Municipal Police Officers' Training Academy Application NOTE: A money order, personal check or cashier s check made payable to Westmoreland County Community College in the amount of $50 must accompany this application. Failure to remit the application fee will result in your application not being considered. The application fee is not reimbursable should you not be selected for the Westmoreland Municipal Police Officers Training Academy. This application along with all supporting documents as mentioned in the cover letter must be postmarked by the advertised deadline. I am applying for: l Part-time Academy l Full-time Academy General Information Name (Last) (First) (Middle Initial) (Maiden Name) Home Address Email Address Phone Numbers (Home) (Cell) (Work) Employer's Name Employer's Address Occupation Supervisor's Name Phone Number Date of Birth Place of Birth Marital Status Height Weight Social Security No. PA Driver's License No. Identifying Scars/Marks Military Veteran (if yes, include copy of DD214) l Yes l No Type of Discharge List name, address, occupation and phone number for each of the following (as applicable): Spouse Name Child(ren) Name(s) Westmoreland Municipal Police Officers' Training Academy Application 1
Education School Name Location Year Began Elementary High School College Post Graduate Business Correspondence Other Year Completed Degree Awarded, If Any N/A Employment List all employers for the past five years beginning with the most recent (include part-time employment): Employer Address Contact Name & Number Date Began Date Ended Reason(s) Left Prior Licenses, Certifications & Police Academies List any license or certificate issued to you by/or related to a law enforcement agency/police employment: Certificate/License No. and Year Issued Agency Involved Is Certification/License Current? l Yes l Yes l Yes l No l No l No Indicate by date, location and school name, any basic law enforcement academy attended: Did you graduate? l Yes l No If no, what was the reason for not completing the program. Westmoreland Municipal Police Officers' Training Academy Application 2
List three references (two personal, one professional): References Name Address Phone No. Occupation Residences List all residences within the past five years beginning with the most recent: Dates (From-To) Residence Address Indicate if Owned or Rented Westmoreland Municipal Police Officers' Training Academy Application 3
Arrest & Conviction Record Responses to the following questions will determine an individual s eligibility to carry a firearm under state or federal law. This portion of the application must be completed and signed by the applicant. Be sure to check all questions Yes or No. A. Have you ever been arrested or charged with a violation of the laws including traffic violations? l Yes l No If yes, explain below and indicate all arrests, citations and dispositions. Note: Citations for illegal parking may be omitted. Date Location Charge Disposition If more space is needed, use a blank page and attach to this application. You must provide a copy of your PA driver s history record which may be obtained online at www.dmv.state.pa.us/ Click on Online Driver & Vehicle Services then Request Your Driver History. Attach a copy to this application. B. 18 Pa. C.S. 6105(a) prohibits persons convicted of any of the following offenses from possessing, using, controlling, transferring, manufacturing or obtaining a license to possess, use, control, transfer or manufacture a firearm in the Commonwealth of Pennsylvania. A conviction includes a finding of guilty or the entering of a plea of guilty or nolo contendere, whether or not judgment has been imposed, as determined by the law of the jurisdiction in which the prosecution was held. The term does not include a conviction which has been expunged or overturned or for which an individual has been pardoned unless the pardon expressly provides that the individual may not possess or transport firearms. Have you ever been convicted of a crime enumerated in the Pennsylvania Uniform Firearms Act, 6105(b)? l Yes l No Note: Crimes listed under 6105(b) appear below. 6105(b) crimes include: 908 911 Prohibited Offense Weapons Corrupt Organizations 3503 Criminal Trespass, if the offense is graded a felony of the second degree or higher *3701 Robbery 912 Possession of a Weapon on School Property 3702 Robbery of Motor Vehicle *2502 *2503 Murder Voluntary Manslaughter 3921 *3923 Theft by Unlawful Taking or Disposition upon conviction of a second felony offense 2504 *2702 Involuntary Manslaughter, if the offense is based on the reckless use of a firearm Aggravated Assault 3925 4906 Theft by Extortion when the offense is accompanied by threats of violence Receiving Stolen Property, upon conviction of the second felony offense False Report to Law Enforcement Authorities *2703 Assault by Prisoner 4912 Impersonating a Public Servant, if the person is impersonating a law enforcement officer *2704 Assault by Life Prisoner 4952 Intimidation of Witnesses or Victims 2709.1 Stalking 4953 Retaliation Against Witness or Victim *2716 *2901 Weapons of Mass Destruction Kidnapping 5121 Escape 2902 Unlawful Restraint 5122 Weapons or Implements for Escape 2910 Luring a Child into a Motor Vehicle 5501 Riot, if the offense relates to a firearm or other deadly weapon *3121 Rape 5515 Prohibiting of Paramilitary Training *3123 Involuntary Deviate Sexual Intercourse 5516 Facsimile Weapons of Mass Destruction 3125 Aggravated Indecent Assault 6110.1 Possession of Firearm by Minor *3301 Arson and Related Offenses 6301 Corruption of Minors 3302 Causing or Risking Catastrophe 6302 Sale or Lease of Weapons or Explosives *3502 Burglary C. Have you ever been convicted of an offense under the Act of April 14, 1972 (P.L. 233, No. 64) l Yes l No known as the Controlled Substance Drug Device and Cosmetic Act that may be punishable by a term of imprisonment exceeding two (2) years? Westmoreland Municipal Police Officers' Training Academy Application 4
