youngsville police department · 2016. 1. 22. · ypd 12/16/15 1 of 12 application for employment...

MinimumqualificationsforemploymentwiththeYoungsvillePoliceDepartment: 1.Mustbe21yearsofage 2.Mustbeahighschoolgraduate 3. Must conform to and abide by laws of the United States, the State of Louisiana and anysubdivisions thereof 4.Musthaveavaliddriver’slicenseandgooddrivinghistory 5.Musthave: A–NoFelonies B–Nomisdemeanorchargesthatwouldprohibityoufromcarryingafirearm. 6. Must be able to pass a physical which includes a drug and back screen through the City ofYoungsville’sappointedphysicians 7.Mustbeingoodphysicalshapeinordertocompletepolicetraining 8.MustbearegisteredvoterProcedurespriortobeginningdateofemployment: 1.Submitcompletedapplication,alongwithcopiesofanycertifications,driver’slicense,andvoter registrationcard. 2.Ifapplyingforreservestatus,youwillfollowthesameproceduresasafull-timeapplicant. 3.Applicantwillbescreenedthroughprioremploymenthistory,criminalhistory,andDLcheck. 4.ApplicantwillbecontactedbyeithertheChiefortheAssistantChief,tosetupandappointmentfortheinterview,onlyintheeventofanopeningandyouareselectedasacandidate

5. If accepted for employment, arrangements will be made for physical, drug screening andpsychologicaltestthroughHumanResourceDepartment.6.Submitprior“PriorServiceCertificate”ifapplicable.7. Prior tobeginningdate, applicantwill be suppliedwith the Youngsville PoliceDepartmentDrugPolicy,andmustseetheHumanResourceDepartmentforsigningofallappropriatepaperwork.8.ThenreceivePolicyManual,equipment,etc.,fromeithertheChieforAssistantChief.9.CompletePropertySheetwiththeCaptainofPatrol.10. Application will receive appropriate paperwork from the Human Resource Department to getsworntodutyandreceivecommissioncardbeforebeingturnedovertohisFTO(FieldTrainingOfficer).

YoungsvillePoliceDepartment P.O.Box310 304FourthStreet

Youngsville,LA70592337-856-5931

337-856-4904fax_______________________________________________________________________________________________

APPLICANTSAREGIVENCAREFUL,FAIRANDEQUALCONSIDERATION.IFITDETERMINETHECHIEFOFPOLICEWISHESANINTERVIEW,YOUWILLBENOTIFIED.

YPD12/16/151OF12APPLICATIONFOREMPLOYMENTYOUNGSVILLEPOLICEDEPARTMENTP.O.BOX310304FOURTHSTREETYOUNGSVILLE,LA70592337-856-5931FAX337-856-4904

POSITIONAPPLIEDFOR: DATEOFAPPLICATION

CHECKONE:FULLTIME()RESERVEOFFICER()CLERICAL() 1.LASTNAME FIRST MIDDLE MAIDEN/OTHER

PRESENTSTREETADDRESS APT.# CITY STATE ZIPCODE

AGE D.O.B. SOCIALSECURITY# RESIDENCEPHONE CELLPHONE

SEX HEIGHT WEIGHT HAIRCOLOR EYECOLOR PLACEOFBIRTH

DISTINGUISHINGMARKS:PHYSICALDEFECTS,BIRTHMARKS,SCARS,ETC.

DRIVERSLICENSE# STATE TYPE EXPIRATIONDATE

2.TheCivilRightsActof1964prohibitsdiscriminationinemploymentbecauseofrace,color,religion,sexornationalorigin.Pleaseindicatewhichgroupyou.(Checkone).AmericanIndian OrientalAmerican CaucasianBlackAmerican SpanishSurnameorSpanish Other

CHECKONEMARITALSTATUS:MARRIED()SINGLE()ENGAGED()SEPARATED()DIVORCED()WIDOW()3.NAMEOFPRESENTSPOUSE D.O.B. SOCIALSECURITY#

HEIGHT WEIGHT HAIRCOLOR EYECOLOR ADDRESS(IFDIFFERENT)

4.COMPLETETHEFOLLOWINGINFORMATIONREGARDINGEX-SPOUSE:NAME(MAIDEN/OTHER) DATEOFBIRTH

5.RELATIVES:LISTYOURCHILDRENINCLUDINGSTEP/ADOPTEDCHILDREN:NAME DATEOFBIRTH RESIDENCE

LEAVETHISAREABLANK:FINGERPRINTEDBY:___________________________PHOTOGRAPHEDBY:__________________________DATE:______________________________________PHYSICAL/DRUGSCREEN:_______________________STARTDATE:_______________ACCEPTED:YESNOIFNO:_______________________________________

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Eventhougharelativeisdeceased,giveallinformationrequestedandindicatelastresidence.

