APPLICANT: As an Applicant for a position with the Signal Hill Department, you are required to complete this form in it s entirety. You are hereby admonished that any false statement or omission on this form shall be cause for immediate disqualification and/or dismissal if an appointment is made. Do you understand this admonishment? Do you have any questions regarding this admonishment? Read and answer the following questions carefully and honestly. Yes answers may not necessarily be grounds for disqualification or non-selection, whereas any untruthful response will be. All answers are subject to verification by polygraph and medical examination, including but not limited to drug screening. Any questions that are answered with a Yes will require explanation. On the back of each page, you will find space to include an explanation. Please include the question number, and all pertinent information for your response. Have you ever committed any of the following acts? 1) Arson (intentionally setting fire) 2) Burglary (entry into structure or vehicle to commit crime or theft) 3) Robbery (theft from a person using force, fear, or intimidation) 4) Homicide or manslaughter 5) Forgery 6) Kidnapping 7) Extortion or blackmail 8) Embezzlement (theft of money or items entrusted to you) 9) Rape (sexual intercourse by force, including your spouse) 10) Sexual intercourse with person under age of 18 11) Incest (sexual activity with immediate family member other than your spouse) 12) Sex in a public or exposed place 13) Assault on another, including spouse 14) Domestic violence, including common-law partner 15) Child Abuse 16) Child molestation (any sexual contact with child under age of 18) 17) Bestiality (any sexual activity involving any animal) 18) Prostitution (any sexual act where you have received compensation) 19) Soliciting prostitution (paying compensation for any sexual act) 20) Accessed websites where child, or other illegal pornography is featured 21) Downloaded images of child or other illegal pornography 22) Possessed images of child or other illegal pornography 23) Public Intoxication (being so intoxicated as to be unable to care for yourself) 24) Been turned down for a concealed weapons permit 25) Carried a concealed weapon without permit 26) Carried an illegal weapon (switchblade, sawed off shotgun, etc.) 27) Possessed illegal weapons, including explosive devices 28) Been present when someone has committed an illegal act APPLICANT INITIALS: Page 1
29) Is anyone likely to report you have illegally carried or used a firearm 30) Did you fail to register for military service as required by law 31) Either as adult or juvenile, have you ever been investigated by law enforcement 32) Been placed on probation as adult or juvenile 33) Had a warrant issued for your arrest 34) Have you been on parole 35) Excluding traffic cites, have you ever been convicted of a crime as adult or juvenile 36) Been wanted by any law enforcement agency for any reason 37) Testified in a criminal proceeding 38) Had a criminal record as adult or juvenile, sealed or not 39) Illegally exposed your genitals 40) Participated in any illegal sex act 41) Registered as a sex offender 42) Participated in any sex related form of paid entertainment 43) Ever fired a firearm 44) Exhibited prejudice against anyone based on race, religion, or other 45) Made derogatory comments towards someone based on race, religion, or other 46) Denied someone equal treatment based on race, religion, or other 47) Frequently lose your temper 48) Been involved in a fight (if so, when was last time) 49) Started any fights 50) Struck someone living with you, or with whom you have a relationship 51) Caused serious injury to another, other than warfare or law enforcement action 52) Caused death to another, other than warfare or law enforcement action 53) Used any weapon (including knife, sap, baton, or other) to inflict injury 54) Anyone likely to report you have violent tendencies 55) Anyone likely to report you have anger or temper control issues 56) Been in trouble or missed days at work due to drinking alcohol 57) Been in trouble or missed work due to misuse of illegal or prescription drugs 58) Arrived at work under influence of alcohol, illegal, or misused prescription drugs 59) Consumed alcohol, illegal, or misused prescription drugs while at work 60) Friends, family, or associates who use, possess, manufacture, or sell illegal drugs 61) Remained in a place where illegal drugs are used, sold, manufactured 62) Purchased illegal drugs, including marijuana 63) Intentionally misused prescription drugs for purpose of becoming high 64) Sold any illegal or prescription drugs, including marijuana 65) Acted as a middle man in the purchase or acquisition of illegal drugs 66) Used prescription drugs for other than legitimate purposes 67) Purchased illegal steroids 68) Injected any substance, including steroids, into your body 69) Been given any illegal drugs without your knowledge 70) Manufacture, possessed, or passed off fake substance for sales 71) Ingested substance you thought was illegal 72) Anyone to report that you have used illegal substances, including marijuana APPLICANT INITIALS: Page 2
