APPLICATION FOR EMPLOYMENT

Read ALL information carefully and fill out all forms COMPLETELY. This application for employment will be considered active for a period of time not to exceed 120 days. Any applicant who desires to be considered for employment beyond this time should resubmit another application. It is your responsibility to provide complete and accurate information and copies of all documents requested. Inaccurate and incomplete information will affect your opportunity for employment with the City.

CONSEQUENCES OF FALSIFICATION

ANY willful misrepresentation or falsification given on ANY FORM herein is just cause for rejecting your application. It will disqualify you from making application in the future for positions with the City of Hernando, or your employment with the City may be terminated. All applications must be notarized before they will be accepted. Review the application to insure that you have completed all sections and provided all information requested. If applicable, copies of the following documents must be turned in for your application to be processed:

1. Driver’s License

2. Birth Certificate

3. Social Security Card

4. High School Diploma / GED (Certified Copies of School Transcripts)

5. Military DD 214 member 1 copy and member 4 copy

6. Military Discharge

7. College Diploma (Certified Copies of School Transcripts)

8. Professional Certificates

9. Certified Copies of Court Abstracts & Police Reports

If a current or previous employer requires the use of a pay service to verify employment it will be the responsibility of the applicant to pay for the service. Failure to do so will result in their application not being processed.

Incomplete and illegible applications will not be processed.

Hernando Police Department

2601 Elm Street

Hernando, MS 38632

We consider applications for all positions without regard to race, color, sex, natural origin, marital or veteran status, the presence of non-job related medical condition or disability, or any other legally protected status. Applications must be complete to be considered for employment.

You may apply for only one position per application completed.

This application must be handwritten! DO NOT TYPE! PLEASE PRINT! If this application packet is NOT LEGIBLE, it WILL NOT BE ACCEPTED.

Position applied for _______________________________________ Date of Application ____________

Referral Source: ____ Advertisement ____ Friend ____ Relative ____Other

If other, please explain: _________________________________________________________________

Name: ________________________________________________________________________________

Last, First, Middle

Current Address: ________________________________________________________________________

Number, Street, City, State, Zip Code

Date of Birth: _____________________ Social Security Number: ___________________________

Telephone Numbers: Home: ( ) _______________________

Work: ( ) _______________________

Cell: ( ) ________________________

Work hours: ________________ Days Off: _______________

Email: ______________________________________________

Drivers License Number: ______________________________ State: ______ Expiration Date: _________

Have you ever been or are you now employed with the City of Hernando? Yes _______ No ________

Are you related by blood or marriage to anyone employed by the City of Hernando? Yes _____ No ____

If yes, state name of relative, relationship to you and the division/department where they work.

_____________________________________________________________________________________

Name of Relative, Relationship, Division/Department

On what date would you be able to begin work? ______________________________________________

Are you available to work: ________ Full Time ________ Part Time ________ Shift

Have you previously submitted an application for employment or tested with the Hernando Police Department or any other law enforcement agency?

_______ Yes _______ No

If yes, list what agency, dates of application, and disposition.

Agency Date Result

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Personal History

Please list a name and phone number of a neighbor or relative with whom you are in regular contact, where a message can be left for you:

_____________________________________________________________________________________

Are you a United States Citizen? _______ Yes _______ No

Birthplace: ________________________________________

City / County/ State / Country

List any maiden name or any other names that you have ever used, including all married names or nicknames, etc.

______________________________________________________________________________________

______________________________________________________________________________________

Have you ever had your name changed? _________ Yes _________ No If yes, provide documentation.

Personal References

Give THREE (3) references that are responsible adults of reputable standing in their community that you have known well for at least THREE YEARS. REFERENCES CANNOT BE RELATIVES, CURRENT OR FORMER EMPLOYERS OR CURRENT OR FORMER SUPERVISORS.

