POLICE OFFICER

EMPLOYMENT APPLICATION PACKET

Completion of the Police Officer Employment Application Packet is the first step in the employment process. The information in these forms will be used to judge your qualifications for the position of Police Officer. Read all the questions carefully and answer all them completely and honestly.

You must complete this application packet yourself. Type or print the forms using a ball point pen. Do not leave any blank spaces. If a question does not apply, write “DNA” in the answer space. All information in this application is subject to verification. Any false, misleading, or incomplete information will result in your application being eliminated from consideration.

This packet contains the following forms:

Police Officer Employment Application

Waiver of Liability Release Form

Credit Information Release Form

Pre-Employment Drug Screen Consent Form

Police Officer Position Description

Return the entire packet along with a resume (no longer than 2 pages, please) to the address below:

St. Matthews Police Department

3940 Grandview Ave

St. Matthews, KY 40207

Indicate which you position you are applying for:	Full Time Part Time Both

Date received: _____________________
(For Office Use Only)

POLICE OFFICER EMPLOYMENT APPLICATION

Instructions:

You must complete this application yourself. It may be printed in ink or typed. Your ability to completely and honestly complete this application is part of the process to determine your suitability for employment. If you intentionally leave out any information that might be detrimental to obtaining a job, it will automatically eliminate you from consideration from employment. Once submitted, this application becomes the property of the City of St. Matthews. When entering dates, use this format (00/00/0000).

Basic Personal Information

Name:

Last First Middle

Please list any other names you have used:

Home Address:

Street	City State Zip

Telephone:

Home Cell Daytime

Date of Birth:	Social Security Number:

Driver’s License:

Number State

Place of Birth:

City State Country

Eligibility

Are you at least 21 years of age?	Yes No

Do you have a legal right to work in the United States? (Check one)	US Citizen
Permanent Resident Status Other (Please Specify)

Are you a licensed Peace Officer in the State of Kentucky?	Yes No

If yes, where and when did you obtain your license?

State Certified Training Academy or Department

Address City State Zip Date

Has your Kentucky Peace Officer’s license ever been suspended?	Yes No

(If yes, please explain on a separate sheet of paper).

Are you a commissioned/licensed Peace Officer in another state of the U.S.?	Yes No

If yes, give details of your commission/license:

State Certified Training Academy or Department

Address City State Zip Date

Have you ever applied for a position with the City of St. Matthews before?	Yes No
If yes, when?	What position?

Military Service

Please make copies of all applicable service records including any discharge papers and attach to this application.

Branch:	Serial Number:

Date of Service:	to	Reserve Status:

Type of Discharge:	If not honorable, explain why below:

Grade and duty assignment at discharge/separation:

Are you registered for the Selective Service?	Yes No

Selective Service Number:	Classification:

Are you a member of the Reserves or National Guard?	Yes No

If yes, give unit, location, grade, and duty assignment:

Unit

Location Grade Duty Assignment

Education

Please complete the information that applies and attach copies of your diploma(s) and/or copies of your transcript(s) to this application.

If you did not complete High School, do you have a GED?	Yes No

School Name: Full name of school

Type: (High School – HS) (College or University – C/U) (Graduate – G) (Specialized – S)

Address: List City and State only

Graduate: Yes/No (Year of graduation only)

Course of Study: Major and/or minor

School Name	Type	Address	Graduate	Course of Study
Yes No Year:	Major: Minor:
Yes No Year:	Major: Minor:
Yes No Year:	Major: Minor:
Yes No Year:	Major: Minor:
Yes No Year:	Major: Minor:
Yes No Year:	Major: Minor:
Yes No Year:	Major: Minor:

Specialized Skills

Do you speak another language other than English?	Yes No	Fluent?	Yes No

If Yes, what language(s):

Briefly list any computer skills you have. If you have copies of any certificates for computer training you have received, please attach them to the application:

Please list any social internet sites (Facebook, MySpace, personal blogs) that you have an active or past account with:

