bPD_Application – City of Booneville, MS

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INSTRUCTIONS - READ CAREFULLY BEFORE PROCEEDING!

These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is essential that the information be accurate in all respects. It will be used as a basis for a background investigation that will determine your eligibility for employment. 1: Your Personal History Statement should be printed legibly in ink. Answer all questions to the best of your ability. 2: If a question is not applicable to you, enter N/A in the space provided. 3: Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is correct and in proper sequence before you begin. 4: You are responsible for obtaining correct addresses. If you are not sure of an address, check it by personal verification. Your local library may have a directory service or copies of local phone directories. 5: If there is insufficient space on the form for you to include all information required, attach extra sheets to the Personal History Statement. Be sure to reference the relevant section and question number before continuing to answer. 6: An accurate complete form will help expedite your investigation. On the other hand, deliberate omissions and falsifications may result in disqualification.

POSITION APPLYING FOR:(Required)

WHERE DID YOU HEAR ABOUT THIS POSITION?(Required)

WHAT/WHO INFLUENCED YOU TO APPLY WITH THE BOONEVILLE POLICE DEPARTMENT?

PERSONAL HISTORY STATEMENT

Applicant Identification: Information provided in this section is used for identification purposes only.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Nickname(s), Maiden Name, or other names by which you have been known:(Required)

Social Security Number:(Required)

Example: 111-11-1111

Date of Birth:(Required)

Driver's License Number / State / Expiration Date:(Required)

Example: 123456789 / MS / 01-23

Height(Required)

Example: 5ft 11in

Hair Color / Eye Color(Required)

Example: Brown / Brown

United States Citizen(Required)

YES

NO

SCARS, TATTOOS, OR OTHER DISTINGUISHING MARKS:(Required)

EXAMPLE: IF YES, GIVE DETAILS. IF NO, SIMPLY ENTER NO.

PERSONAL RESIDENCES:

LISTN ALL ADDRESSES WHERE YOU HAVE LIVED DURING THE LAST 10 YEARS, BEGINNING WITH YOUR PRESENT ADDRESS. LIST DATES BY MONTH AND YEAR.

CURRENT RESIDENCE:(Required)

EXAMPLE: FROM: 01/23 TO: PRESENT ADDRESS: 203 NORTH MAIN STREET, BOONEVILLE MS 38829

PREVIOUS RESIDENCE:

EXAMPLE: FROM: 01/23 TO: PRESENT ADDRESS: 203 NORTH MAIN STREET, BOONEVILLE MS 38829

PREVIOUS RESIDENCE:

EXAMPLE: FROM: 01/23 TO: PRESENT ADDRESS: 203 NORTH MAIN STREET, BOONEVILLE MS 38829

PREVIOUS RESIDENCE:

EXAMPLE: FROM: 01/23 TO: PRESENT ADDRESS: 203 NORTH MAIN STREET, BOONEVILLE MS 38829

PREVIOUS RESIDENCE:

EXAMPLE: FROM: 01/23 TO: PRESENT ADDRESS: 203 NORTH MAIN STREET, BOONEVILLE MS 38829

PREVIOUS RESIDENCE:

EXAMPLE: FROM: 01/23 TO: PRESENT ADDRESS: 203 NORTH MAIN STREET, BOONEVILLE MS 38829

WORK HISTORY 1:

BEGINNING WITH YOUR PRESENT OR MOST RECENT JOB, LIST ALL EMPLOYMENT HELD FOR THE PAST 10 YEARS, INCLUDING PART-TIME, TEMPORARY, AND SEASONAL EMPLOYMENT. INCLUDE ALL PERIODS OF UNEMPLOYMENT.

EMPLOYER NAME:(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

DURATION OF EMPLOYMENT:(Required)

EXAMPLE: 01/22-PRESENT

Phone(Required)

JOB TITLE:(Required)

SUPERVISOR/MANAGER NAME:(Required)

DUTIES AND RESPONSIBILITIES:(Required)

REASON FOR LEAVING:(Required)

MAY WE CONTACT THIS EMPLOYER?(Required)

YES

NO

WORK HISTORY 2:

CONTINUE FROM YOUR PREVIOUS OR MOST RECENT JOB, LIST ALL EMPLOYMENT HELD FOR THE PAST 10 YEARS, INCLUDING PART-TIME, TEMPORARY, AND SEASONAL EMPLOYMENT. INCLUDE ALL PERIODS OF UNEMPLOYMENT.