A.FATHER’SNAME DATEOFBIRTH RESIDENCEADDRESS

MOTHER’SNAME DATEOFBIRTH RESIDENCEADDRESS

B.STEPFATHER’SNAME DATEOFBIRTH RESIDENCEADDRESS

STEPMOTHER’SNAME DATEOFBIRTH RESIDENCEADDRESS

C.BROTHER’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS

SISTER’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS

D.FATHER-IN-LAW’SNAME DATEOFBIRTH RESIDENCEADDRESS

MOTHER-IN-LAW’SNAME DATEOFBIRTH RESIDENCEADDRESS

E.BROTHER-IN-LAW’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS

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SISTER-IN-LAW’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS

ListallrelativesemployedbytheCityofYoungsvilleorPoliceDepartment:

FULLNAME RELATIONSHIP DEPARTMENT

6.Residences:(Listallresidencesforthepastten(10)yearsbeginningwithyourpresentaddress.Includeoff-baseresidenceswhenintheserviceand/ordormitorieswhenincollege.)

MONTH YEAR ADDRESS CITY STATE

7.CharacterReferences:(Listthree(3)personsnotemployeesorrelativeswhoknowyouwellenoughtogivecurrentorformerinformationaboutyou.)

NAME ADDRESS(INCLUDEZIPCODE) HOMEPHONE BUSINESSPHONE

OCCUPATION

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8.EmploymentHistory:Listalljobsheldinthepastfive(5)yearsregardlessoflengthoftimeemployed.Startwithyourpresentplaceofemployment.

DESCRIPTIONOFDUTIES REASONFORLEAVING

DESCRIPTIONOFDUTIES REASONFORLEAVING

DESCRIPTIONOFDUTIES REASONFORLEAVING

DESCRIPTIONOFDUTIES REASONFORLEAVING

DESCRIPTIONOFDUTIES REASONFORLEAVING

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A.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVOR

TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER

B.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR

TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER

C.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR

TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER

D.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR

TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER

E.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR

TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER

DESCRIPTIONOFDUTIES REASONFORLEAVING

9.Education:Listyoureducation,includinghighschool,colleges,businessandtechnicalschool:

SCHOOLNAME ADDRESS FROM TO GRADUATE

YES()NO()

YES()NO()

YES()NO()

YES()NO()

YES()NO()

10.Doyouhaveanyknowledgeortrainingofbusinessmachines?Ifyes,pleaseexplainbelow:

11.HaveyoueverappliesforapositionwiththeYoungsvillePoliceDepartment?

YES NO IFYES,EXPLAINBELOW:

HaveyoueverappliedforapositionwithanotherLawEnforcementorotherGovernmentAgency?

YES NO IFYES,EXPLAINBELOW:

F.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR

TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER

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12.Haveyoueverordoyounowhaveanyofthefollowingillness:

ILLNESSES YES NO ILLNESSES YES NOSYPHILIS TUBERCULOSIS DIABETES CRAMPSINLEGS CANCER KNEEPROBLEMS KIDNEYTROUBLE FREQUENTORSEVEREHEADACHES HEARTTROUBLE DIZZINESSORFAINTINGSPELLS STOMACHTROUBLE NERVOUSTROUBLEOFANYSORT RHEUMATISM/ARTHRITIS ANYDRUGORNARCOTIC EPILEPSY LOSSOFARM,LEG,FINGERORTOE EYETROUBLE CAR,TRAIN,SEA,ORAIRSICKNESS SWOLLENORPAINFULJOINTS WEARGLASSES EXCESSIVEDRINKING WEARANARTIFICIALEYE HIGHORLOWBLOODPRESSURE WEARHEARINGAIDS AIDS STUTTERORSTAMMER MULTIPLESCLEROSIS ATTEMPEDSUICIDE

a.Haveyoueverhadanyoperationswithinthepastfive(5)years?

YES NO IFYES,PLEASEEXPLAINBELOW,GIVINGDATE(S)ANDTYPEOFSURGERYORSURGERIES:

B.Doyouhaveanyotherphysicaloremotionalconditionthatwouldlimityourjobperformanceorendangerothers?

YES NO IFYES,PLEASEEXPLAINBELOW:

13.Doyouoryourspousehaveanyimmediatecivil/criminalactionpendingagainstyou?

YES NO IFYES,PLEASEEXPLAINBELOW:

a.Haveyoueverreceivedatrafficcitationorbeeninvolvedinatrafficaccident?