Briefly list any training or skills, including firearms that would be of assistance in the job you are applying for. If you have any copies of certificates for any training, please attach them to the application:

Personal History

Do you know of any reason that you could not pass a background check?	Yes No

Have you ever been fired or asked to resign from a job?	Yes No

Have you ever received disciplinary action from an employer?	Yes No

Have you ever stolen from an employer?	Yes No

Have you ever committed a crime for which you were not arrested?	Yes No

Have you ever assisted someone in committing a crime?	Yes No

Have you ever falsified a police report?	Yes No

Have you ever accepted money not to report a crime?	Yes No

Has any driver’s license issued to you ever been suspended or revoked?	Yes No

Have you ever used, sold, or otherwise handled any controlled
substance(s) in an illegal manner?	Yes No

If you answered ‘Yes’ to any of the questions listed above, please write a brief explanation for that question on a separate sheet of paper. List the question by number. If you are interviewed, you will be asked about any ‘Yes’ answers. Any ‘Yes’ answers will be closely examined during a background check. A ‘Yes’ answer does not automatically eliminate you from consideration for employment. Your omission of these facts will automatically eliminate you from consideration.

Traffic, Civil Court, and Criminal Record

Please list your history of any traffic citations, any civil court actions in which you were or are a defendant, any arrests, convictions, and court actions. If additional space is needed, list on a separate sheet of paper.

Type of case Jurisdiction City, State

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Financial Status

List all creditors or persons to whom you are financially obligated. If additional space is needed, list on a separate sheet of paper.

NAME ADDRESS BALANCE MONTHLY

PAYMENT

Have you ever declared bankruptcy?	Yes No

If Yes, give date(s) and circumstances:

Employment History

NOTICE: Start with your current job, if employed, and list you past employment in reverse order. Include all employment from high school to the present. Account for any time that you were unemployed by stating the nature of your activities. If additional space is needed, list on a separate sheet of paper.

Dates from:	to

Company:	Position:	FT PT
Address:	City:	St:	Zip:
Supervisor’s Name:	Telephone #:
Job Duties:
Reason for Leaving:

Dates from:	to

Company:	Position:	FT PT
Address:	City:	St:	Zip:
Supervisor’s Name:	Telephone #:
Job Duties:
Reason for Leaving:

Dates from:	to

Company:	Position:	FT PT
Address:	City:	St:	Zip:
Supervisor’s Name:	Telephone #:
Job Duties:
Reason for Leaving:

Dates from:	to

Company:	Position:	FT PT
Address:	City:	St:	Zip:
Supervisor’s Name:	Telephone #:
Job Duties:
Reason for Leaving:

Dates from:	to

Company:	Position:	FT PT
Address:	City:	St:	Zip:
Supervisor’s Name:	Telephone #:
Job Duties:
Reason for Leaving:

____________________________________________________________________________

Residences

List all residences where you have lived during the past 5 years. Begin with your present address and work backwards. List the complete address including street number, street name, city, state, and zip code. If additional space is needed, list on a separate sheet of paper.

ADDRESS CITY ST ZIP DATES

to
to
to
to
to
to
to

Personal References

List three personal references that are NOT related to you. Do not use former or current employers. Be sure to include all of the information requested.

Name	Address	City	ST	Zip
Email Address:	Contact #:

Name	Address	City	ST	Zip
Email Address:	Contact #:

Name	Address	City	ST	Zip
Email Address:	Contact #:

Remarks

Please tell us about yourself. Include any awards, honors, licenses or certificates that you have received. What are your hobbies or interests? You can also use this section to expound upon any answers to any questions on this application:

Please Read Carefully Before Signing This Application

I declare that the foregoing statements are true and correct to the best of my knowledge and belief. I realize that falsification of any information on this application is grounds for disqualification. I further understand that any misrepresentation or omission of facts upon this application will be sufficient cause for cancellation and/or separation from City service if I have been employed.

