NAME: (last name) (first name) (full middle name) (maiden name) ADDRESS: CITY: STATE: ZIP CODE: PHONE NUMBER: MOBILE/OTHER:

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1 BUDA POLICE DEPARTMENT APPLICATION FOR EMPLOYMENT EQUAL OPPORTUNITY EMPLOYER 100 Houston Street, Suite B Buda, TX (512) NOTE TO APPLICANT: Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or the interview process should notify a representative of the Human Resources Department. IT IS MANDATORY FOR THIS APPLICATION TO BE COMPLETELY FILLED OUT. FAILURE TO COMPLETE THE APPLICATION WILL RESULT IN NON CONSIDERATION. ALL LAW ENFORCEMENT APPLICANTS MUST BE AT LEAST 21 YEARS OF AGE. Attach resume, if desired. Position(s) applied for Job Posting # Date of Application Referral Source: Advertisement Employee Relative Government Employment Agency Walk in Private Employment Agency Other: PERSONAL NAME: (last name) (first name) (full middle name) (maiden name) ADDRESS: CITY: STATE: ZIP CODE: PHONE NUMBER: MOBILE/OTHER: EMPLOYMENT DESIRED Are you able to perform the functions of the job as described in the job description? Yes No Are you legally eligible for employment in this city? Yes No Date available for work: What is your desired salary range? Type of position desired Full Time Part Time Temporary Will you work overtime if required? Yes No Will you work weekends if required? Yes No Driver s License Number and Class if required for this job DL# State: 1

2 Buda Police Department Background History Statement Personal Information Page 5 Residences Page 6 Educational History... Page 8 Work History.. Page 9 Military Record. Page 14 Law Enforcement Experience. Page 16 Marital and Family History.. Page 19 References.. Page 23 Traffic Record... Page 25 Arrests and Detentions.. Page 28 Financial History and Obligations Page 31 Civil Suits/Litigations.. Page 36 Special Qualifications, Skills, and Hobbies.. Page 37 Computer Skills.. Page 37 Personal Declarations... Page 38 Read all instruction carefully before Completing your background history statement 2

3 These instructions are provided as a guide to assist you in properly completing your Background History Statement. It is essential that the information be accurate in all respects. It will be used as the basis for your background investigation and any further job interviews with this department. 1. Avoid errors by reading the directions for each question carefully before making any entries on the form. Be sure everything is correct and in proper sequence before entering the information. It is recommended that you make copies of this statement to use as a rough draft. Before turning in the final draft, make a copy to keep for your records. 2. The Background History Statement must be PRINTED LEGIBLY IN BLACK INK OR TYPED BY THE APPLICANT. No photocopies will be accepted. 3. If the question is not applicable to you, enter NA in the space provided. 4. You are responsible for obtaining correct names, addresses, and phone numbers. If you are not sure of an address or phone number, check it by personal verification. Your local library may have a directory service or copies of phone directories. All addresses must have zip codes. 5. If there is insufficient space on the form to include all the information required, attach extra sheets to the application. Be sure to reference the relevant section and question number before continuing your answer. 6. Answering all questions accurately will help expedite our investigation of you. Failure to respond to the question or failure to provide the information requested will result in disqualification. 7. After the Background History Statement has been submitted, you are responsible for notifying the Police Department of any changes in the information provided. Residence and job information frequently change after you have sent in the application. ANSWER EACH QUESTION COMPLETELY AND HONESTLY. MOST PEOPLE ARE NOT HIRED BECAUSE OF OMISSIONS OR CONCEALMENT THAN BECAUSE OF PREVIOUS BEHAVIOR. ANY OMISSION OR CONCEALMENT OF INFORMATION WILL BE CONSIDERED DECEPTION. WHILE MISTAKES, INDISCREATIONS OR OTHER SITUATIONS IN YOUR LIFE HISOTRY MAY OR MAY NOT BE CONDONED, DECEPTION WILL ABSOULUTELY NOT BE TOLERATED. 3

