Police Officer Application

Exactly as extracted, unformatted — for checking against the original. The readable version is easier to read.

POLICE OFFICER
APPLICATION
CENTREVILLE POLICE DEPARTMENT
Town Of Centreville
Maryland

IMPORTANT INSTRUCTIONS
Use this checklist to ensure this police application packet contains the following:
 Employment Procedures and Instructions
 Police Officer Application for Employment
 Centreville Police Department Authorization for Release of Personal Information to Law
Enforcement Agencies for Certification / Employment Purposes
 Selective Service Acknowledgment
 Recruitment Questionnaire
 Fair Credit Reporting Notification
 Acknowledgment Centreville Police Department Notice for Truthfulness
 Personal History Statement
POA Revised 6/20/2020 2

SUBMITTING APPLICATION PACKET
Please ensure the following documents are included when submitting completed
application package:
• Original and one (1) Photocopy of Personal History Statement Booklet (We will not make
photocopies for you.)
• Photocopy of your Valid Driver’s License
• Photocopy of Birth Certificate
• Photocopy of High School Diploma, or an Official High School Transcript, or General
Equivalency Diploma (GED), and if applicable, an Official College Transcript. If not included,
should be submitted at time of background investigation.
• Photocopy of DD-214, if served in the military. If not included, should be submitted at time of
background investigation.
In addition to the above documents, please ensure the following is included
in the completed application packet:
• Police Officer Application for Employment
• Centreville Police Department Authorization and Release to Obtain Information (Previous
Employer)
• Centreville Police Department Authorization for Release of Personal Information to Law
Enforcement Agencies for Certification / Employment Purposes
• Selective Service Acknowledgment
• Recruitment Questionnaire
• Fair Credit Reporting Notification
• Acknowledgment Centreville Police Department Notice for Truthfulness
• Personal History Statement
All forms requiring a notary must be completed prior to submitting application
package. Out-of-State applicants may use a notary from their state of residence.
Return application package to:
Centreville Police Department
420 N. Commerce Street
Centreville, MD. 21617
Telephone: 410-758-8437
Fax: 410-758-8439
Email: centrevillepolice@qac.org
POA Revised 6/20/2020 3

POLICE OFFICER APPLICATION FOR EMPLOYMENT
CENTREVILLE POLICE DEPARTMENT
420 N. COMMERCE STREET
CENTREVILLE, MD. 21617
The Centreville Police Department is an equal employment opportunity / affirmative action employer that does not
discriminate on the basis of race, color, national origin, gender, religion, age or disability in employment or the provision
of services.
Please print clearly or type this application. Complete all sections accurately to the best of your ability.
Your application will be used as a part of the examination process and should reflect your best effort.
Date: ______/______/______ Social Security #: _________ - ______ - __________
Name (LAST, First, Middle): _______________________________________________________________________
Address: ___________________________________________________________
City: _________________________________________ State: _________________ Zip: ______________
Home Phone: (_________)_________-____________ Cell Phone: (_________)_________-____________
Work Phone: (__________)_________-____________ Other Phone: (_________)________-_____________
Do you have a valid driver’s license? Yes  No
State of Issuance: __________________________ Drivers License Number: ____________________________________
D. O. B.: ______ /_______ /_________ EMAIL: ______________________________________________
Note: Data solicited in this block will be used for Equal Employment statistical purposes only.
Ethnic Background  American Indian  Spanish American
 Asian American  White
 African American  Other: __________________
Sex  Male  Female
POA Revised 6/20/2020 4

