CITY OF FLORA FLORA POLICE DEPARTMENT 123 N LOCUST ST. FLORA, IL 62839

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1 CITY OF FLORA FLORA POLICE DEPARTMENT 123 N LOCUST ST. FLORA, IL NAME: Position(s) Applied For: Can you perform the essential functions for the position you have applied for with or without reasonable accommodation? Upon a job offer, applicants are subject to a medical exam and/or other inquiry to confirm the applicant has the ability to perform essential functions with or without reasonable accommodation and for other purposes as allowed by law. Yes No Identifying Information Last Name First Name Middle Initial Address City State Telephone # Date of Birth Sex Race/Ethnicity Height Weight Eye Color Have you ever legally changed your name? (List all names, nick names, maiden names) Have you ever been issued a driver s license by another state? Number of Dependents? Are you currently married? Yes No If yes, Spouse name Do you Smoke? Yes No

2 EDUCATION I. High School graduate or GED equivalence? 2. Number of years completed in college? 3. Associate or Bachelor Degree attained? (Please specify) Graduate studies hours completed or degree: (Please specify) High School Attended and years of completion? College(s) attended and semester hours completed: MILITARY Service in Military, please provide branch of service, years of service, discharge papers, and a brief narrative of specialized training and other information that you may feel is relevant. PRIOR EXPERIENCE Prior service in law/dispatch: please provide certification for previous experience And departments you have worked for, also please attach any and all certifications for specialized training that you may have received. Please designate between full time and part time status and whether state certified as a Telecommunicator and what state certification is maintained. Also provide any other information that you may feel is pertinent in the paragraph provided below: EMPLOYMENT HISTORY In the space provided below please list all employment, starting with most recent and work backwards in the following format: Employer, Job title, Duties, gross income per month, start date-end date, immediate supervisor, cause of separation

3 DISCIPLINARY INCIDENTS Please list any and all incidents that resulted in any type of disciplinary action, along with name of employer and supervisor. Also in the space provided please list any Safety Violations, Vehicle accidents or Damage to company property that occurred during your employment TRAFFIC or CRIMINAL RECORD. Please list any and all violations of the law that resulted in a penalty that exceeded a $75.00 fine. Please use the following space to provide any additional information about your smoking or alcohol consumption that you feel is relevant ILLEGAL DRUG USE The following are yes/no answers and will end with space to provide additional information you may feel is pertinent: Have you ever used or experimented with marijuana? Yes no Have you ever used or experimented with cocaine? Yes no Have you ever used or experimented with amphetamines or "Speed"? Yes no Have you ever used or experimented with any other illegal drug? Yes no We encourage, but do not mandate, a cover letter along with a brief resume consisting of no more than 2 pages. Please include a list of references, minimum of three excluding family members, their addresses and phone numbers with this application. The list of references is mandatory. Failure to provide a list of references will exclude you from the rest of the testing procedure and therefore consideration for employment.

4 CITY OF FLORA FLORA POLICE DEPARTMENT 123 N LOCUST ST. FLORA, IL AUTHORITY FOR RELEASE OF INFORMATION TO: FROM: CONCERNED PERSON OR AUTHORITY REPRESENTATIVE OF ANY ORGANIZATION, INSTITUTION, OR REPOSITORY OF RECORD THE CITY OF FLORA REGARDING: NA ME: A DDRESS: (First) (Middle) (Last) (City) (State) (Zip) DATE OF BIRTH: SS#: DRIVER'S LICENSE#: EXP: STATE: I authorize the City of Flora to perform a background investigation to assist the City in determining my suitability for the position I am seeking. Background investigations will only be conducted if a position is conditionally offered. I respectfully request and authorize you to furnish the City of Flora and its representatives all information that you may have concerning my employment records, school records (to include copy of transcript), character, reputation, military records, criminal history records, and driver s license (where applicable). This information is to be used to assist the City of Flora in determining my qualifications and fitness for the position I am seeking with the City. A copy of this form may be used and relied upon as if it were the original. I hereby release you, your organization, or others from any liability or damage which may result from furnishing the information requested. (Signature of Applicant) (Date)

5 FOR USE IN SCREENING EMPLOYMENT APPLICANTS FOR THE FLORA POLICE DEPARTMENT Application form must be completed by the applicant. Read all questions completely. Answer all questions fully and accurately. All answers are subject to verification. ANY FALSIFICATION ON THIS APPLICATION FORM WILL SUBJECT THE APPLICANT TO DISQUALIFICATION. APPLICATIONS WILL NOT BE ACCEPTED UNTIL ALL ITEMS ARE COMPLETED AND ALL REQUIRED DOCUMENTS HAVE BEEN RECEIVED. If a question does not apply, mark "NIA" in the appropriate space. If the answer requires more space, use the back of the page. Complete mailing addresses for residences, employers and character references are mandatory. Include Zip Codes. ALL ANSWERS MUST BE PRINTED IN INK AND BE COMPLETELY LEGIBLE. DO NOT TYPE ANSWERS. APPLICANT'S SIGNATURE REQUIRES NOTARIZATION. Return this completed application, along with necessary documents, to FLORA POLICE DEPARTMENT located at 123 N Locust St., Flora, IL *I affirm that this personal history form contains no misrepresentations or falsifications, omissions or concealment of material fact, and that all information given by me is true and complete to the best of my knowledge and belief. I am aware that statements made by me on this personal history form are subject to later investigation. I am further aware that should any investigation disclose any such misrepresentation, falsification, omission or concealment of material fact, my application may be rejected, and my name removed from eligibility. Date Application Signature STATE OF ILLINOIS COUNTY OF CLAY The foregoing instrument was acknowledged before me this (date) by, who is personally known to me or who had produced (type of identification) as identification and who did / did not take an oath. Notary s Signature Notary s Name