Town of Guilford Police Department 400 Church Street - Guilford CT 06437 Telephone (203) 453-8061 PRE-OFFER APPLICATION FOR EMPLOYMENT

CASE NUMBER ____________________

DATE ___________

NAME OF APPLICANT ______________________________________________ DATE APPLICATION RECEIVED ________________TIME RECEIVED________________ RECEIVED BY _______________________________________________________________ IF SPACE AVAILABLE FOR ANSWERING ANY QUESTIONS WITHIN THIS DOCUMENT IS INSUFFICIENT, PLEASE USE A SUPPLEMENTAL SHEET.

APPLICANT: A copy of the following, if applicable, must be submitted with your application for employment. 1. Naturalization Papers ___

6. Marriage license Divorce Decree or Legal Separation Papers ___

2. High School Diploma or equivalency ___ 7. CT Motor Vehicle Operator’s License ___ 3. College Diploma ___

8. Motor Vehicle Operator’s License other than Connecticut ___

4. Military Discharge ___

9. Selective Service Card ___

5. Military Separation Form DD-214 ___

10. Pistol Permit ___

INSTRUCTIONS Read each question carefully. ANSWER EVERY QUESTION - LEAVE NO BLANK SPACES - IF QUESTION DOES NOT APPLY TO YOU, SO STATE. A candidate may be rejected “who has intentionally made a false statement of a material fact or practiced, or attempted to practice, any deception or fraud in his or her application.” The candidate will personally prepare this form. All entries except the signature must be printed or typewritten. All entries must be made in either blue or black ink.

PERSONAL HISTORY: Full Name__________________________________________________________________________ Last

First

Middle

Present Address_________________________________________________________________ Street

Telephone (

City

State

Zip

)_________________________

Maiden Name, If applicable ________________________________________________________ List any other names, nicknames, or aliases you have been known by: ___________________

_____________________

_________________

If name was legally changed, give date of change: _______________ Are you a U.S. Citizen?

Yes _________ No ___________

If a naturalized citizen, give date and location of naturalization: Date: __________________

Location __________________Cert..# _________________

Place of Birth _____________________________________________________________________________ City or Town

County

State

Any other person(s) who reside at your residence? Name Date of Birth

Country Zip

Relationship

List chronologically all of your residences, for the past 15 years, other than present: (Use a supplemental sheet if necessary). 1. _______________________________________________________________________________ Street

City

State

Zip Code

From________________________________to______________________________________ date

date

2._____________________________________________________________________________ Street

City

State

Zip Code

From ___________________________________to_______________________________________ date

date

3._____________________________________________________________________________ Street

City

State

Zip Code

From___________________________________to_______________________________________ date

date

*******************************************************************************

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RELATIVES: Give complete names and addresses (if deceased, so state) (use a supplemental sheet if needed). Father _________________________Date of Birth _____________ Deceased - Yes ____ No ____ Address________________________________________________________________________ Street

City

State

Zip Code

Mother ________________________Date of Birth _____________ Deceased - Yes ____ No ____ Address Street

City

State

Zip Code

Brother ________________________Date of Birth _____________ Deceased - Yes____ No_____ Address_________________________________________________________________________ Street

City

State

Zip Code

Brother ________________________Date of Birth _____________ Deceased - Yes____ No____ Address ________________________________________________________________________ Street

City

State

Zip Code

Sister _________________________ Date of Birth _____________ Deceased - Yes ____ No ____ Address_________________________________________________________________________ Street

City

State

Zip Code

Sister _________________________ Date of Birth _____________ Deceased - Yes ____ No ____ Address ________________________________________________________________________ Street

City

State

Zip Code

REFERENCES: Fill in below the names of three persons not related to you, and not former employers, who have known you intimately for at least five years. All people to whom you refer may be asked to appraise your character, ability, experience, personality, and other qualities. (Connecticut resident preferred) _____________________________________________ ____________ ( __)______________ Name

Years Known

Residence Phone

___________________________________________________________________________ Home Address

Street

City

State

Zip Code

_______________________________________________________________(____)___________ Occupation or Profession

Work Phone

_______________________________________________________________________________ Business Address Street

City

State

Zip Code

In what capacity is the above known to you?____________________________________________ _____________________________________________

____________

Name

Years Known

( __)______________ Residence Phone

_______________________________________________________________________________ Home Address

Street

City

State

Zip Code

_______________________________________________________________(____)__________ Occupation or Profession

Work Phone

___________________________________________________________________________________ _______________________________________________________________________________ Business Address Street