4 REQUIRED PAPERS AND DOCUMENTS: YOU MUST BRING THESE DOCUMENTS, ALONG WITH A COPY OF EACH, WITH YOU WHEN RETURNING APPLICATION: 1. An original of your Birth Certificate or Naturalization certificate. (NO EXCEPTIONS) 2. An original of your high school diploma, college or university transcripts must be resented. If the school will not give you the transcripts, have them mailed to: City of Buda, Attn: Buda Police Department, 121 Main Street, Buda, Texas If applicable, a copy of your DD Form 214, Certificate of Discharge from the Armed Forces, for each period of military service, The DD Form 214 must be the copy that reflects Reentry Code. 4. An original of your Social Security card. (NO EXCEPTIONS) 5. An original of your Driver s License. (NO EXCEPTIONS) 6. An original of your TCLEOSE License Card (for all officer applicants) 7. ** A recent Personal Credit Check may be requested at a future point in the application process. ** 8. A copy of a current insurance card or proof of insurance FAILURE TO BRING THESE DOCUMENTS MAY RESULT IN DISQUALIFICATION If you have any questions, please contact Human Resources at

5 BACKGROUND HISTORY STATEMENT PERSONAL INFORMATION APPLICANT: (last name) (first name) (full middle name) Race: Sex: Date of Birth: Age: Residence Address: City: State: Zip: Mailing Address: City: State: Zip: Phone: Work: Cell: Pager: Other: Address: Personal Web Page URL: Place of Birth (city): County: State: Country: Other Names (nicknames, aliases, Maiden Name): SSN: DL #: State: DL Expires: Previous DL: State: Eye Color: Hair Color: Height: Weight: _ Scars, Tattoos, Other Distinguishing Marks: 5

6 RESIDENCES: Beginning with your present address, list all addresses where you have lived during the past 10 years. List by month and year. 1. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 2. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 3. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 4. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: 6

7 Phone: Fax: 5. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 6. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 7. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 8. From: To: Residence Address: City: State: Zip: County: Mortgage Company or Landlord: Address: City: State: Zip: Phone: Fax: 7

8 EDUCATIONAL HISTORY 1. High School(s) attended City/State From To Diploma or GED 2. How many college credit hours do you have? Do you have a degree? What type? Total number of semester you have attended college? Are you currently enrolled? yes no Overall Grade Point Average? 3. College/University attended: City: State: Zip: Dates: Hours completed: Major/Minor: Degree earned & date (if any): College/University attended: City: State: Zip: Dates: Hours completed: Major/Minor: Degree earned & date (if any): College/University attended: City: State: Zip: Dates: Hours completed: Major/Minor: Degree earned & date (if any): 4. Are you the recipient of any student loans? yes no 5. Are you currently making student loan payments? yes no If not, when are you due to being payments? How much is each payment and when is it due? When was the last payment made? Have you ever been delinquent in making payments? yes no Are you delinquent now? If so, how many payments? Have you ever defaulted on a guaranteed student loan? yes no 8

9 If so, when did you do so and to what lending institution? 6. Did you have a co-signer or co-borrower on any of your student loans? yes no If so list the co-signer or co-borrowers for each and his/her relationship to you. 7. Did you ever receive any type of academic or criminal disciplinary action while in college? yes no If yes, then give a brief summary of each incident: 8. Trade Schools attended: City: State: Zip: _ Dates: Hours completed: Major/Minor: Degree earned & date (if any): Trade Schools attended: City: State: Zip: _ Dates: Hours completed: Major/Minor: Degree earned & date (if any): 9. Other schools attended (vocational, business, etc.) Name City/State From To Course/Certification Work History Beginning with your present or most recent job, list all employment for the past 10 years, including part time, temporary, or seasonal work. Include all periods of unemployment, attendance at school and military service. Attach extra pages if necessary. 9

10 1. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: #3 Co-worker s Name: Phone: address: Reason for leaving? 2. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: #3 Co-worker s Name: Phone: address: 10

11 Reason for leaving? 3. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: #3 Co-worker s Name: Phone: address: Reason for leaving? 4. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: #3 Co-worker s Name: Phone: 11

12 address: Reason for leaving? 5. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: #3 Co-worker s Name: Phone: address: Reason for leaving? 6. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: 12

13 #3 Co-worker s Name: Phone: address: Reason for leaving? 7. From: To: Employer: Address: City: State: Zip: Phone: Fax: Job Title: Duties: Average number of hours worked per week? Hourly wage: Supervisor: Phone: address: #1 Co-worker s Name: Phone: address: #2 Co-worker s Name: Phone: address: #3 Co-worker s Name: Phone: address: Reason for leaving? 8. Have you ever been asked to resign? yes no How many times? Employer(s): When? Why? 9. Have you ever quit a job without giving sufficient notice? yes no How many times? Employer(s): Why? 10. Do you have any reason to believe that a former employer(s) may give you a negative job reference? yes No Name of Employer(s): Why? 13