1. Name ______________________________________________ Years known _______________

Home Address _________________________________________________________________

City _________________________________ State _________________________ ZIP _______

Home Phone ( ) _____________________ Business Phone ( ) _____________________________

Business Name _________________________________ Job Title_________________________

Business Address ________________________________________________________________

Best time to contact: Day __ Night __ Time: ____________ Day of Week ______ Pager _______

2. Name ______________________________________________ Years known ________________

Home Address __________________________________________________________________

City _________________________________ State _________________________ ZIP ________

Home Phone ( ) _____________________ Business Phone ( ) _____________________________

Business Name _________________________________ Job Title _________________________

Business Address ________________________________________________________________

Best time to contact: Day __ Night __ Time: ____________ Day of Week ______ Pager _______

3. Name ______________________________________________ Years known ________________

Home Address __________________________________________________________________

City _________________________________ State _________________________ ZIP ________

Home Phone ( ) _____________________ Business Phone ( ) _____________________________

Business Name _________________________________ Job Title _________________________

Business Address ________________________________________________________________

Best time to contact: Day __ Night __ Time: ____________ Day of Week ______ Pager _______

Residence

Chronologically list ALL residences in the past TEN (10) years, regardless of the time you resided there beginning with your present address. If in military service, list dates, branch and duty stations, unless you resided off base. List addresses while attending school if away from home. Note: when living with parents

by indicating with an asterisk (*).

Dates (From/To) Street Address City County State Zip

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Education (Please attach copies of certified copies of school transcripts)

High School/GED

______________________________________________________________________________________

Name Location Dates Attended Year Graduated Credits/Degree

College/University

______________________________________________________________________________________

Name Location Dates Attended Year Graduated Credits/Degree

______________________________________________________________________________________

Name Location Dates Attended Year Graduated Credits/Degree

Graduate School

______________________________________________________________________________________

Name Location Dates Attended Year Graduated Credits/Degree

Trade, business or other schools

______________________________________________________________________________________

Name Location Dates Attended Year Graduated Credits/Degree

______________________________________________________________________________________

Name Location Dates Attended Year Graduated Credits/Degree

Employment

Are you on layoff , subject to recall? ___________ Yes ___________ No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

___________ Yes _____________ No

List entire employment history, including part-time, temporary and seasonal-regardless of time employed. Begin with your current employer or most recent job and work backwards. If unemployed, list dates of unemployment. If needed, additional information may be attached and submitted on 8 ½” x 11” paper.

List all area codes and zip codes-make sure that all addresses and phone numbers are complete and correct.

Make copies of this form as needed to document employment.

Employer __________________________________ Dates of Employment ________________________

Street Address _________________________________________________________________________

City __________________________________ State ____________ Zip ___________________________

Phone Number ( ) ____________________________ Supervisor ______________________________

Position ________________________ Work Duties _________________________ Rate of Pay ________

Reason for leaving (explain in detail) ________________________________________________________

______________________________________________________________________________________

Employer __________________________________ Dates of Employment ________________________

Street Address _________________________________________________________________________

City __________________________________ State ____________ Zip ___________________________

Phone Number ( ) ____________________________ Supervisor ______________________________

Position ________________________ Work Duties _________________________ Rate of Pay ________

Reason for leaving (explain in detail) ________________________________________________________

______________________________________________________________________________________

Employer __________________________________ Dates of Employment ________________________

Street Address _________________________________________________________________________

City __________________________________ State ____________ Zip ___________________________

Phone Number ( ) ____________________________ Supervisor ______________________________

Position ________________________ Work Duties _________________________ Rate of Pay ________

Reason for leaving (explain in detail) ________________________________________________________

______________________________________________________________________________________

Employer __________________________________ Dates of Employment ________________________

Street Address _________________________________________________________________________

City __________________________________ State ____________ Zip ___________________________

Phone Number ( ) ____________________________ Supervisor ______________________________

Position ________________________ Work Duties _________________________ Rate of Pay ________

Reason for leaving (explain in detail) ________________________________________________________

______________________________________________________________________________________

Employer __________________________________ Dates of Employment ________________________

Street Address _________________________________________________________________________