CENTREVILLE POLICE DEPARTMENT
Authorization for Release of Personal information to Law Enforcement Agencies for
Certification/Employment Purposes (Page 1 of 2)
To Whom It May Concern:
I am an applicant for a position with the Centreville Police Department. In order to determine my suitability for
employment, I understand that the Centreville Police Department, Centreville, County of Queen Anne’s,
Maryland must make a thorough investigation of my personal records and personal background. It is in the
public’s best interest that all relevant information concerning my personal and employment history be disclosed
to the above agency.
Therefore, I, ________________________________________________, DOB, _____________________,
Operator’s License # __________________________________, do hereby request and authorize any bank,
credit union, lending or financial institution, credit bureau, consumer report agency, retail business
establishment, former and present employer, educational institution, doctor or health care professional
including mental health, alcohol treatment center, hospital or repository of medical records, insurance
company, governmental agency, criminal and civil courts, certification/licensing commission, military
organization {including National Personnel Records Center, Saint Louis, Missouri}, and any other individual
agency to produce and provide copies of any and all information to the authorized agent of the Centreville
Police Department, Centreville, County of Queen Anne’s, Maryland regarding me, whether of a privileged or
confidential nature.
Moreover, I hereby release the Centreville Police Department, Centreville, County of Queen Anne’s, Maryland
from any civil or criminal liability whatsoever for seeking such requested information and for evaluating such
information as it relates to my employment with the Centreville Police Department, Centreville, County of
Queen Anne’s, Maryland. And, I hereby release the issuing agency and its agents and employees, both
individually and collectively, from any and all liability for damages of whatever kind, which may at any time
result because of compliance with this authorization request.
I further waive all right to inspect or review any information compiled in reference to my application for
certification as allowed by law. I do further authorize the Centreville Police Department, its agents and
employees, to release copies of any and all information to any agency or entity regulating the certification,
authority or conduct of law enforcement officers. This is to include, but not limited to: Maryland Police and
Correctional Training Commission, Maryland Attorney General’s Office, agencies of other states and the federal
government, and the applicant’s / officer’s employing agency.
I hereby acknowledge that this authorization is valid for one (1) year or until the employment application or
investigative process has been completed, whichever is later.
POA Revised 6/20/2020 5

CENTREVILLE POLICE DEPARTMENT
Authorization for Release of Personal information to Law Enforcement Agencies for
Certification/Employment Purposes (Page 2 of 2)
A copy of this document is considered valid, just as the original.
I have read and fully understand the above statements.
________________________________________ _____________________________________________
(Applicants Full Name-PRINT) (Address)
_____________________________________________ __________________________________________________
(Applicants Signature in Full) (City)
_____________________________________________ __________________________________________________
(Telephone Number) (State & Zip)
STATE OF: __________________________________________
COUNTY OF: __________________________________________
On this _________________ day of _________________________________, 20________,
(applicant)________________________________________, whose name is signed to the foregoing instrument
personally appeared before me, acknowledges the foregoing signature to be his, and, having been duly sworn by
me, made oath that the statements made in the said instrument are true.
_________________________________, 20_______ _____________________________________________
My Commission Expires Notary Public and Official Seal
POA Revised 6/20/2020 6

SELECTIVE SERVICE
ACKNOWLEDGEMENT
MALES AGE 18 THOUGH 25 ONLY
State law prohibits local government from employing anyone who has not complied with Selective Service
Registration Regulations. Currently, males from the age of 18 through 25 are required to register with the
federal government in accordance with the Military Service Act. By your signature below, indicate if you have or
have not complied with the requirement.
YES, I have met Selective Service Registration requirement
_______________________________________________
Applicant’s Signature
NO, I have not met Selective Service Registration requirement
__________________________________________________
Applicant’s Signature
POA Revised 6/20/2020 7

RECRUITMENT QUESTIONNAIRE
Applicant Name: ___________________________________________________________
1. Where do you currently live?
City: _________________________________________ State: __________________
2. Were you actively recruited?  Yes  No
 Spoke with a recruiter at a College Career Fair
 Spoke with a Centreville Police Officer
 Toured the Department
 Other (explain) _____________________________________________________
3. Did you see or hear advertisements for the Centreville Police Department from any of the following?
(check all that apply)
 Radio
 Internet What site? __________________________________________________
 College Program
 Newspaper Advertisement
 Other: _________________________________________________
4. Have you applied with any other Police Departments?  Yes  No
5. Why do you seek employment with the Centreville Police Department?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
POA Revised 6/20/2020 8