14 11. Have you ever participated in any internship with any law enforcement agency? List agency and Supervisor s phone number and how long you were an intern there? 12. Have you ever applied to a law enforcement agency for employment? yes no If so, how many times have you applied? Dates? Were you accepted? Did you start the academy? If so, when? When did you leave? Why? 13. If you applied and were not accepted, what part of the process eliminated you? 14. If you withdrew from the process, why and at what point? Military Record 1. Dates served n U.S Armed Forces- From: To: 2. Branch of service: Current or last unit: Highest Rank held: Type of discharge: 3. Do you have a form DD214? How is your discharge listed on your DD214? (Honorable, General, etc.) 4. How long did you serve on active duty? (give years, months, & days) Have you ever served any time in the Reserves/National Guard? yes no How long? Are you still in the Reserves or National Guard? yes no If so, what is your status? (Ready Reserves, Individual Ready Reserves, Inactive) 5. List the last five military bases you were stationed at starting with the most recent. a. b. c. d. 14

15 e. 6. List the city, state, and military base where you completed basic training and advance training at. 7. List all types of disciplinary actions, including arrest, if any, (letter of reprimand, oral reprimand, court martial, captain s mast, company punishment, office hour, art. 15) while in the military: Charge Date Age at time Disposition 8. Have you ever been the defendant in a court martial? yes no When? What were the charges? What was the outcome of the court martial(s)? How many times have you been court martialed? 9. Have you ever engaged in any activities in another country that would be considered illegal in the United States? yes no If yes, what activity and when/where did it take place? 10. List all incidents where you had contact (in a criminal matter) with the military police. 11. Have you ever applied and been rejected for military service? When? Which branch of the service? Why was your application refused? 12. List all commendations/education received during your military service. 15

16 Law Enforcement Experience 1. Are you a licensed peace officer or have you ever been a licensed peace officer? yes no 2. Have you been employed in the past by a police department or law enforcement agency? yes no Agency: City/State: Dates- From: To: Who was your last supervisor? What was your duties/division? 3. If you have been employed in the past by a police department or law enforcement agency were you fired? Laid off? Asked to resign? Did you voluntarily resign? What is your reason for leaving? Are you eligible for rehire at this agency? 4. List certifications and/or licenses, by any state as a peace officer: Where: When: 5. List all law enforcement agencies to which you have ever applied for employment: (begin with the most recent) Agency Month/Year Status (tested, failed test, etc. ) 16

17 6. List all security agencies that you have applied for. Security Agency Date Outcome (hired/not hired) 7. Are you a reserve officer? yes no For which agency? How many hours per month do you work as a reserve officer? 8. Has any law enforcement or corrections agency ever notified you either verbally or in writing of a citizen complaint against you? yes no How many? When? What for? Outcome? 9. Have you ever been notified in any form by any law enforcement or corrections agency that you were the subject of an in house investigation, be it criminal, civil, or administrative? yes no Detail each occurrence and outcome: 10. Have you ever been notified in any form by a judicial, prosecutorial, or grand jury entity that you are/were the subject of an investigation? yes no Detail each occurrence and outcome: 11. Please define in your own words what constitutes acceptance of a bribe. Have you ever been involved in any activity that would be considered acceptance of a bribe? 12. Have you ever knowingly ingested, inhaled, or injected any illegal substance while employed as a commissioned police officer or correctional employee? yes no 17

18 Detail each occurrence: Name of Illegal Drug Date used On Duty (y/n) Off Duty (y/n) Comments about drug use: 13. Have you ever failed to properly document according to your departments written procedures, found property, or confiscated property, or a prisoner s property? yes no Detail the occurrence and outcome: 14. Have you ever engaged in an undetected on duty or off duty misconduct that violated your departments written policies or any state or federal civil or criminal laws? yes no Detail the occurrence and outcome: 15. Have you ever had any disciplinary actions taken against you as a law enforcement professional? Disciplinary action includes days off without pay, oral reprimands, written reprimands, vacation days surrendered in lieu of days off without pay. Disciplinary action also includes surrender of promotion and/or reduction in rank or pay scale. yes no How many times? When? What for? Each disciplinary action and type: Agency and supervisor taking disciplinary action: Marital and Family History 1. Single: 18