City __________________________________ State ____________ Zip ___________________________

Phone Number ( ) ____________________________ Supervisor ______________________________

Position ________________________ Work Duties _________________________ Rate of Pay ________

Reason for leaving (explain in detail) ________________________________________________________

______________________________________________________________________________________

Military Record

Have you ever been on active duty in the Armed Forces of the United States? _________ Yes ________No

If yes, Branch of Military Services __________________________________________________________

Type of Discharge ________________________ If other than Honorable, explain: ___________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Other than Honorable discharge does not automatically preclude you from employment. All factors will be

considered. If needed, additional information may be attached and submitted on 8 ½ “ x 11 “ paper.

Dates of Active Duty (Month, Day, Year): From ___________________ to _________________________

Are you a member of the Active Guard or Reserves? _________ Yes __________ No

If yes, list branch and unit: ________________________________________________________________

Branch Unit

______________________________________________________________________________________

Address Phone Point of Contact

Can you provide a drill schedule at least three months out? _____________ Yes ______________ No

Did you ever have any type of disciplinary action taken against you while in the military (this includes Article 15 and Captain’s Mast, etc.)

___________ Yes ___________ No If yes, explain: ___________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

****If you received any of the following, you MUST attach a separate sheet of paper, 8 ½” x 11”, with an explanation of the discharge circumstances:

1. Early Out

2. Any discharge other than Honorable

3. Completed less than a regular tour of duty

4. Any disciplinary action

5. Any loss of rank

Court Record

Have you ever been arrested? ___________ Yes ____________ No

Have you ever been charged with, indicted for, subject to Grand Jury presentation, or investigated for any felony crime?

_____________ Yes ____________ No

Have you ever been charged with, convicted of, entered a guilty plea, or plea of nolo contender to any misdemeanor? This includes misdemeanor citations and traffic charges.

_____________ Yes ____________ No

Have you ever had an arrest or conviction expunged? _____________ Yes _____________ No If yes, explain:

____________________________________________________________________________________

____________________________________________________________________________________

List ALL felony/misdemeanor arrests, charges, and traffic citations (including those as a juvenile and those

that have been expunged).

______________________________________________________________________________________

Charge Date City County State Disposition

______________________________________________________________________________________

Charge Date City County State Disposition

______________________________________________________________________________________

Charge Date City County State Disposition

______________________________________________________________________________________

Charge Date City County State Disposition

______________________________________________________________________________________

Charge Date City County State Disposition

______________________________________________________________________________________

Charge Date City County State Disposition

For any of the above, submit a written statement regarding the circumstances and disposition on a separate piece of 8 ½” x 11” paper. If more than one incident , use a separate piece of paper for each incident. You MUST provide certified copies of all arrest reports, incident reports, affidavits, court orders and dispositions and court abstracts pertaining to any of the above incidents with this application. Failure to do so will result in your application not being processed. Are you currently subject to any protective order, temporary protective order, restraining order, temporary restraining order, or any other court order?

_________ Yes ___________ No If yes, explain and attach a copy of the order: ___________________

____________________________________________________________________________________

Drivers License

List all drivers’ license(s) ever held in any other state:

______________________________________________________________________________________

Name Dates Held State Number Reason for surrender

______________________________________________________________________________________

Name Dates Held State Number Reason for surrender

______________________________________________________________________________________

Name Dates Held State Number Reason for surrender

Have you ever had a drivers license(s) suspended or revoked? __________ Yes ___________ No

If yes, explain: _________________________________________________________________________

______________________________________________________________________________________

Law Enforcement / Communications

Describe any specialized training, skills or qualifications you possess? (attach copies of certificates, etc. if

applicable)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Have you ever attended a police academy and failed to graduate? ____________ Yes ____________ No

If yes, explain and list which academy: _____________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Are you currently a certified law enforcement officer in the State of Mississippi?

___________ Yes _____________ No If yes, list certificate number and include copy of your certificate.

B.L.E.O.S.T. Professional Certificate Number: ___________________________________

Are you now, or have you ever been a certified law enforcement officer in any other state?