Fair Credit Reporting Notification / Acknowledgment
Your credit history is an integral part of the employment process with the Centreville Police Department, as it
provides insight into personal attributes such as your level of responsibility, and your ability to manage and plan
daily life functions. Although your credit history is only one of many tools used to assess your suitability for
employment, it could impact the hiring decision regarding your application.
In conjunction with the Fair Credit Reporting Act, 15 U.S.C. 1681M(A), a copy of any credit report used for
employment purposes must be provided to the applicant free of charge. Therefore, credit information, which is
made part of your application portfolio, will be provided to you at the time of your background investigation
interview. If your application is not forwarded to the background portion of the employment process, a credit
report will not be requested and the provisions of this notification do not apply. It is important to recognize that
the agency reporting the credit information to the Centreville Police Department neither approves nor denies
your application for employment, but will address inquiries pertaining to the actual report.
Acknowledgment of Notification
I have read and understand the above stated information pertaining to the Fair Credit Reporting Act, and my
dated signature below acknowledges the receipt of this information.
_________________________________ _________________ ________________________________
Signature Date Social Security Number
POA Revised 6/20/2020 9

Centreville Police Department
Notice for Truthfulness
I,_________________________________________________, am an applicant desiring employment with the
Town of Centreville, Centreville Police Department. I understand that the position for which I am applying
requires truthfulness throughout the application process. I understand that all answers given during the
application process, which includes the application itself and subsequent interviews with the background
investigator, will be verified through the use of a polygraph (to include information I provide in the application
form such as: financial history, work history, use of alcohol or drugs, criminal conduct, disciplinary actions,
medical history, and driving history). Any admissions after the background investigation is completed will be
sufficient grounds to eliminate me from the application process. Information not divulged during the application
process is also considered untruthfulness. Because of this fact, my failure to disclose information that is later
discovered can eliminate me from the application process. I understand that any admissions or statements will
be considered in determining my suitability for employment with the Town of Centreville.
In the event that a false statement made in the application process is not discovered until after an applicant is
employed, disciplinary action, which may include a recommendation for termination of employment, will be
administered.
By signing below, I acknowledge I have read and understand the above statement and certify that all
information (both verbal and written), which I have supplied, is true.
STATE OF: _____________________________________
COUNTY OF: _____________________________________
Subscribed and sworn to before me this ______________day of _____________________________ 20______
________________________________________ _______________________________________
Notary Public and Official Seal (Applicant – Print Full Name)
My Commission Expires: _______________________________________
(Applicant’s Signature in Full)
__________________________, 20________
POA Revised 6/20/2020 10

CENTREVILLE POLICE DEPARTMENT
APPLICATION & PERSONAL HISTORY STATEMENT
INSTRUCTIONS: Using the online form or legibly printing in ink fill out this form completely and accurately. If you need
extra space, add additional pages and identify the information by item number. If an item does not apply to you, indicate by
entering N/A in the blank.
NOTE: All statements are subject to verification and any incorrect statements or omissions may bar or remove you from
certification. Truthful statements to any item requested will not necessarily exclude you from consideration.
NOTE: The Social Security Number is used to make positive identification of applicant and/or law enforcement personnel.
Position applied for: ________________________________________________________________________
Application Date: _____________________________________
PERSONAL
Name (LAST, First, Middle):________________________________________________ SS #:______/ ______/ __________
Maiden Name: _______________________________________________________________________________
Other Previous Last Names: _________________________________________________________________
Nicknames or Aliases: ________________________________________________________________________
Has your name been legally changed after age 12?  Yes  No (If yes, submit documentation with date and attach
to this application)
Present Mailing Address: _______________________________________________________________________________
Permanent Mailing Address: ________________________________________________________________________
Telephone Number: Home: (_______) _______-__________ Work: (______) _______-__________
Cell: (_______) _______-__________
Email Address: ________________________________________________________________
Date of Birth: ______/______/__________ Place of Birth: ___________________________________________
Citizenship:  US Born  US Naturalized  Other – Specify: __________________________________
Have you previously submitted an application for employment with the Centreville Police Department?
 Yes  No If yes, approximate date: ____________________________________________
POA Revised 6/20/2020 11