19 2. If engaged: Name of fiancée: Date of Birth: Address: City: State: Zip: Home phone: Work phone: Address: 3. If married or separated: Date Married: City/State: Spouse s Name: Maiden Name: Address: City: State: _ Zip: Home phone: Work Phone: Address: Employer: Occupation: Work Address: City: State: _ Spouse s Driver s License #: Date of Birth: _ 4. If divorced: Date Married: City/State: Spouse s present Name: Maiden Name: Date of Divorce: Date of Birth: Address: City: State: _ Zip: Home phone: Work Phone: Address: County you were divorced in: 5. If dating: Name of girlfriend/boyfriend: Date of Birth: Home phone: Work phone: Address: City: State: Zip: Address: 6. List all children related to you or your spouse (i.e. natural, adopted foster and step): Name Relation Date of Birth Address 19

20 7. If you have had a child from a previous girlfriend/boyfriend, then list the girlfriend/ boyfriend s name(s), address, and phone numbers. 8. Are you responsible for making child support payments? yes no If so, are you wages being garnished? yes no By whom: Are you current on your payments? yes no If not, how many payments are you behind? How much do you owe and how often do you make your payments? Have you ever been notified by a governmental agency that you were behind on child support or alimony payments? yes no Detail who, when, where, and why of any such notification. Has an arrest warrant ever been issued for you because of non support? yes no By which agency? Has any agency, whether governmental or private, contacted you because of delinquent child support payments? yes no Who contacted you? What was the result? 9. List all other dependents (other than spouse or children) Name Relation Address 20

21 10. List other relatives in the following order: Father, mother (include maiden name), brothers, sisters (including step parents and step siblings), in their birth order. If deceased, indicate in the provided section with an approximate date. Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: 21

22 Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: Relation: Name: Address: City: State: _ Zip: Home #: Work #: Pager #: Fax #: address: Date of Birth: Date of death: 11. List any additional person(s) living in your household: Name Date of Birth Relation 12. Have any members of your immediate family ever been arrested as adults that you are aware of either through personal knowledge or hearsay (parents, brothers, sisters, spouse, children, or close relatives)? yes no If yes, complete the following for FELONY and MISDEMEANOR charges: Arrestee s Name DOB Arresting Agency Offense a. b. c. d. 22

23 Relationship to person Misdemeanor or Felony Disposition of charges a. b. c. d. References List five (5) persons who have know you for a minimum of two (2) years and can provide current information about you. Do not list City of Buda employees or relatives, supervisors or co-workers listed previously in this application. You may list City of Buda employees on a separate page and attach to this application. 1. Name: Years Known: Address: City: State: Zip: _ Home #: Work #: Work address: City: State: _ Zip: Fax #: Address: 2. Name: Years Known: Address: City: State: Zip: _ Home #: Work #: Work address: City: State: _ Zip: Fax #: Address: 3. Name: Years Known: Address: City: State: Zip: _ Home #: Work #: Work address: City: State: _ Zip: Fax #: Address: 4. Name: Years Known: Address: City: State: Zip: _ Home #: Work #: 23

24 Work address: City: State: _ Zip: Fax #: Address: 5. Name: Years Known: Address: City: State: Zip: _ Home #: Work #: Work address: City: State: _ Zip: Fax #: Address: 6. Do you know officers from any other law enforcement agencies? yes no List their first and last name(s), how you know them and what agency they work for. 7. List the name of any current or past Buda Police Department commissioned officer or civilian employee you are acquainted with or related to in any capacity. Detail the relationship. (friend or know from ride along, etc.) 8. List all agencies you have participated in a ride along with and the officer you rode with. Traffic Record 1. List all driver s licenses that you have EVER held and whether or not any or all of them are currently active. 24

