Applicant Screening Questionnaire

Applicant Screening Questionnaire APPLICANT S PRINTED NAME: INSTRUCTIONS: Use Black/Blue Ink only. Please answer all of the questions by circling Yes or No. If you have any questions, please call (321) 433-5638 or 321-433-5640 and ask to speak with an investigator. The Eastern Florida State College Basic Recruit Law Enforcement Academy is a limited access program. Please refer to our website, www.brevardpolice.org, for guidance on eligibility requirements and admission standards. Also refer to the Florida Statutes for help concerning BPTC s admission standards and Florida s Officer Certification requirements (FS 943.13) and Moral Character Standards (F.A.C. 11B-27.0011). Notice Be completely truthful in all responses. Any omissions, false or misleading information may lead to disqualification from the selection process. You will be given a polygraph examination at a later date to verify the truthfulness of your answers. Except for Questions 1-5, any answers require complete explanations in the space provided that Include: the question number (#), dates & ages you engaged in the activity, and number of times. Thefts must additionally include item descriptions, place(s) where stolen, and dollar values of individual items. MINIMUM STANDARDS FOR ALL APPLICANTS (1-7) 1. Are you 19 years of age? 2. Are you a United States Citizen? 3. Do you have a high school diploma or GED? 4. Do you have a valid Driver s License? State: 5. If you have any military service, indicate the type of discharge or separation: Honorable Dishonorable Other N/A 6. Have you ever been convicted of any felony offense? 7. Have you ever lied under oath (Perjury) or made a false claim, report or statement? 1

8. Have you ever been arrested or stopped for an alcohol-related offense? 9. Have you ever consumed alcohol while under age 21? 10. Have you ever gotten intoxicated to the point of being too sick or hung over to report for work the next day? 11. Have you ever come to work under the influence of alcohol or drugs? 12. Have you ever used alcohol or any drugs at work including lunch and breaks? 13. Have you ever operated machinery or a motor vehicle while under the influence of alcohol or drugs whether detected or not? 14. Have you ever provided alcohol to a minor under age 21? 15. Have you ever driven a vehicle with an open alcohol container? 16. Have you ever used any prescription medication, whether prescribed to you or not, for recreational purposes? 17. Have you ever manufactured, sold, or trafficked in any illegal drug, prescription medication or controlled substance? 18. Have you ever delivered or dispensed any drugs to anyone? 19. Have you ever been arrested or detained on a drug-related matter? 20. Have you ever possessed any narcotic drug such as Heroin, Opium, Oxycodone, Morphine or Methadone? 21. Have you ever possessed any Stimulants such as Amphetamines, Cocaine, Crack, Crank, or Khat? 22. Have you ever possessed any Depressants such as Barbiturates, Benzodiazepines, GHB, or Rohyphol? 23. Have you ever possessed any Hallucinogens such as Ecstasy/MDMA, K2/Spice, Ketamine, LSD, Psilocybin (Mushroom), or Peyote? 24. Have you ever possessed Marijuana/Cannabis, Hashish or their derivatives and synthetics? 2

25. Have you ever illegally used any inhalants such as ordinary household and/or automotive products such as glue, benzene, antifreeze, aerosols, nitrous oxide or cleaning fluids? 26. Have you ever possessed any drugs such as Bath Salts, DXM, Adderall, Ritalin or Steroids? 27. Have you ever possessed or illegally used any other drugs or substances not previously mentioned? 28. Have you ever been around someone who was using illegal drugs? 29. Have you ever purchased any illegal drugs? 30. Have you ever accompanied anyone to buy illegal drugs whether knowingly or unknowingly (found out after the fact)? 31. Do you currently know anybody who produces, sells, delivers or distributes any illegal drugs? 32. Have you ever delivered any illegal drugs or prescription medications? 33. Have you ever been involved in any illegal drug activity not previously mentioned? 34. Have you ever failed a drug test, or provided or received urine in order to help pass a drug test? 35. Have you ever forged a prescription? 36. Have you ever been arrested or detained by law enforcement? 37. Have you ever been charged for a crime as a juvenile? 38. Have you ever had a criminal case expunged, pardoned or sealed? 39. Have you ever resisted a law enforcement officer? 40. Do have any criminal charges pending in any jurisdiction? 41. Have you ever had any criminal charges dismissed, adjudication withheld or been granted pre-trial diversion? 42. Have you ever been granted, denied or violated bail? 43. Have you ever failed to appear as directed by any Court of Law (i.e. criminal, civil, traffic, family, etc.)? 3