EDUCATION
Indicate below the schools you have attended.
# of
Name Dates Graduated Degree/Diploma
Years Major
Address (City & State) Attended (Yes/No) Awarded
Attended
High Schools
Universities or
Colleges
Extension or
Trade Schools
Other
If you did not graduate from high school, have you passed the General Education Development (GED) Test?
 Yes  No If yes, when and where did you complete the GED?
___________________________________________________________________________________________
Do you speak/read any foreign language(s)?  Yes  No
If yes, which language(s)? ________________________________________________________________________
Rate your proficiency:  Poor  Good  Fluent
POA Revised 6/20/2020 12

MARITAL
Marital Status (check one)  Single  Married  Divorced
 Engaged  Separated  Widowed
Name of Spouse (LAST, First, Middle):______________________________________________________________________
Address of Spouse: ____________________________________________________________________________________
Phone # of Spouse: (__________)___________-__________________
Name of Former Spouse(s) (LAST, First, MI): #1_______________________________________________________________
#2_______________________________________________________________
#3_______________________________________________________________
Do you have any objections to the Centreville Police Department contacting your former spouse(s)?  Yes  No
If yes, whom and why? _______________________________________________________________________________
_______________________________________________________________________________
List all of your children, including any adopted or stepchildren:
Name Birth Date Relationship Address Phone Number
POA Revised 6/20/2020 13

FAMILY HISTORY
Are you related by blood or marriage to any person(s) currently employed by the Town of Centreville or the Centreville
Police Department?
 Yes  No
If yes, provide name and relationship: ___________________________________________________________
List all of your siblings, whether living or deceased
Name Phone Deceased/
Birth Date Relationship Address
(LAST, First Middle) Number Living
List your parents, whether living or deceased
Name Phone Deceased/
Birth Date Relationship Address
(LAST, First Middle) Number Living
FATHER
MOTHER
Is any member(s) of your immediate family currently in prison or on either probation or parole?
 Yes  No
If yes, provide name, relationship and details:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
POA Revised 6/20/2020 14

RESIDENCES
List every city/county in which you have lived since attaining the age of 18, with present address at top:
From Mo/Yr To Mo/Yr Address City/County/State
Present
POA Revised 6/20/2020 15

FINANCIAL
What income other than salary do you have at present?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
List all businesses you currently own or have financial interest in (do not list any stocks or bonds):
____________________________________________________________________________________________________
Have you ever been sued with a civil judgment being rendered against you? Please note this includes repossessions,
evictions, executions, failure to pay child support, etc. (Do not include divorce)
 Yes  No  Not Sure (Explain)
If yes or not sure, provide details: ________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
What is the total amount of all your debts at present? $___________________________
What is the average monthly total of all of your bills, payments and current living expenses? $_________________
List credit references, including creditors to which you make monthly payments (do not include utility bills):
Creditor Name Address Amount Owed
POA Revised 6/20/2020 16

