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Fillable Printable Police Service Commission Form - Michigan

Fillable Printable Police Service Commission Form - Michigan

Police Service Commission Form - Michigan

Police Service Commission Form - Michigan

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100 E. Michigan Blvd. * Michigan City, IN 46 360 * Telephone: (219) 87 3-1570 *
Emergency: Dial911
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 Copyof 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 toanyduly authorized agent of theMichigan 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 specificpurpose 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
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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.
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