CITY OF ALAMOSA POLICE APPLICATION FOR EMPLOYMENT

Position(s) applied for:*

Date of application:*

Date

How did you learn about us?*

Name*

First NameLast Name

Please list any other names that you have used.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

Are you 21 years of age or older?*

YesNo

Have you ever filed an application with us before?*

YesNo

If Yes, give date:

Date

Have you ever been employed with us before?*

YesNo

If Yes, what was the reason for leaving?

If Yes, give date:

Date

Are you related to any current City of Alamosa employee?*

YesNo

If Yes, state who and describe your relationship.

Are you able to be lawfully employed in this country?*

YesNo

On what date would you be available for work?*

Date

Do you have a valid driver license?*

YesNo

What is the Driver's License Number, State and Type*

Are you available to work:*

Full TimePart TimeShift workTemporary

Are you currently on "lay-off" status and subject to recall?*

YesNo

Can you travel if required?*

YesNo

Are you a licensed peace officer in the State of Colorado?*

YesNo

Have you ever held a Peace Officer Certification in another state?*

YesNo

If yes, what state and expiration date.

Has your peace officer’s license ever been suspended?*

YesNo

If yes, explain the circumstances.

Branch:

Date of service From:

Date

Date of service To:

Date

Reserve Status

Type of discharge

If not honorable, explain

Grade and duty assignment at discharge/separation

Are you registered for the Selective Service?

YesNo

Are you a member of the Reserves or National Guard?

YesNo

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

EDUCATION

	Name and Address of School	Course of Study	# of years completed	Diploma or degree received
High School
Undergraduate College or University
Other (Specify)

Indicate any foreign languages you can speak, read and/or write.

	Fluent	Good	Fair
Read
Speak
Write

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:*

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

Personal History*

	Yes	No
Do you know of any reason that you could not pass a background check?
Have you ever been fired or asked to resign from a job?
Have you ever received disciplinary action from an employer?
Have you ever stolen from an employer?
Have you ever committed a crime for which you were not arrested?
Have you ever assisted someone in committing a crime?
Have you ever falsified a police report?
Have you ever accepted money not to report a crime?
Have you ever slept on the job?
Has any driver’s license issued to you ever been suspended or revoked?
Have you ever used, sold, or otherwise handled in an illegal manner any controlled substance?
Have you ever been bonded?
Have you ever been refused bond?

If you answered "yes" to any of the questions listed above, please write a brief explanation for the question(s). 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.

	Type of case	Jurisdiction	City, State
1
2
3
4

Residences List all residences where you have lived during the past five years. Begin with your present address and work backwards. List the complete address including street number, street name, city, state, and zip code.

	Address	City, State	Zip	Dates
1
2
3
4

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job related to military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. This section must be completed, even if a resume is attached.

Employer*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Job title:*

Supervisor name:*

Reason for leaving:*

Dates Employed

From:*

Date

To:*

Date

Work performed:*

Employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Job title:

Supervisor name:

Reason for leaving:

Dates Employed

From:

Date

To:

Date

Work performed:

Employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Job title:

Supervisor name:

Reason for leaving:

Dates Employed

From:

Date

To:

Date

Work performed:

Employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Job title:

Supervisor name:

Reason for leaving:

Dates Employed

From:

Date

To:

Date

Work performed:

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

ADDITIONAL INFORMATION

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

Specialized Skills-List Skills/Equipment Operated

Computer Hardware/Software

Office Equipment

Other (list)

Note to Applicants. DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job or occupation is attached.

YesNo

REFERENCES

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

APPLICATION FORM WAIVER

All information contained in the application is subject to verification. The City of Alamosa will conduct background checks including, but not limited to, work references, driving records, criminal background records, and educational attainment.

I understand an employment offer is contingent upon successful completion of a pre-employment alcohol/drug test, review of work references, and results of the background check.

I understand that specific positions at the City of Alamosa require proof of an acceptable driving record and that maintaining an acceptable driving record is a condition of continued employment.

I understand that the CITY OF ALAMOSA-EMPLOYEES ("the Organization") may obtain information about me from a consumer reporting agency for consideration of employment with the Organization. Thus, I may be the subject of a "consumer report" which may include information about my character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding my criminal history, motor vehicle records ("driving records"), or other background checks. Please be advised that the nature and scope of the most common form of consumer report obtained with regard to applicants for employment, or continued employment is a criminal record report conducted by Background Investigation Bureau, LLC, ("BIB"), 9710 Northcross Center Court, Huntersville, NC 28078, (877) 439-3900.

I also understand that in the event I am placed in a job which does serve youth my name, date of birth, and social security number will be submitted annually to check for any criminal history record information pertaining to me, as a condition of my continued employment and that finding of information determined to be inappropriate will result in my immediate dismissal or discharge.

If employed, I agree to provide proof of identity, relevant licensure or credentials, and authorization for employment in the United States.

If employed, I agree to abide by all policies, regulations, and guidelines established by the City of Alamosa.

I certify that all the information provided herein is true and complete to the best of my knowledge. I agree and understand that omissions, misstatements, and falsifications will cause forfeiture on my part of all eligibility to any employment with the City of Alamosa and may be cause for rejection of this application, removal of my name from eligibility lists, or discharge from City service.

In addition, I give the City of Alamosa the right to investigate and verify any information obtained through the application process. Permission is granted and I release from any and all liability any employer, agency or individual assisting the City of Alamosa in providing relevant, job-related information that will assist in this process.

I understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with the City of Alamosa is an “at-will” nature, which means that the employee may resign at any time and the City may discharge an employee at any time with or without cause. It is further understood that this “at-will” employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.

I have read and I understand the “Application Form Waiver” and I am acknowledging the same by my dated signature hereafter.

Signature*

DateTime*

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APPLICATION FOR POLICE EMPLOYMENT

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Military Service

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