44. Are you currently under investigation, or pending charges, for any criminal act(s) in any jurisdiction? 45. Have you ever engaged in any illegal sexual activity (i.e., prostitution, voyeurism, rape, etc.)? 46. Have you ever abused or engaged in sexual activity with an animal? 47. Have you ever physically abused another person (i.e., beaten, punched, slapped, or held someone against their will)? 48. Have you ever engaged in sexual activity, battery or molestation of a minor under 18 years old? 49. Have you ever drugged anyone in order to have sex with them? 50. Have you ever viewed or possessed child pornography? 51. Have you ever viewed pornography using any electronic device while at work, or off duty using a company device? 52. Have you ever stolen anything in your lifetime? 53. Have you ever engaged in any misconduct while serving in the U.S. military forces (i.e., assault, DUI, drug use, theft, prostitution)? 54. Have you ever illegally accessed/hacked a company s or anyone s private computer or email? (Includes exceeding authorized access) 55. Have you ever counterfeited, possessed or used any type of personal identification (Includes fraudulently-obtained genuine ID)? 56. Have you ever been investigated, arrested or charged for a crime of battery? 57. Have you ever been investigated, arrested or charged for a crime of domestic violence? 58. Have you ever committed a hate crime? 59. Have you ever committed any vandalism? 60. Have you ever trespassed or damaged someone else s property? 61. Have you ever set fire to anything in public to cause damage or harm? 62. Have you ever exploded anything in public to cause damage or harm? 4

63. Have you ever downloaded any digital movie, music or game content from the internet without paying it? 64. Have you ever associated with family members, relatives or friends involved in criminal activity? 65. Are you currently residing with anyone who is involved in any criminal activity or who has been arrested or convicted of a crime? 66. Have you ever been associated with members of any gangs or groups that advocate criminal activity to overthrow the government? 67. Have you ever provided support or participated in para-military or terroristic training while in the United States or overseas? 68. Have you ever viewed any materials or websites expressing extremist ideologies or that advocated violence against certain individuals or groups? 69. Other than your driver license, have you ever had a certification, license or permit censured, denied, revoked or suspended? 70. Have you ever intentionally sabotaged someone s computer or spread a computer virus, malware or worm, etc.? 71. Have you ever lied or engaged in a fraudulent scheme or activity to obtain money, goods, discounts, or services from any person, merchant or employer? 72. Within the last (5) years, have you been convicted or had adjudication withheld for a criminal traffic charge (i.e., DUI/DWI, Reckless Driving, Leaving the Scene, etc.)? 73. Within the last (5) years, have you received more than five (5) moving traffic violations where you were convicted or had adjudication withheld? 74. Has your License ever been suspended for excessive points or for failure to maintain insurance? 75. Has your License ever been suspended for failure to pay traffic fines? 76. Have you ever been involved in any at-fault driving accidents? 77. Have you ever received any traffic warnings instead of a citation? 78. Have you ever received any boating citations, fines or warnings? 79. Has your driver s license ever been revoked? 80. Do you have any unpaid traffic citations pending against you anywhere? 5

