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| 1. | Are you a United States citizen? |
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Yes
No |  |  |  |  |
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| 2. | Do you have a high school diploma or equivalent? |
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Yes
No |  |  |  |  |
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| 3. | Have you ever been in the military? |
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Yes
No |  |
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 | If yes, check type of discharge or status. |
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Honorable
General under Honorable
Dishonorable
Still Active |
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 | A. What Branch? |
| B. How Long?
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 | C. Highest rank |
| D. What was your job? |
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 | E. Are you currently in the military? |
Yes
No |
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 | If you answer Yes to any of the next four questions, please provide detailed information below about the date and location of the offense; the identity of the other party/parties involved; the type of charge, and the disposition of the case (plea, nol pros, withholding of adjudication, conviction, etc.); the nature of the relationship between the parties (spouse, cohabitant, parent, etc.); and a general description of the incident. |
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| 4. | Have you ever been arrested, incarcerated or charged with any crime? |
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Yes
No | If yes, please describe the charge(s) and give date(s) in OFFENSE DETAILS below. |
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| 5. | Have you ever been arrested or charged with any offense which involves stalking, the use or attempted use of force or any weapon, involving a current or former spouse, parent, or guardian? Current or former spouse, parent or guardian are persons who share a child in common, are cohabiting or have cohabited with another, as a spouse, parent, or guardian. |
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Yes
No | If yes, explain in OFFENSE DETAILS below. |
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| 6. | Have you ever been found guilty, pled guilty, or pled no contest to a felony? |
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Yes
No | If yes, please describe the offense(s) and give date(s) in OFFENSE DETAILS below. |
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| 7. | Have you been found guilty, pled guilty, or pled no contest to a misdemeanor in the last five years? |
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Yes
No | If yes, please describe the offense(s) and give date(s) in OFFENSE DETAILS below. |
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| Questions 8 and 9 refer to the sale/possession/usage of controlled substances outside the realm of law enforcement. Do NOT answer 'Yes' to these questions if you dealt with controlled subtances in the line of duty as a law enforcement officer. |
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| 8. | Have you ever sold any type of controlled substance (e.g., marijuana, cocaine, ecstacy, heroin, LSD), whether for profit or not within the last 10 years? |
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Yes
No |
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| 9. | Have you used or possessed any type of illegal controlled substance (e.g., marijuana, cocaine, ecstacy, heroin, LSD) within the last 3 years? |
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Yes
No |
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 | If yes, give date(s) and type of drug(s): |
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| 10. | Have you received any traffic citations, excluding parking tickets, within the last three years? |
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Yes
No |
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 | If yes, please give dates and type of infraction: |
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| 11. | Have you ever had a driver's license, professional license or certificate suspended or revoked? |
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Yes
No |
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 | If yes, please give dates and explain: |
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 | Date |  | Explanation |  |
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| 12. | Has your driver's license been suspended within the last 12 months? |
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Yes
No |
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 | If yes, please give reason for suspension and date(s): |
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| 13. | Have you been involuntarily terminated or asked to resign from a job within the last 12 months? |
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Yes
No |
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A. | Job title: |
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B. | Date of termination/resignation: |
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C. | Reason for leaving: |
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| 14. | Have you ever worked as a police officer? |
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Yes
No |
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A. | Where: |
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B. | Dates of employment: | From: |
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 | If still employed, leave 'To' field at default date (today). Otherwise change to correct ending date. |
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