YES NO IFYES,PLEASEEXPLAINBELOW:

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b.Haveyoueverbeenarrestedorconvictedofafelony?

YES NO IFYES,PLEASEEXPLAINBELOW:

c.Listallmisdemeanorarrestsand/orconvictionsbelow:

DATE CHARGE(S) DETAININGORARRESTINGAGENCY PENALTY

14.Haveyouoryourspouseeverhadyourwagesgarnished?

Yes No

a.Haveyouoryourspouseeverbeenpartytoasmallclaimsorothercourtaction?

Yes No

b.IfemployedbytheYoungsvillePoliceDepartment,doyouanticipateanyincomeotherthanyourincomingpoliceincome? YesNoc.Haveyoueverbeenrefusedalife,auto,healthorotherinsurancepolicy?YesNo 15.Whentheanswertoanyoftheabovequestionsisyes,pleaseexplainbelow:

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16.Listallorganizations,clubsandsocialgroupsofwhichyouarenow,orhavebeenamember:

17.Ifitbecamenecessary,inthecourseofyourpolicyduties,totakeahumanlife,wouldyouhaveanyreluctancetodosobecauseofreligiousorotherbeliefs? YesNo 18.HaveyoueverservedintheArmy,Navy,MarineCorps,AirForce,R.O.T.C.,orothermilitaryorsemi-militaryorganizations?

YES NO ORGANIZATIONENLISTMENT

DATEDISCHARGE

DATE TYPE RANK

Presentdraftclassification:

19.Wearelookingforapermanentemployeeandwillmakeaninvestmentintraining.Isthereanyreasonwhyyouwouldnotexpecttofinishtrainingandstaywiththedepartment?YesNoYPD12/16/15Page9of12

20. Do you understand that the police academy training is a period of selection, that you must complete itsuccessfully,thatmaydischargedfromthisschoolatanytime,thatyoumustsubmityourselftostrictdisciplineandthatyoumaynothaveanyotheremploymentorattendanyotherschoolwhilearecruitinthepolicyacademy? YesNo 21.Specialskillsandabilities:

22.Haveyoueverreceivedcompensationforinjuries?YES NO IFYES,EXPLAINBELOW:

23.AreyouaUnitedStatecitizen?YesNo

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Iamawarethatanymisrepresentationorfalsificationsmadeinconnectionwithmyobtainingemploymentwiththe

Youngsville Police Departmentwill be grounds for rejection or dismissal. The fact set forth inmy application for

employment are true and correct. I understand that if employed, false statements on this application shall be

consideredsufficientcausefordismissal. Youareherebyauthorizedtomakeany investigationofmypersonaland

financial record through any investigative agencies or bureaus of your choice. In making this application for

employment, Ialsounderstandthataninvestigativereportmaybemadewherebyinformationisobtainedthrough

personal interviewswithmy neighbors, friends or others withwhom I am acquainted. I understand that if I am

successful candidate for employment, I will be required to take a physical examination, psychological test, drug

screenandperhapsappearinfrontoftheMayorandCouncilMembers.

____________________________________________APPLICANTSSIGNATURE____________________________________________WITNESS(COMPANYINTERVIEWER)

I have applied for employment with the Youngsville Police Department for the position of

______________________________, with requires a personal background check. I hereby authorize their

investigationofmyprevious recordandcharacterand toascertainanyandall informationwhichmayconcernmy

recordandcharacter,whetherthesameisofrecordornot. Thisauthorizationincludes,but isnot limitedtobank,

credit, school, selective services, physical, hospital, or employer records, and releases all persons, organizations,

corporationsfromanychargesbecauseoffurnishingsaidinformation.Aphotostaticcopyofthisauthorizationshall

beconsideredaseffectiveandvalidastheoriginal.

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Bysigningbelow,youagreetoenterintoacontractwiththedepartmentinreferenceto:Ifyouvoluntarilyleavethe

Youngsville Police Department within 362 days of your employment, you will be required to reimburse the

department for the cost of your employment, your pre-employmentphysical, your pre-employmentphysical, your

pre-employment drug test, uniforms, training andpolicy academy fees (if applicable) and anyother costs that are

spentonthetrainingperiod. Youalsoagreetopayall legalcost incurredbytheYoungsvillePoliceDepartmentto

enforce this contract, and agree that any amount due can be withheld from your final pay or any retirement

accumulated.

TOBECOMPLETEDBYAPPLICANT:

_________________________________________________________________________________________(PRINTNAME)(SIGNATURE)_________________________________________________________________________________________(ADDRESS) (DATE)WhydoyouwanttobecomeemployedwiththeYoungsvillePoliceDepartment?(Inyourownhandwriting)

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