81. Have you ever been involved in any illegal street racing? 82. Have you ever had to pay child support or alimony? 83. Do you have any current alimony or child support obligations? 84. Have you ever been under an injunction for protection, or a restraining order? 85. Other than for a traffic offense, have you ever had a civil fine or judgment entered against you? 86. Have you ever declared bankruptcy? 87. Have you ever failed to file your tax returns or pay your taxes? 88. Have you ever had anything repossessed? 89. Have you complied with the Federal Draft Registration Law? 90. Have you ever separated from employment due to misconduct, or quit while under investigation pending discipline or termination? 91. Have you ever had any disciplinary action at work? (i.e., verbal counseling, warning reprimand, admonishment, suspension, termination, etc.) 92. Within the past five (5) years, have you traveled outside the U.S.? 93. Have you ever stolen any cash, merchandise, tools or supplies from an employer? 94. Have you ever been involved in an illegal demonstration (i.e., affray, blocking a thoroughfare or premises, riot, setting fires, vandalism, hurling rocks or other missiles, setting off explosives, looting)? 95. Have you ever been adjudicated an incapacitated person or committed to a mental institution under Florida laws or similar laws of any other state (i.e., Florida Baker or Marchman Acts)? 96. Have you ever taken a polygraph examination? 97. Have you withheld any information about your involvement in any serious undetected crime? 98. Have you withheld any information about your arrests or detentions, including for traffic stops? 99. Have you counterfeited, forged or falsified anything in connection with your BPTC Application? 100. Do you wish to provide any other information (Non-Medical-related) affecting your suitability to be a certified law enforcement officer? 6

CANDIDATES: Use this space for any answers that require further explanation. Indicate the question number (#), dates and full details in your explanation. 7

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Moral Character Supplement (F.A.C. 11B-27.0011(4.)(b)(1.)) 1. In your lifetime, have you ever been involved in any of the following violations? (Check box) Statute Violation a. FS 316 Driving Under the Influence (DUI) b. FS 327 Boating Under the Influence (BUI) c. FS 365 Obscene or Harassing Telephone Calls d. FS 414 Welfare Fraud e. FS 741 Domestic Violence f. FS 784 Assault-Battery-Violating Protective Injunction-Stalking- Culpable Negligence-Dating/Sexual Violence g. FS 790 Firearms/Weapons Violations: Possession/Sale with altered serial number, Carrying Concealed w/o Permit, Improper Display/Discharging Firearm in Public h. FS 794 Failure to Report Sexual Battery i. FS 796 Prostitution or Lewdness j. FS 800 Unnatural or Lascivious Act- Exposure of Sexual Organs k. FS 806 False Fire Alarm/Report of Fire-Criminal Mischief l. FS 810 Illegal Trespass, Voyeurism, Video Voyeurism m. FS 812 Theft-Farm/Retail/Utility-DL Suspended for Theft Conviction- Trespass/Theft Larceny of Utility Fixtures/Services n. FS 817 False Report of a Crime-Removal/Alteration of Identification Marks- Sale of Counterfeit Controlled Substance(s) Fraudulent Urine Drug Test-Fraudulent Use of Credit Cards- Receiving Money, Goods, Services Through Fraudulent use of Credit Cards o. FS 827 Child Abuse, Neglect, Delinquency or Dependence p. FS 828 Cruelty to/abuse of Animals q. FS 831 Prescription Fraud, Forgery, Uttering Sale/Manufacture of a Counterfeit Controlled Substance(s) r. FS 832 Passing Bad or Worthless Check/Credit Card s. FS 837 Perjury not in an Official Proceeding- False report to Law Enforcement Officer During Investigation 9

False Official Statement t. FS 839 Falsifying Records, Refusing to Execute Criminal Process u. FS 843 Resisting an Officer W/O Violence Obstruction by Disguised Person Refusal to Aid a Law Enforcement Officer Impersonating a Police Officer v. FS 847 Pornography/Obscenity and related Offenses w. FS 856 Loitering or Prowling x. FS 870 Affrays and Riots y. FS 893 Drug Abuse Prohibited Acts-Use, Possession, Manufacture, Delivery, Transportation, Advertisement, Retail Sale of Drug Paraphernalia z. FS 901 Giving False Name or Identification at Arrest aa. FS 914 Tampering with or Harassing a Witness, Victim, or Informant bb. FS 934 Interception/Disclosure of wire, oral, electronic Communications (i.e., Wiretapping) cc. FS 944 Excessive Use of Force, Bribery, Interference with Prisoners EXPLANATION: 10

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INVESTIGATOR ONLY Candidate Self Report/Undetected Crime Notations: Please do not sign this form until you are interviewed by a BPTC Staff member. I do hereby solemnly swear/affirm that, to the best of my knowledge and belief, the information I have provided in this questionnaire and moral character supplement is true, correct and complete. Applicant s Signature Date Interviewer Date 12