WORK HISTORY
Have you ever been denied employment by a law enforcement agency or corrections agency which requires certification or
licensure, after a conditional offer of employment was made?
 Yes  No
If yes, provide agency name and details:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever held a position as a certified and/or licensed law enforcement or corrections officer?  Yes  No
 If yes, for what agency and when? __________________________________________________________
 If yes, was your certification or license ever suspended, revoked or any sanctions taken against it by the issuing
authority/employing agency?  Yes  No
 If your certification or license was ever suspended, revoked or any sanctions taken against it by the issuing
authority/employing agency, please list the agency’s name taking the action against the certification or
license, date of the action, reason for the action and the period of time for the suspension, revocation or
sanction:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever been discharged, terminated, requested to resign or allowed to resign in lieu of termination, from any
position because of criminal or personal misconduct or rules violations?  Yes  No
If yes, list organization name and give details:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever been the subject of disciplinary action from any employer?  Yes  No
If yes, explain; _________________________________________________________________________________________
POA Revised 6/20/2020 17

Do you object to wearing a uniform?  Yes  No
Do you object to working nights?  Yes  No
Do you object to working rotating shifts?  Yes  No
Do you object to working Holidays?  Yes  No
Do you object to working weekends (Saturday & Sunday)?  Yes  No
Do you object to occasionally being away from home overnight and for other periods of time attending meetings, acquiring
training and otherwise performing official duties?  Yes  No
List ALL jobs, positions or appointments you have held in the last ten years to include temporary, part-time, paid or not paid
employment, active or in-active reserve and internships. Put your present or most recent job first. List a reason for leaving
for each job. Include military service in proper time sequence and temporary part-time jobs. If there are gaps in your
employment, please provide an explanation for each period of unemployment.
1. Title of present or last position: _________________________________________________________________
Employer Name: _________________________________________________________________
Employer Address/ Phone Number: __________________________________________________
__________________________________________________
__________________________________________________
Name/Title of Supervisor: ________________________________________________________________________
Date Began Employment: ___________________ Date Separated Employment: __________________
Staring Salary: $___________________ Last Salary $__________________
 Full-time  Part-time  Temporary
Job Duties/Description: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason for Leaving: ________________________________________________________________________
POA Revised 6/20/2020 18

2. Title of present or last position: _________________________________________________________________
Employer Name: _________________________________________________________________
Employer Address/ Phone Number: __________________________________________________
__________________________________________________
__________________________________________________
Name/Title of Supervisor: ________________________________________________________________________
Date Began Employment: ___________________ Date Separated Employment: __________________
Staring Salary: $___________________ Last Salary $__________________
 Full-time  Part-time  Temporary
Job Duties/Description: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason for Leaving: ________________________________________________________________________
3. Title of present or last position: _________________________________________________________________
Employer Name: _________________________________________________________________
Employer Address/ Phone Number: __________________________________________________
__________________________________________________
__________________________________________________
Name/Title of Supervisor: ________________________________________________________________________
Date Began Employment: ___________________ Date Separated Employment: __________________
Staring Salary: $___________________ Last Salary $__________________
 Full-time  Part-time  Temporary
Job Duties/Description: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason for Leaving: ________________________________________________________________________
POA Revised 6/20/2020 19

4. Title of present or last position: _________________________________________________________________
Employer Name: _________________________________________________________________
Employer Address/ Phone Number: __________________________________________________
__________________________________________________
__________________________________________________
Name/Title of Supervisor: ________________________________________________________________________
Date Began Employment: ___________________ Date Separated Employment: __________________
Staring Salary: $___________________ Last Salary $__________________
 Full-time  Part-time  Temporary
Job Duties/Description: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason for Leaving: ________________________________________________________________________
5. Title of present or last position: _________________________________________________________________
Employer Name: _________________________________________________________________
Employer Address/ Phone Number: __________________________________________________
__________________________________________________
__________________________________________________
Name/Title of Supervisor: ________________________________________________________________________
Date Began Employment: ___________________ Date Separated Employment: __________________
Staring Salary: $___________________ Last Salary $__________________
 Full-time  Part-time  Temporary
Job Duties/Description: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason for Leaving: ________________________________________________________________________
POA Revised 6/20/2020 20