___________ Yes _____________ No If yes, list information below:

State Agency/Position Held Dates P.O.S.T. Certificate Number

______________________________________________________________________________________

______________________________________________________________________________________

Are you APCO, EMD, or NCIC Terminal Operator Certified?

___________ Yes _____________ No (Please attach copies of certificates)

Do you posses state certification as a telecommunicator in this or any other state?

___________ Yes ____________ No If yes, attach a copy of certificate

Telecommunications Professional Certificate Number: _________________________________

Have you ever been involved in any civil lawsuit involving your position as a Law Enforcement Officer/

Communications Officer?

_____________ Yes _______________ No

If yes, explain: _________________________________________________________________________

______________________________________________________________________________________

Have you ever received any disciplinary actions during your employment as a Law Enforcement Officer/Communications Officers?

______________ Yes _______________ No If yes, explain: ____________________________________

______________________________________________________________________________________

Miscellaneous

Are you willing to submit to a drug screen test, physical, polygraph, and/or psychological examination as

terms of your employment with the City of Hernando?

_________ Yes ___________ No

Are there any special considerations you might request regarding employment?

___________ Yes _____________ No If yes, explain ___________________________________

Do you read or write any language other than English? ___________ Yes ____________ No

If yes, please list:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Statement to Applicant

This application for employment will be considered active for a period of time not to exceed 120 days. Any applicant who desires to be considered for employment beyond this time should resubmit another application. It is your responsibility to provide complete and accurate information and copies of all documents requested. Inaccurate and incomplete information will affect your opportunity for employment with the City. Any willful misrepresentation or falsification given on any form is just cause for rejecting your application.

It will also disqualify you from making application in the future for positions with the City of Hernando, or your employment with the City will be terminated. Upon employment by the Mayor and Board of Aldermen, the prospective employee will be required to submit and pass a drug screen and a physical examination at a facility designated by the City of Hernando as part of a conditional offer of employment. Should the prospective employee fail to meet any component of the conditional offer of employment, then said conditional offer of employment is null and void. Should the prospective employee meet all of the components of this conditional offer and begin employment with the City, then such prospective employee shall be deemed an employee of the City, with all right and benefits of a City employee and subject to the policies of the City from and after the first date of employment.

Applicant’s Statement

I certify that answers given in this application are true, correct and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationships with this organization are of an “At Will” nature, which means that the employer may discharge the employee without cause. It is further understood that this “At Will” employment relationship

may not be changed by any written document or conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or

interview(s) may result in my discharge. I understand, also, that I am required to abide by all rules and

regulations of the employer. I also understand the components of the conditional offer of employment and if requested I hereby agree to

a polygraph and/ or psychological examination.

This form MUST be notarized by a notary before your application will be accepted. You must sign

this form in front of your notary.

__________________________________________________________________

Signature of Applicant Date

Witness my signature this the ____________ day of __________________, _______________.

____________________________

Signature of Notary

(SEAL)

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I, ____________________________________ , do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized agent of the City of Hernando., Mississippi, whether the said records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions, financial or credit institutions, including records of loans, the records of commercial or retail agencies (including credit reports and /or ratings), psychiatric treatment and/or consultation, including hospitals, clinics, private practitioners, and the U.S. Veteran’s Administration, employment and pre-employment records, complaints, or grievances filed by or against me or another person in any case, either criminal or civil, in which I presently have or have had an interest. I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly, in who or in part, upon this release authorization will be considered in determining my suitability for employment by the City of Hernando. I also certify that no person(s) will be held liable for releasing such information.

A copy of this release form will be valid as an original thereof, even though the said photocopy does not contain writing of my signature.

This form MUST be notarized by a notary before your application will be accepted. You must sign this form in front of the notary.

__________________________________________________________________

Signature of Applicant Date

Witness my signature this the ____________ day of __________________, _______________.

____________________________

Signature of Notary

(SEAL)