City

State

Zip Code

In what capacity is the above known to you?____________________________________________

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____________________________________________ Name

____________ Years Known

( __)______________ Residence Phone

___________________________________________________________________________ Home Address

Street

City

State

Zip Code

_______________________________________________________________(____)___________ Occupation or Profession

Work Phone

_______________________________________________________________________________ Business Address Street

City

State

Zip Code

In what capacity is the above known to you?____________________________________________ *********************************************************************************** EMPLOYMENT: List chronologically, ALL EMPLOYMENT, including summer and part-time employment, paid or unpaid. (Use a supplemental sheet if needed) 1. Name ___________________________________ From ______________ To_______________ Salary __________________________________ Type of Work_________________________ Name of Immediate Supervisor _______________________________Phone No. ___________ Name of President/Dept. Head ____________________________________________________ Address _____________________________________________________________________ Street

City

State

Zip Code

Reason for Leaving____________________________________________________________ _________________________________________________________________________ 2. Name ___________________________________ From ______________ To_______________ Salary ___________________________________ Type of Work_________________________ Name of Immediate Supervisor _______________________________Phone No. ____________ Name of President/Dept. Head ____________________________________________________ Address _____________________________________________________________________ Street

City

State

Zip Code

Reason for Leaving______________________________________________________________ 3. Name ___________________________________ From ______________ To_______________ Salary _________________________________ Type of Work_________________________ Name of Immediate Supervisor _______________________________Phone No. ____________ Name of President/Dept. Head ____________________________________________________ Address______________________________________________________________________ Street

City

State

Zip Code

Reason for Leaving_____________________________________________________________

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4. Name ___________________________________ From ______________ To_______________ Salary ___________________________________ Type of Work_________________________ Name of Immediate Supervisor _______________________________Phone No. ____________ Name of President/Dept. Head Address _____________________________________________________________________ Street

City

State

Zip Code

Reason for leaving_____________________________________________________________ If currently, employed are you aware that we will be contacting your present employer? Yes ____ No____ Have you ever been dismissed or asked to resign from any employment or position you have held? Yes ____ No ____ Have you ever received a disciplinary notice or suspension; either verbal or written? Yes ____ No ____ If so, the employers name___________________________________________________________ ____________________________________________________________________________ Date __________ Reason ____________________________________________________ ******************************************************************************* EDUCATION: High School __________________________________

Location

Name

City

State

Zip Code

Dates Attended: ________________________________ to________________________________ Diploma Received?______________________________ College/University _______________________________________________________________ Location:_______________________________________________________________________ Date of Diploma or Degree: _____________________________ Major __________________________ Minor ___________________________ Technical Schools/Other School(s) - List Name- Location- Dates ___________________________________________________________________________________ ___________________________________________________________________________________ _______________________________________________________________________ Any other training, experiences, skills, (i.e., - Foreign Language, Shorthand, Telecommunications training, computer background, etc.) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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*********************************************************************************** MILITARY RECORD: Are you registered with the Selective Service?

Yes _____ No _____

If so, date registered:_______________________________________________________________ Location where you registered City

State

Have you ever served on active duty in the armed forces of the U.S.? Yes ____ No _____ Branch _______________________________ Date of Service _______________________ Serial Number _________________________ Type of Discharge _____________________ Highest Rank Held_________________________________ Location of Separation Center_______________________________________________________ Special Duties/Training____________________________________________________________ Are you now a member of the Reserves or National Guard? ________ Service Branch __________________________________________________________________ Reserve Status (active, ready, standby, voluntary ________________________________________ If you are in a pay status, where do you attend drills, meeting, or camps. Gave name of unit and location, Name of Supervisor, phone number:_______________________________________ ___________________________________________________________________________ While in military service, were you ever charged with a crime or disciplined in any way Yes ____ No _____ If yes, please explain: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ******************************************************************************* BANKRUPTCY/CIVIL LITIGATION/PAY GARNISHMENT: Have you ever filed bankruptcy? Yes_____ No ____If yes, state the year and location ____________________________________________________________________________ Have you ever been party to a civil litigation? (Divorce is a legal litigation) Yes ____ No ____ If yes, state the year, location and give specific details: ___________________________________________________________________________________ ________________________________________________________________________ Sued: ______________________________________ Plaintiff:_____________________________