6. Title of present or last position: _________________________________________________________________
Employer Name: _________________________________________________________________
Employer Address/ Phone Number: __________________________________________________
__________________________________________________
__________________________________________________
Name/Title of Supervisor: ________________________________________________________________________
Date Began Employment: ___________________ Date Separated Employment: __________________
Staring Salary: $___________________ Last Salary $__________________
 Full-time  Part-time  Temporary
Job Duties/Description: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason for Leaving: ________________________________________________________________________
POA Revised 6/20/2020 21

MILITARY SERVICE
Were you ever in the U.S. Military Service or any other military organization?  Yes  No
Were you ever denied entrance into the military?  Yes  No If yes, why?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
THE FOLLOWING QUESTIONS ARE APPLICABLE ONLY TO VETERANS
What is your service number? _________________________________________________
What was the highest rank that you held? ____________________________________________________
What was the last rank that you held? _____________________________________________________
What was the date and location of your first enlistment or commission? _________________________________________
Have you ever received any of the following types of discharge:
Uncharacterized:  Yes  No
Honorable:  Yes  No
General (under honorable conditions)  Yes  No
Under other than honorable conditions  Yes  No
Bad Conduct Discharge  Yes  No
Dishonorable Discharge  Yes  No
Dismissal  Yes  No
Were you ever court-martialed, tried on charges, or the subject of a summary court, deck court, non-judicial punishment,
captain’s mast, company punishment, article 15, and/or any other disciplinary action while a member of the military,
national guard or reserve unit?  Yes  No
If yes, explain what occurred and what type of punishment you received: ____________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
List all medals and decorations awarded you during your military service:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
POA Revised 6/20/2020 22

USE OF ALCOHOL & DRUGS
Do you drink alcoholic beverages?  Yes  No
If yes, to what extent? _________________________________________________________________________
*****NOTE: In the next two questions, the word ‘used’ means one time or more, including experimentation. If any
answer is yes, give full and complete details ( Attach extra sheets if necessary)
Have you ever used, to include tasting, any illegal drugs including but not limited to marijuana, steroids, opiates, pills,
heroin, cocaine, crack, LSD, designer or synthetic drugs, etc., to include even one time use or experimentation?
 Yes  No  I don’t know (explain below)
If yes, what were the circumstances, drugs used and when did the usage last occur?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever used prescription drugs other than under the supervision of, or as prescribed by a physician?
 Yes  No  I don’t know (explain below)
If yes, what were the circumstances, drugs used and when did the usage last occur?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Are you now using or at any time in the past used Medical marijuana?  Yes  No
If yes, what were the circumstances and when did the usage last occur?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever purchased, possessed, manufactured, grown, delivered or sold any amount of illegal drugs or controlled
substances for which you did not have a valid prescription?  Yes  No  I don’t know (explain below)
If yes, identify the drug(s) and provide details concerning the purchase, possession, manufacture, growth delivery or sale
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
POA Revised 6/20/2020 23

CRIMINAL OFFENSE RECORD
NOTE: Answer all of the following questions completely and accurately. Any falsifications or misstatements of fact may be
sufficient to disqualify you. If any doubt exists in your mind as to whether or not you were arrested or charged with a
criminal offense at some point in your life or whether an offense remains on your record, you should answer “Yes.” You
must list any and all criminal charges regardless of the date of offense and the disposition (to include dismissals, not guilty,
nol pros, PBJ, or any other disposition where you entered a plea of guilty). Juvenile charges or arrests should also be listed.
Include all offenses other than minor traffic offenses. Specifically include DWI, DUI, driving while under the influence of
drugs, driving while license suspended or revoked, speeding to elude arrest, or duty to stop in event of accident.
You must include any and all convictions regardless of whether or not the convictions were expunged.
Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense?
(The term ‘charged’ as used in this question includes being issued a criminal citation or summons.)  Yes  No
If so, list below
Offense Charged Date Disposition Law Enforcement Agency
Have you ever had a Domestic Violence Protection Order issued against you?  Yes  No
If yes, explain: _______________________________________________________________________________
Are you now or have you ever been involved as a plaintiff or defendant in any criminal court action?  Yes  No
If yes, explain in detail: __________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
POA Revised 6/20/2020 24

