Chief of Police Kenton L. Doze HOISINGTON POLICE DEPARTMENT 109 E. 1 st St. Hoisington, KS 675440060 Telephone (620) 6534995 Fax (620) 6532422 Captain of Police Josh Nickerson Job : Police Officer Under the supervision of the Captain of Police, protect the lives and property of the public through crime prevention and law enforcement. Serves the public by rendering aid to those in need and enforcement of existing state and local laws. GENERAL DESCRIPTION Be at least 21 years of age. Have a High School Diploma or equivalent. Have no felony convictions. Pass a physical fit test by a physical therapist designated by the City of Hoisington. Pass a psychological screening examination by an agency designated by the City of Hoisington. Have a valid driver s license. College education is preferred. KLETC certification is preferred. REQUIREMENTS AFTER EMPLOYMENT Satisfactorily complete a six month probationary period. Obtains certification from KLETC within 12 months of employment, if not previously certified. Maintain CPOST required 40 hours of annual inservice training following KLETC certification. Qualify with a department issued firearm annually. Satisfactorily perform the duties of a Police Officer as designated by the City of Hoisington. Abide by the policies and procedures of the Hoisington Police Department and the City of Hoisington. Successfully complete yearly certification, as required by state law, of CPR and First Aid.
Authorization for Release of Information Name Social Security Number Address Date of Birth (mm/dd/yyyy) City, State and Zip Code TO WHOM IT MAY CONCERN: I am an applicant for a position within the Hoisington Police Department, Hoisington, Kansas. The department requires a thorough investigation of my background, including employment and personal history, to evaluate my qualifications for the position to which I have applied. It is in the public s best interest that all relevant information concerning my personal and employment history be disclosed to the above department. I hereby authorize any representative of the Hoisington Police Department bearing this release to obtain any information in your files pertaining to me and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a full review of and full disclosure of all records, or any part thereof, concerning me, by and to any authorized agent of the Hoisington Police Department, whether said records are of a public, private or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the Hoisington Police Department to consider in determining my suitability for employment in that department. It is my specific intent to provide access to personal information, however personal or confidential it may appear to be. I consent to your release of any and all public and private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including but not limited to any arrest records or any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and disciplinary actions, including any files which are deemed to be confidential and/or sealed. I hereby release you, your organization, and all other from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I hereby release you, as the custodian of such records, including your organization s officers, employees or related personnel, both individually and collectively, from any and all liability or damages of whatever kind, which may at any time occur to me, my heirs, family or associates, because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct you to release such information upon request of the duly accredited representative of the Hoisington Police Department regardless of any agreement I may have made with your previously to the contrary. The law enforcement organization requesting the information pursuant to this release will discontinue processing my application if you refuse to disclose the information requested. For and in consideration of the Hoisington Police Department s acceptance and processing my application for employment, I agree to hold the Hoisington Police Department, its agents and employees, harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the Hoisington Police Department. I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities. I understand my rights under 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those rights with the understanding that
information furnished will be used by the Hoisington Police Department in conjunction with employment procedures. A photocopy or facsimile of this release form will be valid as an original thereof, even though said photocopy or facsimile copy does not contain an original writing of my signature. This waiver is valid for a period of onehundred and eighty (180) days from the date of my signature. Should there be any questions as to the validity of this release, you may contact me at the address and/or telephone number listed above. I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form. I agree to indemnify and hold harmless the person to who this request is presented and to their agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney s fees, arising out of or by reason of complying with this request. Printed Name of Applicant Signature Date State of Kansas County of Barton Signed or attested before me this day of 20 My Appt Expires Seal Notary
HOISINGTON POLICE DEPARTMENT PERSONAL HISTORY STATEMENT PERSONAL The following information is requested of you for verification and contact purposes: Last Name First Name Middle Name Other names (include nicknames) you have used or been known by Address City State & Zip Code Home Cell Phone Number Email Address (if applicable) Driver s License Number State of Issue Expiration Date (mm/dd/yyyy) Date of Birth (mm/dd/yyyy) Social Security Number* Best times to contact you *In accordance with the Federal Privacy Act of 1974. Disclosure is voluntary. Used for identification purposes to ensure proper records are obtained. For the purposes of identification, please provide the following: Height Weight Hair Color Eye Color Scars, marks or Tattoos: RELATIVES AND REFERENCES During the course of the background investigation, persons who know you will be asked to comment upon your suitability for the position of Police Officer. Inquiries will be confined to jobrelated matters. Please supply the appropriate information in the spaces provided below. If a category is not applicable put N/A. For additional spouse(s), sibling(s) or stepsibling(s), use extra sheets and attach. If living, name your: Father Mother Spouse FatherinLaw MotherinLaw Former Spouse
Sibling Sibling Sibling StepFather StepMother StepSibling StepSibling StepSibling Other relatives with who you have or have had a close personal relationship (including children) Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship
