CITY OF SAYRE, OKLAHOMA AN EQUAL OPPORTUNITY EMPLOYER

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1 CITY OF SAYRE, OKLAHOMA AN EQUAL OPPORTUNITY EMPLOYER PRE-EMPLOYMENT POLICE DEPARTMENT APPLICATION We make decisions regardless of race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or disability, or any other legally protected status NAME DATE ADDRESS STREET PO BOX CITY STATE ZIP CODE D.O.B. SOCIAL SECURITY# HOME PHONE# CELL PHONE# MESSAGE # HAVE YOU EVER FILED AN APPLICATION WITH THE CITY? YES NO IF YES PLEASE GIVE DATES HAVE YOU EVER BEEN EMPLOYED WITH THE CITY BEFORE? YES NO IF YES PLEASE GIVE DATES DATE AVAILABLE FOR EMPLOYMENT FULL TIME PART TIME TEMPORARY POSITION TYPE OF EMPLOYMENT DESIRED ARE YOU AT LEAST 20 YEARS OF AGE? DRIVERS LICENSE # STATE EXP. DATE ARE YOU A CITIZEN OF THE UNITED STATES? YES NO (Proof of citizenship will be required upon employment)

2 SCHOOL COLLEGE NAME & ADDRESS OF SCHOOL GRADUATE YEAR DEGREE HIGH SCHOOL ELEMENTARY ARE YOU A CERTIFIED POLICE/CORRECTIONAL OFFICER? YES NO IF YES, PLEASE LIST STATE IF NO ARE YOU PRESENTLY ENROLLED IN ANY PROGRAM IN ORDER TO OBTAIN CERTIFICATION? YES NO NAME OF INSTITUTION DATE OF COMPLETION INDICATE ANY FOREIGN LANGUAGE YOU CAN: SPEAK READ WRITE 1. SPEAK READ WRITE 2. SPEAK READ WRITE 3. HAVE YOU EVER BEEN CONVICTED OF A FELONY? DATE IF YES PLEASE EXPLAIN PLEASE LIST ANY ARRESTS OR CRIMINAL/CIVIL OFFENSES YOU HAVE HAD OR STILL HAVE P DATE LOCATION OFFENSE DISPOSITION

3 PLEASE LIST ANY SPECIAL SKILLS AND QUALIFICATIONS ACQUIRED FROM EMPLOYMENT OR OTHER EXPERIENCES THAT MAY QUALIFY YOU FOR THE POSITION ARE YOU OR HAVE YOU EVER SERVED IN THE ARMED FORCES? BRANCH DATE TO - FROM REFERENCES: PLEASE LIST NAME, ADDRESS,, & YEARS KNOWN I HEREBY CERTIFY THAT ALL THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION FORM IS TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND IS MADE IN GOOD FAITH. I AGREE AND UNDERSTAND THAT ANY MISSTATEMENT OF FACTS CONTAINED IN THIS APPLICATION MAY DISQUALIFY ME FOR ANY EMPLOYMENT OR RESULT IN THE REMOVAL OF EMPLOYMENT WITH THE CITY OF SAYRE POLICE DEPARTMENT. APPLICANT SIGNATURE DATE

4 EMPLOYER, ADDRESS EMPLOYER, ADDRESS EMPLOYER, ADDRESS EMPLOYER, ADDRESS

5 CONFIDENTIAL EMPLOYEE INFORMATION NAME LAST FIRST MIDDLE DATE & PLACE OF BIRTH HEIGHT WEIGHT RACE SEX HAIR COLOR EYE COLOR MARITAL STATUS (CIRCLE ONE) SINGLE SEPARATED DIVORCED MARRIED WIDOW SPOUSE NAME EMERGENCY CONTACTS NAME ADDRESS NAME ADDRESS NAME ADDRESS LIST ANY MAJOR ILLNESSES OR SURGERIES YOU HAVE HAD IN THE PAST 5 YEARS? WRITE A BRIEF PARAGRAPH AS TO WHY YOU WOULD LIKE TO WORK FOR THE SAYRE POLICE DEPARTMENT

6 Chief of Police Ronnie Harrold CITY OF SAYRE POLICE DEPARTMENT 214 North Fourth Street SAYRE, OK Assistant Chief of Police Armando Villegas PHONE: (580) FAX: (580) AUTHORIZATION TO RELEASE INFORMATION TO: I HEREBY REQUEST AND AUTHORIZE RELEASE OF ALL OR ANY INFORMATION CONCERNING MY WORK RECORD, FINANCIAL STATUS, CRIMINAL RECORD, EDUCATIONAL HISTORY, MILITARY RECORD, GENERAL REPUTATION AND PAST OR PRESENT MEDICAL CONDITION TO THE CITY OF SAYRE POLICE DEPARTMENT. I HEREBY RELEASE YOU AND YOUR ORGANIZATION FROM ANY LIABILITY WHICH MAY OR COULD RESULT FROM FURNISHING THE INFORMATION REQUESTED ABOVE, OR ANY SUBSEQUENT USE OF SUCH INFORMATION IN DETERMINING MY QUALIFICATIONS TO SERVE AS AN EMPLOYEE FOR THE SAYRE POLICE DEPARTMENT. SIGNATURE OF APPLICANT DATE NOTE: THIS FORM MAY BE RETAINED IN YOUR FILES. NOTARY SUBSCRIBED AND SWORN BEFORE ME THIS DAY OF 20. NOTARY PUBLIC NAME MY COMMISSION EXPIRES NAME OF EMPLOYER

7 NAME OF APPLICANT SS# EMPLOYED FROM TO NAME OF ARE THE EMPLOYMENT DAYS LISTED CORRECT [YES] [NO] IF NOT, WHAT ARE THE CORRECT EMPLOYMENT DATES WHAT WERE THIS PERSON S PRIMARY DUTIES? WAS THIS PERSON S WORK CONSIDERED TO BE SATISFACTORY? YES [ ] NO [ ] IF NOT PLEASE EXPLAIN IS THIS PERSON ELIGIBLE FOR REHIRE? YES[ ] NO[ ] IF NOT WHY? WHAT WAS THE REASON FOR TERMINATION? IF THE PERSON RESIGNED WAS THE RESIGNATION VOLUNTARY? YES [ ] NO [ ] WAS THERE ANY PROBLEM WITH TARDINESS, ABSENTEEISM, OR EXCESSIVE SICK LEAVE? YES[ ] NO[ ] IF YES PLEASE EXPLAIN DID THIS PERSON GET ALONG WITH S, CO-WORKERS, AND THE GENERAL PUBLIC YES [ ] NO [ ] WAS THERE EVER ANY REASON TO DOUBT THIS PERSONS HONESTY YES [ ] NO [ ] IF YES PLEASE EXPLAIN DID THIS PERSON EVER COLLECT WORKERS COMPENSATION OR OTHER DISABILITY PAYMENTS YES [ ] NO [ ] IF YES PLEASE EXPLAIN DID THIS PERSON EVER HAVE ANY PERSONAL, DOMESTIC, OR FINANCIAL PROBLEMS WHICH INTERFERED WITH EMPLOYMENT YES [ ] NO [ ] IF YES PLEASE EXPLAIN PLEASE EXPLAIN THIS PERSONS GENERAL REPUTATION AMONG CO-WORKERS AND S NAME TITLE TELE DATE