25 State License Number Date Surrendered or Expired 2. How many years of driving experience do you have? 3. List any and all incidents where your driver s license has been suspended, revoked, or put on probation in any county or state: Date Location Reason 4. For any reason whatsoever, have you ever in your lifetime failed to pay or otherwise legally dispose of any traffic, parking, or other misdemeanor citation? yes no Have you ever been arrested on a traffic warrant? yes no If so, when and by what agency? For the purpose of answering the above question, arrested is defined as: Being detained by any law enforcement agency or agent acting on a warrant of arrest or summons issued in your name indicating a failure to properly dispose of a traffic, parking or other misdemeanor citation within the prescribed number of days after receipt of the citation. Detained means transport to jail, transported to a magistrate, or transported before a court clerk where a fine had to be paid or bond posted to avoid your incarceration, whether or not the fine and/or bond was actually posted by you or someone else. 5. List any and all vehicles current owned by you, registered in your name, or that you frequently drive. Year Make Model Color LP#/ State 25

26 6. List your auto insurance carrier, police number and agent s phone number. 7. Have you ever received a ticket for not showing proof that the vehicle you were driving was covered by insurance? yes No Have you ever been convicted of driving without insurance? yes no If so, how many times? 8. Have you ever been ARRESTED (whether convicted or not) for the offense of driving while intoxicated or driving under the influence of drugs? yes no If so, when? Who was the arresting agency? What was the outcome of the arrest? 9. List all moving and non-moving tickets excluding parking tickets (i.e. speeding, ran red light, unsafe lane change, expired registration, no insurance, etc.) that you have received starting with the most recent ticket. Disposition of Ticket means how you chose to take care of the ticket (i.e. did you plead guilty and take defensive driving, pay a fine, have the ticket dismissed by a judge, received deferred adjudication, etc.) Date Agency Offence Disposition Post Speed Citation Speed 10. List all of the accidents you have been involved in as a driver starting with the most recent accident. For this form, the determination of At Fault/Not at Fault is the listed opinion made by the investigating officer, not yours. 26

27 Date of Location Investigating At Fault/ Accident (city/state) Agency Not at Fault Arrests and Detentions If you are not sure whether or not you were actually under arrest, contact the Buda Police Department and explain the situation. The excuse I didn t realize I was under arrest will not be accepted if questions arise later in the application process. (This includes, non-traffic, misdemeanor release citations, curfew violations, urinating in a public place, minor in possession, drug paraphernalia, possession of marijuana, etc.) 1. Have you ever been adjudicated as a Child in Need of Supervision or a Delinquent Child? yes no If yes, what were the circumstances of that adjudication? 2. Have you ever been arrested as an adult (age 17 and above)? yes No If so, how many times? Complete the following if you ve been arrested as an adult and/or have appeared as a defendant in a criminal proceeding: Date Name of Convicted? Disposition Arrested Offense Yes No 27

28 3. Which criminal courts have you appeared in as an adult defendant? 4. List any and all pending criminal charges against you: Offense charged City/State Date Agency Disposition 5. Have you ever committed any of the following offenses as an adult or juvenile? Whether or not you were arrested. If yes, check the appropriate box and explain below. Arson Family Violence Assault Forgery Auto Theft Impersonating a Police Officer Burglary Kidnapping Perjury Robbery Resisting Arrest Credit/Debit Card Abuse Sexual Assault Criminal Mischief Theft Illegal possession of a weapon * Specify weapon: Explanation: 6. Have you ever engaged in any illegal activity that, to your knowledge was not report to a law enforcement agency? yes no Detail whom, what, where, when and why each occurrence. 28

29 7. List all incidents when the police have been called to a location where you were at even if you were not involved. 8. Have you ever been a suspect in a crime? yes no If yes explain in full. 9. List any and all cash and/or items that you have ever stolen. This includes any money or item that you took without permission or authorization from any individual, employment, business, store, etc., whether or not a report was made to a law enforcement or prosecutorial agency. When Dollar Item Quantity month/ year Value From Whom 10. Have you ever purchased items that you knew or suspected were stolen? yes no If yes, complete the following: 29

30 When Original Item Quantity month/ year Value Amount Paid 11. What in your opinion is the worst thing you have ever done? 12. List any Emergency Protective Orders, Exparte, and Restraining Orders, both expired and active that pertains to you. Financial History and Obligations 1. What is your present net monthly income: $ 2. What is your spouse s net monthly income: $ 3. List and identify any other monthly net income source: $ $ $ 4. Total monthly net income (add 1,2, & 3) $ 5. Total monthly financial obligations: $ 6. Income left over after obligations (subtract line 5 from line 4) $ 7. List any and all accounts or property that ere repossess or charged off: Account/Property Date Explanation 30