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Has your pay ever been garnished? When?_______Why?________________________________ _______________________________________________________________________________ Do you now have any garnishments, wage assignments, or judgements against you or your property? Yes _____ No ____ If yes, give details: _____________________________________________ ______________________________________________________________________________ ******************************************************************************* MOTOR VEHICLE RECORD: Have you been convicted of a motor vehicle offense or received a motor vehicle infraction, citation, summons, ticket? Yes ____ No ____ If yes, list the offense(s), date(s), disposition(s). Offense

Date

Location

Disposition

Have you ever possessed, utilized, or forged any legal document; to include drivers’ licenses or license applications from this State or any other State? Yes ____ No ____ If yes, explain in detail

******************************************************************************* GENERAL INFORMATION: Are you a licensed Connecticut motor vehicle operator ? Yes _____ No _____ If yes, type: ______________________________ License # _______________________________ Have you ever possessed any operator’s license, other than listed above? Yes ____ No ____ If yes, State: ______________________________ License #_________________________ Date: From _______________________________to______________________________________ Have you ever been involved in a motor vehicle accident as an operator, occupant or pedestrian? Yes _____ No ____ Details: ____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Have you ever had any of the above operator’s license(s) or motor vehicle registration(s) suspended or revoked for any reason Yes ____ No ____ Reason for suspension/revocation____________________________________________________ State _______________________ Date of suspension/ revocation __________________________ List below any motor vehicle(s) presently owned by you? Vehicle ID# Make Type Date Purchased

License Plate #

State

Are you presently applying or have you ever applied for employment with any other law enforcement agency or public or private security agency? Yes ____ No ____ If yes, list agencies or employers *********************************************************************************** PRIOR PEACE OFFICER APPLICATIONS: ____Local Municipality ____ State Police Sheriff’s Dept. Federal Agency Other Date of application: ______________ Name of Department _________________________________________________________________ Location/Address: ___________________________________________________________________ Disposition of Application: ____Local Municipality ____ State Police ____ Sheriff’s Dept. _____ Federal Agency _____ Other Date of application: ______________ Name of Department:_________________________________________________________________ Location/Address:____________________________________________________________________ Disposition of Application : ____Local Municipality ____ State Police Sheriff’s Dept. _____ Federal Agency Other Date of application:____________ Name of Department:__________________________________________________________________ Location/Address:____________________________________________________________________ Disposition of Application : ____Local Municipality ____ State Police ____ Sheriff’s Dept. _____ Federal Agency _____ Other Date of application: ______________ Name of Department:__________________________________________________________________ Location/Address:____________________________________________________________________ Disposition of Application : ____Local Municipality ____ State Police ____ Sheriff’s Dept. _____ Federal Agency _____ Other Date of application: ______________ Name of Department:__________________________________________________________________ Location/Address:____________________________________________________________________ Disposition of Application:

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Have you ever applied with/tested with a private police testing firm? Yes ____ No _____ If yes, identify firm/date of test? _______ _______________________________________________________________________________ Firm Date For which Police Agency ? _____________________________________________________________ Have you ever been refused appointment/employment with any other law enforcement agency or public or private security agency? Yes _____ No _____ If yes, identify agency and date, and state reason of refusal: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Have you ever applied for a permit to carry a firearm or dangerous weapon? Yes ____ No ____ If yes, give date and location:_________________ ___________________________________________________________________________________ Are you now or have you ever been a member of, been employed by, attended meetings of or gatherings of, corresponded with, contributed to, subscribed to publications of, published materials for, or donated your services to any organization or group which advocates the overthrow of our constitutional form of government or which has adopted the policy of advocating or approving the commission of acts of adopted the policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the constitution of the United States or which seeks to alter the form of government of the United States by unconstitutional means? Yes _____ No ____ If yes, what organization and what is your association with it? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

***********************************************************************************

DRUG/ALCOHOL USE: The following list of drugs and substances are to be examined by you to determine the extent of use, if any, of each particular category of drug. Please indicate by checking the appropriate

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response to each question, if you have used any particular drug in the past or present.