EMPLOYER NAME:(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

DURATION OF EMPLOYMENT:(Required)

EXAMPLE: 01/22-PRESENT

Phone(Required)

JOB TITLE:(Required)

SUPERVISOR/MANAGER NAME:(Required)

DUTIES AND RESPONSIBILITIES:(Required)

REASON FOR LEAVING:(Required)

MAY WE CONTACT THIS EMPLOYER?(Required)

YES

NO

WORK HISTORY 3:

CONTINUE FROM YOUR PREVIOUS OR MOST RECENT JOB, LIST ALL EMPLOYMENT HELD FOR THE PAST 10 YEARS, INCLUDING PART-TIME, TEMPORARY, AND SEASONAL EMPLOYMENT. INCLUDE ALL PERIODS OF UNEMPLOYMENT.

EMPLOYER NAME:

Address

Street Address City State / Province / Region ZIP / Postal Code

DURATION OF EMPLOYMENT:

EXAMPLE: 01/22-PRESENT

Phone

JOB TITLE:

SUPERVISOR/MANAGER NAME:

DUTIES AND RESPONSIBILITIES:

REASON FOR LEAVING:

MAY WE CONTACT THIS EMPLOYER?

YES

NO

WORK HISTORY 4:

CONTINUE FROM YOUR PREVIOUS OR MOST RECENT JOB, LIST ALL EMPLOYMENT HELD FOR THE PAST 10 YEARS, INCLUDING PART-TIME, TEMPORARY, AND SEASONAL EMPLOYMENT. INCLUDE ALL PERIODS OF UNEMPLOYMENT.

EMPLOYER NAME:

Address

Street Address City State / Province / Region ZIP / Postal Code

DURATION OF EMPLOYMENT:

EXAMPLE: 01/22-PRESENT

Phone

JOB TITLE:

SUPERVISOR/MANAGER NAME:

DUTIES AND RESPONSIBILITIES:

REASON FOR LEAVING:

MAY WE CONTACT THIS EMPLOYER?

YES

NO

WORK HISTORY 5:

CONTINUE FROM YOUR PREVIOUS OR MOST RECENT JOB, LIST ALL EMPLOYMENT HELD FOR THE PAST 10 YEARS, INCLUDING PART-TIME, TEMPORARY, AND SEASONAL EMPLOYMENT. INCLUDE ALL PERIODS OF UNEMPLOYMENT.

#5 EMPLOYER NAME:

Address

Street Address City State / Province / Region ZIP / Postal Code

DURATION OF EMPLOYMENT:

EXAMPLE: 01/22-PRESENT

Phone

JOB TITLE:

SUPERVISOR/MANAGER NAME:

DUTIES AND RESPONSIBILITIES:

REASON FOR LEAVING:

MAY WE CONTACT THIS EMPLOYER?

YES

NO

MILITARY RECORD:

HAVE YOU SERVED IN THE U.S. ARMED FORCES, INCLUDING NATIONAL GUARD?

YES

NO

DATE OF SERVICE:

EXAMPLE: FROM: TO:

SERVICE ID#:

BRANCH OF SERVICE:

UNIT DESIGNATION:

HIGHEST RANK HELD:

TYPE OF DISCHARGE:

WERE YOU EVER DISCIPLINED IN THE MILITARY SERVICE, INCLUDE COURT-MARSHALS, CAPTAIN MASTS. COMPANY PUNISHMENTS, ETC.?

YES

NO

IF YES, PROVIDE DETAILS OF EACH INSTANCE.

EXAMPLE - PROVIDE THE FOLLOWING INFORMATION IN THE DESCRIPTION: CHARGE / AGENCY / DATE / TIME / AGE / DISPOSITION

IF YOU RECEIVED A DISCHARGE OTHER THAN HONORABLE, GIVE COMPLETE DETAILS:

DO YOU HAVE AN UNDISCLOSED OBLIGATION TO ANY BRANCH OF THE MILITARY?

YES

NO

ALL APPLICANTS WITH MILITARY SERVICE ARE REQUIRED TO ATTACH A COPY OF THEIR DD-214

File

Max. file size: 512 MB.

EDUCATIONAL HISTORY

DID YOU GRADUATE?

HIGH SCHOOL DIPLOMA

GED CERTIFICATE

HIGH SCHOOL ATTENDED OR GED SCHOOL:(Required)

CITY / STATE:(Required)

DATES:(Required)

EXAMPLE: FROM: TO:

EDUCATION MAJOR:(Required)

EXAMPLES: COLLEGE PREP

COLLEGE ATTENDED:

CITY / STATE:

DATES:

EXAMPLE: FROM: TO:

DID YOU GRADUATE?

YES

NO

EDUCATION MAJOR:

EXAMPLES: COLLEGE PREP

ADDITIOINAL COLLEGE ATTENDED:

CITY / STATE:

DATES:

EXAMPLE: FROM: TO:

DID YOU GRADUATE?