31 8. List financial obligations: (Give names and addresses of individuals, companies, or other to whom you are indebted and the extent of your debt. Include payments for rent, mortgages, vehicles, charge accounts, credit cards, utilities, food, gas, loans, insurance, child support, and other debts that are paid monthly and payments). Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment 31

32 Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment Address City State Zip Creditor s name/type Current Balance Monthly payment # of Payments Behind Date of last payment 32

33 Address City State Zip Monthly Total: $ Total Debt: $ 9. What do you consider your current financial condition to be? Excellent Good Fair Poor Why? 10. Have you ever written any checks which were returned for insufficient funds or been notified by a bank that your account was overdrawn? (Excluding overdraft protection) yes no If yes, explain (include date, bank name, and amount of check) 11. Do you currently hold a joint account with anyone? yes no Who? Relationship? How many individuals have permission to sign on your checking account? Who are they? 12. Are you currently behind on any accounts? yes no If so, complete the following: Name of Account Amount you were behind # of days you were behind 13. Have you ever been referred to a collection agency? yes no How many times? when was the last time? What was the outcome for each time? How much did you owe for each account referred to collection? 33

34 14. Have you ever had any repossession? yes no How many times? By what business? Why? How much did you owe at the time of repossession? How far behind where you? If you ve ever had a vehicle repossessed, what is the year and model of the vehicles(s) involved? 15. Have you ever in your life voluntary or involuntary declared Bankruptcy? yes no If yes, declared under which chapter? Detail each occurrence (who, what, when, where, why and the status). 16. Is your credit re-established? yes no 17. List the names of the creditors involved in your bankruptcy and any arrangements made for payment of the debt: 18. Were you delinquent on these accounts when you filed bankruptcy? yes no If so, for how long? 19. When we check your credit history with a credit bureau, how do you think the report will look? Excellent Good Fair Poor Why? Civil Suits/Litigations 1. Have you ever had a monetary judgment entered against you by a court of law or a lien filed against you or your property? yes no If yes, explain: 2. Do you have any pending lawsuits against the City of Buda? yes no If yes, explain: 34

35 Special Qualifications, Skills, and Hobbies 1. List any special skills and/or qualifications you may possess (i.e. pilot, radio operator, scuba diver, computer programs, typing skills, etc.): 2. List guns or weapons that you are familiar with or own and any qualifications or license (i.e. FFL, CHL, etc.) List license or permit number. 3. If you are fluent in a foreign language or sign language, indicate in each are your degree of fluency. (Excellent, Good, Fair) Language Reading Speaking Understanding Writing 4. Are you certified in the language(s)? yes no If yes, where did you get your certification? 5. List hobbies you participate in: 6. List all organizations you have ever been a member of: 7. List all sports your participated in during high school: Computer Skills 1. List all Operating Systems you have working knowledge of (Windows, Mac, Windows NT, etc.) 35

36 2. What computer skill courses have you taken? 3. Detail your knowledge of computers and software. (Self taught, formal schooling, etc.) Personal Declarations 1. Have you ever actively ingested, inhaled, or injected any substance listed below with or without a prescription? yes no Detail each occurrence (who, what, when, where, and why) Yes No Approximate Date(s)- Month/Year a. Marijuana b. Hashish c. Speed d. Methamphetamine e. Heroin f. Mushrooms g. Peyote h. LSD i. Cocaine j. Crack k. PCP l. Ice 36

37 m. Ecstasy n. Mandrix o. Steroids p. Amphetamines q. Barbiturates 2. Have you ever ingested, inhaled, or injected any other substance you know or suspect as being illegal? yes no Explain: 3. Have you ever actively ingested, inhaled, or injected any legal substance illegally? yes no (Example: prescription medication not prescribed to you: 4. List in detail your use of any other illegal drugs or illegal substance not covered in the previous list: 5. Will anything prevent you from enforcing federal, state, and local drug laws? yes no If so, what? 6. How many of your friends or family members use illegal drugs? Friends: Family: Do they try to involve you? yes no 7. How often are illegal drugs used in your presence? 8. When was the last time anyone used illegal drugs or an illegal controlled substance in your presence? What illegal drug was it and under what circumstances did you see the illegal drug used? 37