Are you now or have you ever been involved as a plaintiff or defendant in any civil court action?  Yes  No
If yes, explain in detail: __________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Under federal law you may be disqualified to receive or possess a firearm if you meet any of the following conditions:
(a) currently under Indictment or Information in any court for a crime punishable by imprisonment for a term
exceeding one year.
(b) have been convicted in any court of a crime punishable by imprisonment for a term exceeding one year. A person
would not be ineligible under this criteria if the person has been pardoned for the crime or conviction, the crime or
conviction has been expunged or set aside, or the person has had his/her civil rights restored, and under law where
the conviction occurred the person is not prohibited from receiving or possessing any firearm.
(c) are a fugitive from justice.
(d) are an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or any other
controlled substance.
(e) have been adjudicated mentally defective or have been involuntarily committed to a mental institution.
(f) have been discharged from the Armed Forces under dishonorable conditions.
(g) are illegally in the United States.
(h) have renounced your citizenship, having previously been a citizen of the United States.
NOTE: A “crime punishable by imprisonment for a term exceeding one year” as discussed in (a) and (b) above is
defined in federal law so as to exclude most misdemeanors in Maryland.
If any of the above (a through h) apply, please note below and submit an explanation on a separate sheet of paper which
accompanies this form. Your signature on the attestation found on this document indicates you have read this section and
understand each of the disqualifiers.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
POA Revised 6/20/2020 25

Have you been convicted of a misdemeanor under federal or state law which has, as an element, the use or attempted use
of physical force or threatened use of a deadly weapon?  Yes  No
• If so, did you commit the act(s) against a current or former spouse, parent or guardian or against a person with
whom you were or are cohabitating (Domestic Violence Offense)?  Yes  No
Offense Charged : __________________________________________________________________
Investigating Agency: __________________________________________________________________
Date: __________________________ Disposition: _________________________________
Have you ever been charged with a felony? (Including any charges expunged)  Yes  No
If yes, provide details: ________________________________________________________________________
___________________________________________________________________________________________
Have you ever been placed on probation?  Yes  No If yes, provide details:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you possess a valid driver’s license?  Yes  No
Driver’s License #:______________________________________ State:_____________ Expiration: ____________
Do you currently have any points on your driver’s license?  Yes  No If yes, how many? ___________
Do you now possess or have you ever possessed a driver’s license issued by any other state than Maryland?
 Yes  No If yes, provide License #:________________________________________ State:______________
Has your driver’s license ever been suspended or revoked?  Yes  No
If yes, provide details including date: ____________________________________________________________________
POA Revised 6/20/2020 26

CAREER OBJECTIVES
Briefly explain your reasons for applying for this position:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
List special skills, training, fields of work for which you are licensed, registered and/or certified which may be useful in the
performance of the duties of the position for which you have applied:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
What are your feelings about the use of deadly force if it became necessary in the performance of your official
duties?_______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
What are your career goals for the next 5 years? _____________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
POA Revised 6/20/2020 27

REFERENCES
Provide the names of five responsible persons, other than relatives, who could provide information about your character,
ability, experience, personality and other qualities
NAME ADDRESS TELEPHONE
MISCELLANEOUS
Are you now or have you ever been a member of any organization that seek to overthrow the Constitutional form of
government of the United States, State of Maryland or any other government entity by means of force or violence or any
other unlawful means?  Yes  No
If yes, provide the organization name and describe: __________________________________________________________
Have you ever been issued a permit or license to carry a firearm or other weapon on your person?  Yes  No
If yes, provide issuing agency and license #: _________________________________________________________________
POA Revised 6/20/2020 28