Applicant Signature: ____________________________________ Date: _________________

The St. Matthews Police Department accepts applications once a year or as needed to fill vacancies. This is what will happen with your application:

Your application is reviewed to ensure you meet the minimum qualifications for a Police Officer position and for accuracy, legibility, and completeness.

If the application is accepted, you will receive a letter notifying you of your acceptance. Letters are NOT sent for rejected applications.

Your application will be placed on file until a list is established

All accepted applicants on file will be notified by mail of their interview date.

Failure to appear on the scheduled interview date disqualifies the applicant and their application will be discarded. You will be required to submit another application for the next available posted opening.

WAIVER OF LIABILITY AND RELEASE FORM

In consideration of the St. Matthews Police Department and the City of St. Matthews, Kentucky, hereinafter referred to as the Agency, processing my application for employment, I

hereby irrevocably agree to the following

Full Name (typed or printed)

terms and conditions:

The term “background investigation” as used in this document refers to any and all information and sources of information that the Agency, in its sole discretion, may deem necessary to obtain or contact, to determine my fitness as a candidate for employment with the Agency.

I hereby release from liability and promise to hold harmless under any and all possible causes of legal action any Officer, Agent, or Employee of the Agency who conduct my background investigation.

I hereby release from liability and promise to hold harmless under any and all possible causes of legal action, any and all person and entities who shall furnish any information or opinions to the Officers, Agents, or Employees of the Agency who conduct my background investigation.

I authorize any person or entity contacted by the Agency’s Officers, Agents, or Employees during the course of my background investigation, to furnish such Officers, Agents, or Employees any information opinions they may have, and hereby expressly waive any and all legal privilege, the clergyman – pertinent privilege, the husband-wife privilege, and the accountant – client privilege.

I hereby release from liability and promise to hold harmless, under any and all possible causes of legal action, the political subdivision, the Agency, or any of its Officers, Agents, or Employees for any statements, acts or omissions in the course of my background check.

I expressly waive all of my legal rights and causes of actions to the extent that the Agency background check may violate or infringe upon these legal rights and causes of actions.

I expressly agree that I will never, under any circumstances, attempt to obtain the results of my background investigation as conducted by the Agency, realizing such information must of necessity remain confidential.

DO NOT SIGN BEFORE READING:

This release from liability given by me to the political division, the Agency, its Officers, Agents, and Employees, and all others as mentioned above, shall apply to my right of action of any nature whatsoever that might accrue to me, my heirs, or my personal representative.

Date:	Signature of Applicant:

Date of Birth:	Social Security #:

Driver’s License number and State:

Date:	Witnessed By:

Printed Name and Signature

CREDIT INFORMATION RELEASE FORM

Credit Report Disclosure

By this document, the City of St. Matthews discloses to you that a credit report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment. Please sign below to signify receipt of the foregoing disclosure.

Applicant Full Name (typed or printed)

Applicant Signature

Date

Witness Printed Name Signature

Date

Credit Report Authorization

This document shall authorize the procurement of a credit report by the City of St. Matthews as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for the City of St. Matthews to procure consumer reports at any time during my employment period.

Applicant Full Name (typed or printed)

Applicant Signature

Date

Witness Printed Name Witness Signature

Date

PRE-EMPLOYMENT DRUG SCREEN CONSENT

I, ________________________________, as an applicant with the City of St. Matthews,
(Printed)

Kentucky consent to allow my blood, breath and/or urine to be tested for drugs. I further consent to allow the results of such testing to be released to the City of St. Matthews, Kentucky or its authorized agents to representatives.

I hereby release the City of St. Matthews and its employees from any action that may arise out of results of such tests or information being released to the City of St. Matthews.

I understand that if I fail to sign and return this consent to the City of St. Matthews, Kentucky, my application will no longer be considered. I understand that if I test positive for any illegal substance, any offer of employment I have received will be withdrawn.

Applicant Signature

Date

Witness Printed Name Witness Signature

Date