38 9. Have you ever transported any legal drugs, legal substances, illegal drugs, or illegal substances across the borders of the United States of America? yes no Detail each occurrence (who, what, when, where, and why) 10. Have you ever bought or sold any type of illegal drugs or illegal controlled substance, including steroids? yes no Detail each occurrence (who, what, where, when, and why) 11. Do you or have you ever consumed alcoholic beverages? yes no 12. Describe in your own words your use of alcoholic beverages: 13. What do you usually drink? Check all that apply: Beer Wine Liquor 14. Define in your own words and feelings, the word tipsy and intoxicated. Expound on the differences, if any between the two. 15. When were you last tipsy? 16. When were you last intoxicated? 17. Have you ever attended a meeting of a radical or subversive organization? yes no When? Why? Which one(s)? Where? How many meetings? 38

39 18. Since police work includes working weekends and rotating shifts, please provide specifics if this would be a problem for you: 19. What are the reasons you are considering law enforcement as a career and when did you decide to pursue it? 20. Now is the time to consider anything in your background, not covered in this application, that you believe should be considered: 39

40 ****************************************************************************** Must Initial Applicant s Statement I certified that all information included in this application packet is true and correct to the best of my knowledge. I authorize City of Buda to investigate all information contained in this packet as may be necessary in arriving at an employment decision. This application will be considered for a period not to exceed 90 days. In the event of employment, I understand that false or misleading information given in my application package or interview may result in discharge. I also understand that I am required to abide by all rules and regulation of the employer in the event of employment. I understand that no person shall be denied employment with City of Buda on the basis of discrimination involving, but not limited to race, color, creed, religion, gender, national origin, age, disability, marital status, veteran status, sexual orientation, or any other legally protected status. I understand that all appointments must serve a probationary period of 180 days, in addition to any time in a Field Training Officer (FTO) Program, during which time the employee must demonstrate his or her fitness for continued employment by the Buda Police Department. I also understand that any appointment tendered me will be contingent upon the results of a complete character and fitness investigation. I hereby certify that there are no willful misrepresentations, omissions or falsifications in the above statements and answers to questions. I further certify that all statements are mine and are accurate and correct to the best of my knowledge. I am aware that should investigation disclose such misrepresentations, falsifications or inaccuracies, my application will be rejected and I will be disqualified for a minimum of two (2) years. Signature of Applicant Date 40

41 Buda Police Department Background History Statement- Supplement 41

42 BUDA POLICE DEPARTMENT TO WHOM I MAY CONCERN: AUTHORITY TO RELEASE INFORMATION I, Hereby authorize Buda Police Department and its authorized representative baring this release, or a copy thereof, within one year of its date, to obtain any information in your files pertaining to my employment, military, credit, education, or medical records, including not limited to academic, achievement, attendance, athletic, personal history, and disciplinary records, and medical records, and credit records. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for official use. Consent is granted to all parties to furnish such information, as described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as a custodian of such records, and any school, college, university, or other educations institution, hospital, or other repository of medical records, credit bureau, lending institutions, consumer reporting agency, or retail business establishment including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or attempt to comply with it. I am furnishing my Social Security Account Number and voluntary basis with the understanding such is not required by any law or regulation. I have been advised that all parties will utilize this number only to facilitate the location of employment, military, credit, and educations records concerning me in connection with this application. Should there be any questions as to the validity of this release, you may contact me as indicated below: Applicant s Printed Full Name: Address: Telephone Number: Applicant s Signature: Sworn to and signed before me, on this the day of,, in and for the State of Texas. Signature of Notary Public: 42

43 Statement of Non-Military Service To Whom It May Concern: I,, have not served in any branch of the military. Signature Social Security Number NOTARY: Sworn this the day of, Notary Public in and for State of Texas My Commission expires ** If you have served in the Military for any length of time you MUST provide a DD-214 at the time of application; as noted in the front of the application packet. 43

44 City of Buda Equal Opportunity Data Sheet Date: Name: SSN: Position Number: 1. Completion of this section is strictly voluntary. The information will be used to accommodate Equal Employment Opportunity tracking and reporting requirements. Ethnic Origin: Asian Black Hispanic American Indian Caucasian Other Gender: Male Female Veteran: No Vietnam Other 2. Completion of this section is strictly voluntary. The information will be used to determine if reasonable accommodations circumstances exist. Disable: No Yes 44