Name Relationship Name Relationship Name Relationship Name Relationship In the spaces below, please list between 3 and 5 individuals who have knowledge of you and your qualifications. Exclude relatives and former employers. Name Name Name Name Name EDUCATION The Commission on Peace Officer Standards and Training requires a peace officer to possess a U.S. high school diploma or its equivalent. Please indicate your current situation with regard to this requirement by checking one of the appropriate boxes I possess a high school diploma from a U.S. institution. I passed the General Educational Development exam (G.E.D.) I possess a twoyear college degree I possess a fouryear college or university degree I do not currently have a high school diploma or its equivalent, but I plan to satisfy the requirement in the future as follows: When: How:
Please indicate below all the schools you have attended beginning with high school. During the back ground investigation, persons who have known you in a learning environment will be contacted. A review of your school records may be made in conjunction with those contacts. Name of School City & State From To (mm/yyyy) School References Have you ever been suspended or expelled from any high school or postsecondary school? (Postsecondary schools include two and fouryear colleges, universities, business and vocational schools any formal education beyond the high school level.) Yes No If Yes, please explain (include school, date and circumstances) RESIDENCE Individuals who have become acquainted with you by reason of your residing in different locations are often helpful in providing useful information for the background investigation. Please list all of your residences for the last ten (10) years (list no information prior to your 15 th birthday.) Begin with your current address. From (mm/yyyy) To (mm/yyyy) If rental, landlord name and address
EXPERIENCE & EMPLOYMENT Beginning with your most current, please list all employment, including parttime, temporary and voluntary positions, you have had in the past ten (10) years. If you have any intervening periods of military service or unemployment please list those periods in sequence in the spaces provided. Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s)
FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s)
FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) FullTime Seasonal PartTime Volunteer Name(s) of coworker(s) Would any problem result if your present employer was contacted during the course of the background investigation? Yes No If no when should such contact be made? If you have no prior employment, please explain in the space below: Have you had any extended work absences for reasons other than earned vacations? Yes No If yes please explain (include when, name of employer and why.) Have you ever been fired or asked to resign from any place of employment? Yes No If yes please explain (include when, name of employer and why.) Have you ever applied for the position of peace officer with another agency? Yes No If yes please explain (include when, name of agency and circumstances.)
MILITARY SERVICE If you are a male under the age of twentysix (26) please provide the following: Selective Service Number Approximately date of registration (mm/dd/yyyy) 26 or older Address at time of registration Do you now or have you ever served in the armed forces, including the National Guard or military reserves? Yes No If yes please provide the following information: Branch of Service Service Number Dates of Service (mm/yyyy) Type of Discharge Are you currently serving in any military reserve or National Guard program? Yes No Have you ever been subject to any judicial disciplinary action while in the military, National Guard or military reserves? Yes No If yes please provide details including branch of service, when, where and circumstances. Past commanding officers or military acquaintances are potential sources of relevant information pertaining to your background. Please list those individuals who know you well enough to provide accurate information about you. Name Rank Address Telephone Years known Name Rank Address Telephone Name Rank Address Telephone Years known Years known LEGAL If you have ever been arrested or convicted of any crime (excluding traffic infractions) please provide the following: (The fact that your record may have been affected by a sealing, an expungment, a release or a pardon has specific legal implications as to how you should answer this question.) Expunged dates must be reported. Approximate Date Law Enforcement Agency Circumstances Approximate Date Law Enforcement Agency Circumstances Approximate Date Law Enforcement Agency Circumstances Approximate Date Law Enforcement Agency Circumstances Approximate Date Law Enforcement Agency Circumstances
Have you ever been placed on court probation as an adult? Yes No If yes please give details (include when, where, why) Were you ever required to appear before a juvenile court for an act which would have been a crime if committed by an adult? Yes No If yes please give details (include when, where, why) Have you ever been reported to a law enforcement agency as a missing person or runaway? Yes No If yes please give details (include date, agency, circumstances) Are you now or have you ever been involved as a plaintiff or defendant in any civil court action? Yes No If yes please give details (include when, where, name and location of court, circumstances)
MOTOR VEHICLE OPERATION Operation of a motor vehicle is an integral part of the position of patrol officer. An investigation of your driving history will be made through a records check. Please provide the following information: Driver s License Number Issuing State Expiration Date (mm/dd/yyyy) Name under which license was granted Driver s licenses issued by additional States Driver s License Number Issuing State Expiration Date (mm/dd/yyyy) Name under which license was granted Driver s License Number Issuing State Expiration Date (mm/dd/yyyy) Driver s License Number Issuing State Expiration Date (mm/dd/yyyy) Have you ever been refused a driver s license by any state? Yes No If yes please give details (include when, where, why) Name under which license was granted Name under which license was granted Please list all traffic citations (excluding parking citations) you have received within the last five (5) years: Offense Cited Issuing Agency, City & State Date (mm/dd/yyyy) Fine/Action taken on DL Offense Cited Issuing Agency, City & State Date (mm/dd/yyyy) Offense Cited Issuing Agency, City & State Date (mm/dd/yyyy) Offense Cited Issuing Agency, City & State Date (mm/dd/yyyy) Fine/Action taken on DL Fine/Action taken on DL Fine/Action taken on DL Has your license ever been restricted, placed on probation, suspended or revoked? Yes No If yes please give details (include what, when, where, why) FINANCIAL Have you ever filed for bankruptcy or been sued by a creditor? Yes No If yes please give details (include who, what, when, where, why)
GENERAL INFORMATION Have you ever applied for a permit to carry a concealed weapon? Yes No Was the permit granted? Yes No If yes please provide the following information: Issuing State Date (mm/dd/yyyy) What was your purpose for seeking a permit? Permit Number I hereby certify that all statements made in this personal history are true and complete to the best of my knowledge. I understand that any misstatements of material facts will subject me to disqualification or dismissal. Signature Date (mm/dd/yyyy)