such applic ant’s

appointment or reappointment shall thereby be rendered ineligible indefinitely

for an appointment to the Department.

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

COMPLYING WITH ALL PROVISIONS OF

THE AMERICANS WITH DISABILITIES ACT

MICHIGAN CITY POLICE DEPARTMENT

102 West 2

nd

Street Michigan City, IN 46360

EMPLOYMENT APPLICATION

2

I. INITIAL REQUIREMENT AREA

A. Are you a U.S. Citizen? _______ If no, explain on a separate sheet and attach documentation.

B. Social Security Number _______________________ __________________ _______

(For background clearance and p ayroll informatio n this number is required. The applicatio n will not be processe d without it.)

C. Age __________ Date of Birth _______________________________ Sex ____________

(Attach Copy of Birth Certificate)

Race ____ ____ _______ ____ _______ ____ __ (Information requested for EEO compliance only)

II. FAMILY DATA

A. Marital Status: Married ______ Single ______ Divorced ______ Separated ______

B. Spouse’s Name (If applicable) ________________________________________ ___________

C. Dependents (If applicabl e)

NAME AGE RELATIONSHIP

D. If divorced, are you legally required to make child support payments? __________

Are you current on child support payment s? If no, explain _____________________________________ ___

______________________________________________________

III. EDUCATION DATA (ATTACH TRANSCRIPTS FOR ALL)

List information for High School and all accredited Colleges/Universities you have attended.

NAME & ADDRESS OF SCHOOL

COURSE OF

STUDY

NUMBER OF HOURS

COMPLETED

GP A ON 4.0

SCALE

DID YOU

GRADUATE?

LIST

DIPLOMA

OR

DEGREE

3

IV. EMPLOYMENT DATA

A. Have you ever been discharged or resigned to prevent being discharged from a position of employment? _____

If yes, please explain on a separate sheet.

B. List chronolo gically (most recent emplo y ment first) all past and current employment, including part-time.

(Use additional sheets if necessary)

Name of Employer or Business _______ _________________________________ ___________________________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip _____________________ Phone # ____________________

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip _____________________ Phone # ____________________

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip _____________________ Phone # ____________________

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip ________ _____________ Phone # ____________________

4

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip _____________________ Phone # ____________________

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip _____________________ Phone # ____________________

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip _____________________ Phone # ____________________

Name of Employer or Business _______________________________________________________ ____________

Your Title ______________________________ Duties ______________________ ________________________

Date of Employment From : ______________________________ To: _____ _________________ _____________

Month Year Month Year

Reason for Leaving ___________________________ _________________________________________________

____________________________________________________________________________________________

Address of Business _________________________________________ __________________________________

City _____________________________ State & Zip ________ _____________ Phone # ____________________

5

V. REFERENCES: (Please do not list relatives as references)

Name ________________________________________ Phone __________________________________

Address _________________________________________________________________________________

City ____________________________________ State _______ ____________ Zip _________________

Name ________________________________________ Phone __________________________________

Address _________________________________________________________________________________

City ____________________________________ State _______ ____________ Zip _________________

Name ________________________________________ Phone __________________________________

Address _________________________________________________________________________________

City ____________________________________ State _______ ____________ Zip _________________

VI. RESIDENCE: (List The Last Five Years Other Than Present)

DATES

STREET CITY STATE

FROM TO

VII. MILITARY HISTORY AND STATUS

A. Have you ever served in the military on active duty? (Include initial active duty training with the National Guard

and the Reserves. ) ___ _____ If yes, attach a copy of your DD214.

D

A

TES

MILITARY BRANCH

FROM

TO

HIGHEST RANK ATTAINED AND

RANK AT SEPARATION

TYPE OF DISCHARGE AND

REENLISTMENT CODE

B. Are you eligible to reenlist? ________ If no, explain fully on a separate sheet.

C. List any citations and awards received. ________ _________________________________ ________________

________________________________________________________________________________________

D. Were you ever disciplined (court martial, article 15, captain’s ma st, etc.) while on active duty? _____________

If yes, explain fully on a separate sheet.

