Police Officer Application

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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.

(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