D. Are you an individual who has been adjudicated by any court for conduct which, if committed by an l Yes l No adult, would constitute one of the crimes code sections preceded by an asterisk (*) on the preceding page in 6105(b)? i. Are you an individual who has been adjudicated delinquent by any court, as a result of l Yes l No conduct which would constitute an offense enumerated under 6105(b) of the Pennsylvania Uniform Firearms Act? ii. Has it been 15 years since the delinquent adjudication? l Yes l No iii. Are you thirty (30) years of age or older? l Yes l No E. Are you a United State citizen? If no, enter immigration identification number l Yes l No F. Are you subject to an active protection from abuse order, which provides for the confiscation of l Yes l No firearms during the period of time the order is in effect? G. Have you ever been convicted of a misdemeanor crime of domestic violence? l Yes l No Note: the conviction must be for a misdemeanor-graded offense and have, as an element, the use or attempted use of physical force, or the threatened use of a deadly weapon, committed by a current or former spouse, parent or guardian of the victim, by a person with whom the victim as a spouse, parent or guardian, or be a person similarly situated to a spouse, parent or guardian of the victim. H. Are you a fugitive from justice? l Yes l No I. Have you ever been adjudicated as an incompetent or been involuntarily committed to a mental l Yes l No institution for inpatient care and treatment under 302, 303 or 304 of the Pennsylvania Mental Health Act (Act of July 9, 1976, P.L. 817)? J. Are you now, or have you been, a member of an organization advocating violence or disobedience l Yes l No of the laws of the Commonwealth of Pennsylvania or of the United States? K. Do you have a favorable credit rating reflecting financial responsibility? l Yes l No *Please attach a copy of your credit report with this application. L. Do you have any reason to believe you are not qualified to be a police officer? l Yes l No Physical Fitness & Reading Tests You will be notified of the dates and times of tests. Is there a time of day and/or day of the week that is most convenient for testing? Additional Information Use the following space to explain or provide any additional information that you want considered. Please include the category of this application that you are commenting on for easy reference. Notice of Nondiscrimination Westmoreland County Community College will not discriminate in its educational programs, activities or employment practices based on race, color, national origin, sex, sexual orientation, disability, age, religion, ancestry, union membership or any other legally protected classification. Announcement of this policy is in accordance with state law including the Pennsylvania Human Relations Act and with federal law, including Titles VI and VII of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, Section 503 and 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and the Americans with Disabilities Act of 1990. Inquiries should be directed to the Affirmative Action Officer (presently Sylvia Detar) at 724-925-4190 or in Room 4100D, Westmoreland Business & Industry Center, Youngwood, PA 15697. Westmoreland Municipal Police Officers' Training Academy Application 5
Certification This application must be completed and signed by the applicant. The Oath of Applicant on the last page must be signed by the applicant and notarized. WARNING to the applicant: Do not sign and submit this application if any of the information which you have provided is not true and correct. I certify that this application contains no misrepresentation or falsification, omissions or concealment of material act and that the information given is true and complete to the best of my knowledge and belief and that I am signing this document with the full understanding that any false information or statement will subject me to the criminal penalties of 18 Pa. C.S.A. 4904, relating to unsworn falsification to authorities and will result in permanent disqualification from entering a Pennsylvania Municipal Police Officers' Training Academy program. Signed Date Release of Information I, of Print Name Print Address hereby authorize any former or current employer, any doctor or medical facility or any police officer or criminal justice facility/agency to release for examination to Westmoreland County Community College any and all records related to my employment history, medical history or criminal history, if any. I further hereby release and forever discharge said persons, agencies and schools from any liability whatsoever for release of said authorized information. Signed Date Westmoreland Municipal Police Officers' Training Academy Application 6
Oath of Application (To be read to Applicant) COMMONWEALTH OF PENNSYLVANIA COUNTY OF: SSN: (applicant) Before me, a (Title of person administering oath) in and for said Commonwealth and County, personally came the below-named applicant for admission to a Pennsylvania Law Enforcement Academy, who being duly sworn according to law, deposes and says that the statements contained in the foregoing application are true and correct. Further, the below-named applicant affirms this application contains no misrepresentations, omissions or concealment of material fact that may mislead officers of a Pennsylvania Law Enforcement Academy in deciding upon the admission of said applicant. The applicant is aware that all statements made by the applicant on the application are subject to investigation and that should any investigation at any time disclose any such misrep- resentation, omission, falsification or concealment of fact, the application may be rejected and applicant is sub- ject to prosecution for perjury or other criminal violation(s) as punishable by law. If appointed as a Police Officer, based upon graduation from the academy, the applicant may be dismissed from the appointed position. If selected, the applicant understands that, should the need for medical attention arise during training at Westmoreland, the applicant will be responsible for paying his/her own medical treatment. Westmoreland is not responsible, nor shall it be held liable for said medical attention. Witness my hand and seal of the office this day of 20. (Signature of Person Administering Oath) My Commission Expires: (Place seal here) (Signature of Applicant) (Date) (Type or Print Name) Westmoreland Municipal Police Officers' Training Academy Application 7