6

VIII. VEHICLE ACCIDENT AND ARREST RECORDS

A. Do you currently possess a valid automobile license? ___________ Expiration Date ____________________

License Num ber _________________________ License Type ______ ________________ State ______ ____

Has your drivers license ever been suspended? _______ If yes, explain. _____________________________

_________________________________________________________________________________________________________________

B. List vehicle accidents in which y ou have been involved as a driver. Give date(s) and location(s).

DATE LOCATION WHAT HAPPENED

C. Have you ever received a ti cket for a traffic offense? _ ________ If yes, describe below:

DATE LOCATION CHARGE FINE OR SENTENCE

D. Have you ever been arrest ed for a criminal offense? _________ If yes, describe below:

DATE LOCATION CHARGE FINE OR SENTENCE

E. Have you ever been arrest ed for an act that would have been a crime had it been committed by an adult? ______

If yes, describe below:

DATE LOCATION CHARGE FINE OR SENTENCE

7

F. Have you ever been convicted of a felony? ___________ (If yes, explain on a separate she et of paper.)

G. Have you ever been or are you currently involved as a plaintiff, defendant, petitioner or respondent in any civil

court action? ____ ______ (If yes, explain on a separate sheet of paper.)

X. MISCELLANEOUS

A. Do you own your home? _______ If yes, how much i s cu rrent mortgage indebtedness? _________________

B. What is the amount of your indebtedness, other than home? ___________________________ _

C. Annual Income: Applicant _____________ ___________ Spouse _______ _______________

D. Are you a proprietor or part owner of any business or firm? _______ If yes, describe nature of business.

______________________________________________________________________________________

Are there any licenses for this/these business(s) in your name, i.e. liquor license? If yes, please describe.

______________________________________________________________________________________

E. Have you ever applied for a permit to carry a handgun? _____ Reaso n:_________________ __________

__________________________________________________________ Status: _____________________

F. What special skills have you developed through hobbies, education, occupation, or other special interests?

______________________________________________________________________________________

_______________ ________________________________________________ _______________________

G. If offered an appointment as an officer with the Michigan City Police Department are you willing to become a

bona fide resident of the County of Laporte, or any contiguou s County within the State of Indiana (Porter

Starke, or St. Joseph Counties); have adequate means of transportation into the City; and maintain your

residence tel ephone service with the City within 90 days after being appointed to the department? _______

8

Photograph to be front view, head and shoulders.

2 ½” square, and taken within the past six months.

Other photographs are not acceptable.

I certify that:

1. All required items are included with this application.

A. Birth Certificate (copy only)

B. High School and/or College Transcripts (Grade reports are not accepted)

C. Military – DD214 (if veteran), DD217 (if active duty)

D. Valid Drivers License (copy only)

E. High School or GED Dip loma (copy only)

F. Social Security Card (copy only)

2. I have personally completed this application.

I swear or affirm under penalty of perjury that all

Information contained in this application is true

and accurate to the best of my knowledge.

Signature ______________________________

Date ______________________________

CHECK APPLICATION CAREFUL L Y, BE CERTAIN ALL ITEMS ARE COMPLETE BEFORE MAILING

THIS APPLICATION WILL BE RETURNED TO YOU IF ALL INFORMATION IS NOT

COMPLETED AND ALL REQUIRED DOCUMENTS ARE NOT ATTACHED.

MAIL TO:

MICHIGAN CI TY POLICE CIVIL SERVICE COMMISSION

100 E. MICHIGAN BLVD.

MICHIGAN CITY, IN 46360

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

Complying will all provisions of the Americans with Disabilities Act.

Mount Photograph

In

This space.

Affix securely

9

MICHIGAN CITY POLICE DEPARTMENT

102 West 2

nd

Street Michigan City, IN 46360

Authority for Release of Information

Last Name

First Name Middle Name

Social Security Number

Sex Race Date of Birth (i.e. 00/00/00)

City County State Country

Place of Birth

I, __________________________, do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning

myself, by and to any duly authorized agent of the Michigan City Police Department and/or Michigan City Police Civil Service

Commission whether the said records are of public, private or confide ntia l nature.