73) Possessed any of the following, even one time. If yes, on reverse, indicate last use, how many times used, and means of ingestion. Marijuana Hashish, hash oil Cocaine Barbituates, depressants Methamphetamine Heroin, opium, morphine, methadone LSD, mushrooms, peyote, hallucinogenics Ecstasy or other rave/designer drugs PCP Steroids Toluene, glue, paint thinner, spray paint Prescription drugs for illegitimate purposes Anything not listed that you have ingested for purpose of getting high 74) Received non-judicial punishment while in military (Article 15, Capt. Mast) 75) Considered to be AWOL, or taken unauthorized military leave 76) Been confined to base or post 77) Received any military discipline 78) Reduced in grade or rank while in military 79) Received court martial 80) Less than Honorable Discharge from military 81) Been denied re-enlistment into military 82) Used deadly force while in military combat operations 83) Had problems with gambling 84) Had gambling losses cause problems with meeting financial obligations 85) Had to borrow to cover gambling debt 86) Engaged in illegal gambling (bookie operations, off-shore gambling) 87) Placed bets for others on sporting events 88) Collected funds as a result of illegal gambling for yourself or others 89) Had employment problems due to gambling 90) Covered gambling losses with credit card 91) Filed false information on a loan document 92) Inflated earnings to secure a loan 93) Had account go to collections 94) Bounced or floated a check 95) Been late on paying taxes 96) Had salary attached for payment of debts 97) Declared bankruptcy, or filed for debt reorganization 98) Failed to make child support or spousal payments APPLICANT INITIALS: Page 3
99) Filed false tax return 100)Filed false insurance claim 101)Obtained financial gain through dishonest means 102)Collected welfare, unemployment when not entitled to 103)Received under the table income not declared or taxed 104)Had traffic citations which do not show up on DMV printout 105)Had ticket go to warrant 106)Driven without auto insurance 107)Driven without license, or with suspended license 108)Been denied auto insurance 109)Placed on probation for traffic related offense 110)Engaged in street racing 111)Been in police pursuit (other than as officer) 112)Fled scene of accident 113)Driven under influence of alcohol/drugs (If Yes, how many and last time) 114)Been in traffic collision 115)Had your vehicle searched 116)Any jobs not listed on Personal History Form 117)Called in sick when you were not 118)Been tardy or absent from work without cause 119)Had issues with co-workers 120)Had complaints made against you by co-workers, public 121)Been formally disciplined by supervisor 122)Been fired or asked to resign in lieu of termination 123)Resigned in order to avoid being fired or disciplined 124)Accused of misconduct in the workplace 125)Been the focus of any investigation regarding policy or criminal violations 126)Borrowed money or property from employer without permission 127)Been overpaid and not reported it to employer 128)Embezzled any money or property from employer 129)Stolen any money or property from employer 130)Accused of sexual harassment or hostile work environment 131)Committed any act in workplace that, if found, would result in termination 132)Intentionally lied or perjured yourself on any official reporting form 133)Taken a polygraph (If yes, by whom and for what purpose) 134)Belonged to any subversive or militant group 135)Committed any dishonest act in order to obtain police position 136)Filed false worker s compensation claim 137)Obtained degrees, diplomas, or transcripts without valid coursework 138)Used false identification, or other s ID as your own 139)Omit any information regarding status with past employers 140)Been named in a restraining order 141)Have or had any civil actions against you APPLICANT INITIALS: Page 4
142)Associated with members from street gang or criminal enterprise 143)Had a member of family associate with street gang or criminal enterprise 144)Attended any gathering of street gang 145)Violated any law while in company or on behalf of any street gang 146)Applied for any police related agency 147)Rejected for employment by any police related agency 148)Withdrawn application from any police related agency 149)Committed any crime not previously listed 150)Any visible tattoo s or marks (If yes then describe) Those applicants who are currently or previously employed as peace officers, reserve officers, correctional officers, or military police officers shall answer the following questions: 151)As a peace officer, have you ever accepted a gratuity 152)As a peace officer, have you ever accepted anything for overlooking a violation 153)As a peace officer, have you ever filed false information on a report 154)As a peace officer, have you used your official position for personal gain 155)As a peace officer, have you accessed confidential date for other than work reasons 156)As a peace officer, have you engaged in sexual activity while on duty 157)As a peace officer, have you withheld evidence in the course of your official duties 158)As a peace officer, have you ever slept while on-duty 159)Have you been the focus of an IA, or similar investigation 160)Have you had citizen s complaints lodges against you 161)Had disciplinary action taken against you 162)Been involved in any action where deadly force was used 163)Had any negative action taken against you that is not in your file I have completed this Pre-Investigative Questionnaire completely and honestly. I am fully aware that any false statements or deliberate omissions will cause my name to be removed from further consideration for employment. I further understand that, if selected for employment, that I am subject to termination if discrepancies or false statements are discovered after my hire date. I understand that I will keep my background investigator informed of any incidents which may require a change to my responses, and that failure to do so could result in my removal from the hiring process. PRINT NAME SIGNATURE DATE APPLICANT INITIALS: Page 5