A. HALLUCINOGENIC DRUGS

YES

NO

DATE OF LAST USE

If applicable Note: How many times used

YES

NO

DATE OF LAST USE

If applicable Note: How many times used

YES

NO

DATE OF LAST USE

If applicable Note: How many times used

MARIJUANA HASHISH/HASH OIL THC(powder or tabs) TETRAHYDROCANABINOL LSD (LYSERGIC ACID DIETHYLAMIDE DMT (DIE THYLTRYPTAMINC) PCP (PHENCYCLIDINE) PEYOTE MESCALINE HALLUCINOGENIC MUSHROOMS KETAMINE INDICATE ANY OTHER B. STIMULANTS COCAINE AMPHETAMINES ECSTASY

C. DEPRESSANTS BARBITURATES TRANQUILIZERS PAIN KILLERS

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D. NARCOTIC DRUGS

YES

NO

DATE OF LAST USE

If applicable Note: How many times used

YES

NO

DATE OF LAST USE

If applicable Note: How many times used

OPIUM MORPHINE HEROIN CODEINE METHADONE DILAUDID DEMEROL PARAGORIC E. SUBSTANCE/CHEMICAL USE ANABOLIC STEROIDS GLUE SNIFFING SNIFFING, PAINT THINNERS, SOLVENTS, SPRAYS, ETC ANYTHING ELSE NOT MENTIONED ABOVE

IF THE ANSWER IS YES TO ANY OF THE ABOVE DRUG RELATED QUESTIONS, PLEASE ANSWER THE FOLLOWING: F. G. H. I. J. K. L. M. N.

At what age did you first experiment with drugs?_________________ When was the last time you used drugs?________________________ What is the largest amount of drugs you have purchased?______________________________ What is the largest amount of drugs you have sold?___________________________________ What is the largest amount of drugs you have transported? Have you ever cultivated any marijuana?___________________ How many close friends do you know who use drugs? __________________ What type of drugs do they use? _______________________________________________ How many times have you used drugs? ____________________________________________ Type of Drugs ______________________ ______________________

Number of Times Used ______________ ______________

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GAMBLING/WAGERING: Have you ever or do you now engage in any type of gambling, betting or wagering of any kind? Yes _____ No _____ If yes, complete below:

TYPE

YES

NO

HOW OFTEN

DATE OF LAST WAGER

AVERAGE BET

STATE LOTTERY CASINO SPORTS HORSE RACING DOG RACING ANIMAL FIGHTING OFFICE POOLS JAI- ALAI ANY OTHER TYPE NOT MENTIONED ILLEGAL SEXUAL ACTIVITY: If you answer yes to any of the following questions, provide details including date and location (city and state). a. Have you every paid a fee to another person as compensation for that person to engage in a sexual act with you or a third person? Yes No b. Have you ever compelled another person through force or threat of force to engage in any sexual act? Yes No c. Have you ever subjected another person to any sexual contact without their consent? Yes No d. Have you ever engaged in sexual intercourse with another person when such other person did not consent or was unable to consent? Yes No e. Have you ever engaged in sexual intercourse with an animal? Yes

No

f. Have you ever engaged in sexual intercourse with a corpse? Yes

No

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g. Have you ever exposed yourself in public for sexual gratification? Yes

No

h. Have you ever secretly photographed, recorded, videotaped, looked at or listened to anyone without their knowledge or consent for your own sexual gratification when that person is not in plain view and they reasonably would have expected privacy? Yes No i. Have you ever engaged in any illegal sexual activity not mentioned above? Yes No If yes to any of the above questions, provide details here

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NOTICE:

CONNECTICUT GENERAL STATUTE 53a-157

“ A person is guilty of false statement when he intentionally makes a false statement under oath or pursuant to a form bearing notice, authorized by law, to the effect that false statements made therein are punishable, which he does not believe to be true and/or which statement is intended to mislead a public servant in the performance of his official function.” I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision. I understand that this questionnaire is but one element of the selection process for employment with the Guilford Police Department and that an acceptable background investigation does not guarantee my selection. In the event of employment, I understand that false or misleading information given herein or during interview(s) will result in my being disqualified from future consideration and/or termination from employment by the Police Department. I, ________________________________, being duly sworn, depose and say that I am the above named person. I have read and answered each and every preceding question and I do solemnly swear that each and every answer is full, true and correct to the best of my knowledge and belief. I further agree that should any investigation disclose any misrepresentation, falsification or omission, my application may be rejected and my name removed from the eligible lists. If already appointed, I may be discharged. Date _________________

Applicant’s Signature _______________________________

Subscribed and sworn to me this _________ day of ______________, ____________.

__________________________________________ Notary Public

GPD 257

March 2013

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