The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions, financial

or credit institutions, includin g records of deposits, withdrawals and balanc es of checking and s avings accounts, and loans, and also the

records of commercial or retail credit agencies (including credit reports and/or ratings); public utility companies; employment and pre-

employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me, and salary

records; real and personal property tax statements and records, and other financial statements and records wherever filed; records of

complaint, arrest, trial and/or convictions for alleged or actual violations of law, including criminal, civil and/or traffic records; the results

of any polygraph examinations; records of complaint of a civil nature made by or against me, wheresoever located, and to include the

records and collections of attorneys at law, or of other counsel, whether representing me or another person in any case in which I

presently have, or have ha d an interest.

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 life, for the specific purpose of pursuing a background investigation which may provide pertinent data for the Michigan City

Police Civil Service Commission to consider in determining my suitability for employment with the Michigan City Police Department. It

is my specific i ntent to provid e acc ess to per sona l informati on, however person al or co nf ide ntial it ma y app ear to b e, and th e sources of

information specifical ly identified herein.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in

whole or in part, upon this release authorization will be considered in determining my suitability for employment by the Michigan City

Police Dep artment. I unders tand t hat all m aterials pertai ning to this back ground inv estigation b ecome t he propert y of the M ichigan City

Police Department, Michigan Cit y Police Civil Service Commission and will not be retur ned to me.

I agree to indemnify and hold harmless the person to whom this request is presented and his/her 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, I further understand that in the event my application is disqualified, the sources of confidential information

cannot be revealed to me.

AGILITY TEST WAIVER

During the course of the physical fitness and agility test, I understand that there is a possibility that I may be injured. I hereby release

the Michigan City Polic e Department an d their princ ipals, agents and emplo yees, from any and all liability con nected with this agility test

and waive any rights I may have against the Michigan City Polic e Department, their agents and employees in connection herewith.

I also agree to provide a doctor’s statem ent, at my cost, indicating that I am able to take the physical fitness and agility test.

A photocop y of this release fo rm will be valid as an origin al here of, even though the said photocop y does not cont ain an ori ginal writing

of my signature.

Address

MUST BE SIGNED IN THE PRESENCE OF A NOTARY

Subscribed and sworn before me this ______ day of ____________ 20 _____

My Commission expires : _______ / _______ / _______

Notary Public Resident of __________________ County

Notary Signature ______________________________________________

Applicant Signature

City State Zip

10

MICHIGAN CITY POLICE DEPARTMENT

E

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QUESTIONAIRE

The City of Michigan City is an Equal Employment Opportunity/Affirmative Action Employer.

To

maintain our E.E.O. records and to check on how effective our recruitment program is, we ask that

you VOLUNTEER the following information. THIS INFORMATION WILL NOT BE USED IN

DETERMINING YOUR ELIGIBILITY FOR EMPLOYMENT. Please DO NOT

write your name or

social security number on this page.

POSITION APPLYING FOR: AGE: SEX:

Do you consider yourself to be handicapped ? ______________

Do you suffer from any dis ability? ____________

If so, please explain the disability or handicap and what reasonable accommodation could be made.

___________________________________________________________________________________

RACE

:

___ Caucasian (White)

___ Black

___ Hisp anic

___ A.A. (Oriental)

___ American Indian

___ Other

How did you learn about this position:

_____ Walk In ____ Recruiting Bulletin Board

_____ Referred by City Employee ____ Newspaper

_____ Indiana Employment Security Division ____ Radio

_____ Profes sional Journal ____ Internet

_____ Other (please speci fy) ________ ________ ___ ____

Thank you for helping us meet the needs of our community. Once again, this information is

strictly for statistical purposes and in no way will this information be used to determine your

employment opportunity.

Fillable Printable Police Service Commission Form - Michigan

Fillable Printable Police Service Commission Form - Michigan

Police Service Commission Form - Michigan