YES

NO

EDUCATION MAJOR:

EXAMPLES: COLLEGE PREP

LAW ENFORCEMENT TRAINING:

SCHOOL OR COLLEGE ATTENDED:

CITY / STATE:

DATES:

EXAMPLE: FROM: TO:

ATTACH COPIES OF ANY TRAINING CERTIFICATES:

Max. file size: 512 MB.

LIST OTHER SCHOOLS ATTENDED (TRADE, VOCATION, BUSINESS, ETC):

EXAMPLE: SCHOOLING / CITY & STATE / DATES: FROM: TO: / GRADUATED: YES OR NO / MAJOR:

ARE YOU CERTIFIED LAW ENFORCEMENT OFFICER?(Required)

YES

NO

IF YES, ATTACH A COPY OF CERTIFICATION FROM MS BOARD OF MINIMUM STANDARDS AND TRAINING. FAILURE TO DO SO WILL RESULT IN AN INCOMPLETE APPLICATION AND BE DISQUALIFIED FOR CONSIDERATION FOR EMPLOYMENT.

Max. file size: 512 MB.

CONVICTIONS, ARRESTS, AND DETENTIONS:

HAVE YOU EVER BEEN CONVICTED, ARRESTED, DETAINED, OR SUMMONED INTO COURT?(Required)

YES

NO

IF YES, COMPLETE THE FOLLOWING: LIST BOTH JUVENILE AND ADULT OFFENSES:

EXAMPLE: EACH OFFENSE CHARGED / CITY & STATE / DATE / DISPOSITION OF CASE

TRAFFIC RECORD

HAVE YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED?(Required)

YES

NO

IF YES, GIVE DATE / LOCATION / AND REASON(S):

EXAMPLE: EACH OFFENSE CHARGED / CITY & STATE / DATE / DISPOSITION OF CASE

WITH WHAT COMPANY DO YOU CARRY AUTO INSURANCE?(Required)

LIST, TO THE BEST OF YOUR MEMORY, ALL DRIVING CITATIONS YOU HAVE RECEIVED AS AN ADULT OR JUVENILE EXCLUDING PARKING TICKETS:

EXAMPLE: MONTH & YEAR / CHARGED / CITY & STATE / DISPOSITION OF CASE

MARITAL & FAMILY HISTORY:

MARITAL STATUS:(Required)

SINGLE

MARRIED

SEPARATED

DIVORCED

WIDOWED

IF MARRIED, SPOUSE'S NAME:

LIST ALL CHILDREN RELATED TO YOU OR YOUR SPOUSE (BIOLOGICAL, ADOPTED, FOSTER, & STEP-CHILDREN):

EXAMPLE: NAME / RELATION / AGE / SUPPORTED BY

LIST ALL DEPENDENTS:

EXAMPLE: NAME / RELATION / AGE / SUPPORTED BY

LIST OTHER RELATIVES IN THE FOLLOWING ORDER (1: FATHER 2: MOTHER - INCLUDE MAIDEN NAME 3: BROTHERS/SISTERS (PLEASE INDICATE IF DECEASED)

EXAMPLE: NAME / RELATION / DECEASED

PERSONAL REFERENCES:

LIST 5 INDIVIDUALS WHO YOU HAVE KNOWN FOR AT LEAST 5 YEARS AND WHO CAN PROVIDE CURRENT INFORMATION ABOUT YOU. *DO NOT LIST RELATIVES OR FORMER EMPLOYERS

REFERENCE #1 NAME:(Required)

First Last

Address(Required)

Street Address City State / Province / Region

Phone(Required)

YEARS KNOWN:(Required)

* DO NOT LIST RELATIVES OR FORMER EMPLOYERS

REFERENCE #2 NAME:(Required)

First Last

Address(Required)

Street Address City State / Province / Region

Phone(Required)

YEARS KNOWN:(Required)

* DO NOT LIST RELATIVES OR FORMER EMPLOYERS

REFERENCE #3 NAME:(Required)

First Last

Address(Required)

Street Address City State / Province / Region

Phone(Required)

YEARS KNOWN:(Required)

* DO NOT LIST RELATIVES OR FORMER EMPLOYERS

REFERENCE #4 NAME:(Required)

First Last

Address(Required)

Street Address City State / Province / Region

Phone(Required)

YEARS KNOWN:(Required)

* DO NOT LIST RELATIVES OR FORMER EMPLOYERS

REFERENCE #5 NAME:(Required)

First Last

Address(Required)

Street Address City State / Province / Region

Phone(Required)

YEARS KNOWN:(Required)

* DO NOT LIST RELATIVES OR FORMER EMPLOYERS

FINANACIAL HISTORY:

HAVE YOU EVER FILED FOR BANKRUPTCY?(Required)

YES

NO

OTHER RELEVANT INFORMATION:

HAVE YOU EVER USED MARIJUANA OR ANY OTHER DRUG NOT PRESCRIBED BY A PHYSICIAN?(Required)

YES

NO

IF YES, WHAT AND WHAT WERE THE CIRCUMSTANCES?

HAVE YOU EVER SOLD OR FURNISHED DRUGS OR NARCOTICS TO ANYONE?(Required)

YES

NO

IF YES, EXPLAIN IN DETAIL.

WILL YOU WORK THE NIGHT SHIFT AND/OR WEEKEND?(Required)

YES

NO

HOW FREQUENTLY DO YOU CONSUME ALCOHOLIC AND/OR INTOXICATING BEVERAGES?(Required)

HAVE YOU EVER BEEN FIRED, FORCED TO RESIGN, OR RESIGNED IN LIEU OF TERMINATION?(Required)

YES

NO

IF YES, PROVIDE EMPLOYER NAME AND REASON:

ARE YOU RELATED TO A CITY OF BOONEVILLE EMPLOYEE IN ANY CAPACITY?(Required)

YES

NO

PROVIDE RELATIVE'S NAME:

First Last

RELATIONSHIP:

CITY DEPARTMENT & POSITION:

HAVE YOU EVER WORKED FOR CITY OF BOONEVILLE IN ANY CAPACITY?(Required)

YES

NO

IF YES, REASON FOR LEAVING:

ARE THERE ANY INCIDENTS, EVENTS, OR CIRCUMSTANCES NOT MENTIONED IN THIS APPLICATION WHICH MIIGHT CAUSE INELIGIBILITY FOR EMPLOYMENT WITH THE BOONEVILLE POLICE DEPARTMENT?(Required)

YES

NO

IF YES, EXPLAIN:

REQUIRED DOCUMENTS ARE TO BE TURNED IN WITH THIS COMPLETED APPPLICATION:

BIRTH CERTIFICATE

Max. file size: 512 MB.

DRIVER'S LICENSE

Max. file size: 512 MB.

SOCIAL SECURITY CARD

Max. file size: 512 MB.

EDUCATIONAL DOCUMENT

Max. file size: 512 MB.

HIGH SCHOOL GRADUATION

EDUCATIONAL DOCUMENT

Max. file size: 512 MB.

COLLEGE DEGREE

TRAINING CERTIFICATE DOCUMENT

Max. file size: 512 MB.

LAW ENFORCEMENT CERTIFICATE DOCUMENT

Max. file size: 512 MB.

OTHER CERTIFICATE DOCUMENT #1

Max. file size: 512 MB.

OTHER CERTIFICATE DOCUMENT #2

Max. file size: 512 MB.

OTHER CERTIFICATE DOCUMENT #3

Max. file size: 512 MB.

OTHER CERTIFICATE DOCUMENT #4

Max. file size: 512 MB.

PERSONAL HISTORY STATEMENT AGREEMENT

I hereby certify that the answers and statements in the forgoing personal history statement are true and accurate without consequential omissions of any kind. I hereby agree that any falsification contained in this information shall be considered good and sufficient cause for rejection of this application and/or discharge. I understand that a complete background investigation will be conducted as a condition of this employment. I authorize the aforementioned companies, persons and/or public institutions to give any information concerning me and my employment whether or not it is in their records. I hereby release said companies, persons, or public institutions of all liability for any damages whatsoever from issuing this information. I will accept employment for a temporary period depending upon my ability to satisfy the requirements of: this agency, the Law Enforcement Officer Training Program (section 45-6-1 to 45-6-17 of the Mississippi Code as amended), and the Board of Law Enforcement Officer Standards and Training. I hereby authorize the employing agency to deduct from my wages due me at anytime, the value of monies or property advanced to me or on my behalf for which I am accountable, such as but not limited to, travel expenses, agency credit cards, and/or agency property damaged, lost, or misappropriated by me. Subsequent to an offer of employment, I hereby give my voluntary consent to be medically examined and to provide a sample of urine or hair which may be tested for the use of drugs and/or controlled substances. If employed on either a permanent or temporary basis, I agree to abide by all rules, policies, and regulations of the agency now in force or which may be hereafter established. I also agree to submit to a polygraph or voice stress examination if requested to do so by the Chief of Police or Mayor and Board of Aldermen. Failure to submit to requested exams may be grounds of/for disciplinary action including termination. My signature affirms that all information is true to the best of my knowledge and that I understand that any misstatement of fact(s) may result in disqualification or dismissal.

Consent(Required)

I agree to the privacy policy.

BY CHECKING THIS CONSENT I AM IN AGREEMENT WITH PERSONAL HISTORY STATEMENT DETAILED IN THIS APPLICATION BY THE BOONEVILLE MISSISSIPPI POLICE DEPARTMENT.

DIGITAL SIGNATURE:

First Last

DATE OF SUBMITTING APPLICATION:

CAPTCHA

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