Job Application - City of De Soto, Iowa

City of De Soto: Chief of Police Position

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Fill out this form completely and accurately. 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 our application process. Truthful statements to any item requested will not necessarily exclude you from consideration.

The SSN is used to make a positive identification of an applicant and or law enforcement personnel. DISCLOSURE IS VOLUNTARY. However, failure to provide this information may result in a delay in the processing of application materials and may result in inaccurate records being assigned to you.

PERSONAL

1. Name *

First

Middle

Last

All Previous Names *

Nicknames or Aliases *

2. Last 4 Digits of SSN:

3. Present Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Permanent Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Personal Phone Number (Include Area Code) *

Work Phone Number (Include Area Code) *

Email *

4. Date of Birth *

City, State, Country

5. Place of Birth *

City, State, Country

6. Citizenship *

U.S. Born
U.S. Naturalized
Other

7. Ethnic Background *

Data solicited in this box will be used for Equal Employment statistical purposes only.

Can you communicate in any foreign languages? *

If yes, which languages?

If yes, which forms of communication?

Speaking
Reading
Writing

8. Gender *

Male
Female

9. Have you previously submitted an application for employment with De Soto PD? *

If yes, what was the approximate date?

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EDUCATION

11. If you did not graduate from high school, have you passed the General Educational Development (GED) Test? *

If yes, when and where did you complete the GED?

High School

10. Indicate below the high school(s) you have attended. (Include any incomplete courses as well.)

Name & Location *

Years Attended *

Degree Awarded *

Name & Location

Years Attended

Degree Awarded

Name & Location

Years Attended

Degree Awarded

Did you graduate High School? *

University or College

10. Indicate below the college(s) you have attended. (Include any incomplete courses as well.)

Name & Location *

Years Attended *

Degree Awarded *

Major Field *

Name & Location

Years Attended

Degree Awarded

Major Field

Name & Location

Years Attended

Degree Awarded

Major Field

Did you graduate college? *

Please list any extension or correspondance courses you completed in addition to the above education history.

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MARITAL

NOTE: Questions included in the next section are intended to assist in the conducting of a background investigation and are not intended for use by the employing agency as disqualifying factors for employment as a police officer.

12. Marital Status *

Single
Engaged
Married
Separated
Divorced
Widowed

13. Name of Spouse *

Children

List all your children, including any adopted or step children

Name

Birthdate

Relationship

Resides With

Name

Birthdate

Relationship

Resides With

Name

Birthdate

Relationship

Resides With

Name

Birthdate

Relationship

Resides With

Name

Birthdate

Relationship

Resides With

Name

Birthdate

Relationship

Resides With

FAMILY HISTORY

15. Are you related by blood or marriage by any person(s) currently employed by this city? *

If yes, give names and details:

16. Is any member(s) of your immediate family in prison or on either probation or parole? *

If yes, give details:

RESIDENCES

17. List any addresses for past 10 years starting with most recent address on top.

Dates *

Address *

City & State *

Landlord

Dates

Address

City & State

Landlord

Dates

Address

City & State

Landlord

Dates

Address

City & State

Landlord

Dates

Address

City & State

Landlord

Dates

Address

City & State

Landlord

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FINANCIAL

18. What income other than salary do you have at present? *

19. Are you now supporting all children born to you, adopted by you, and stepchildren? *

If no, give details:

20. Are there persons, other than your spouse and listed children who are presently dependent on you for support? *

If yes, give names and details:

21. Have you ever been sued with a civil judgement being rendered against you? *

22. What is the total amount of all your debts at present? *

23. What is the average monthly total of all your bills, payments, and current living expenses? *

CREDIT REFERENCES

24. List credit references, including businesses to which you make monthly payments.

1. Business Name *

Amount Owing *

Business Address *

City & State *

2. Business Name *

Amount Owing *

Business Address *

City & State *

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WORK HISTORY

25. Have you ever been denied employment by a criminal justice agency? *

If yes, list agency name and details:

26. If you have ever been discharged or requested to resign from any position because of criminal or personal misconduct or rules violations, give details:

27. Do you object to wearing a uniform? *

28. Do you object to working nights? *

29. Do you object to working rotating shifts? *

30. 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? *

EMPLOYMENT HISTORY

Upload a resume listing all the jobs you have held in the last 10 years with the details listed below when able. Put your present or most recent job first. Please include any part time jobs or military jobs as well.

1) Title of Position

2) Employer Address & Phone

3) Dates of Employment

4) Starting Salary & Last Salary

5) Name of Supervisor

6) Full Time or Part Time

7) Reason For Leaving

Resume Upload *

Click or drag a file to this area to upload.

Please be descriptive in your history.

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MILITARY SERVICE

32. Were you ever in the U.S. Military Service or any other military organization? *

QUESTIONS 33-41 ARE APPLICABLE ONLY TO VETERANS

33. What is your service number?

34. What is the highest rank you held?

35. What was the date and location of your first entrance into active duty?

Date, Location

Please list below the details of your unit assignment(s) in service.

Branch

Unit

Location

Dates

Branch

Unit

Location

Dates

Branch

Unit

Location

Dates

37. What was the date and location of your last discharge from active duty?

Date, Location

38. Was your last discharge honorable?

If no, was it characterized by bad conduct or dishonorable?

39. Were you ever court-martialed, tried on charges, or were you the subject of a summary court, deck court, captain's mast or company punishment, or any other disciplinary action while a member of the armed forces?

If yes, explain:

40. List any disciplinary action taken against you in the national guard or other reserve unit:

41. List all the medals and decorations awarded to you during your military service:

42. If you are presently a member of the National Guard or any other military reserve, give the unit, location, and describe your obligation:

Unit, Location, and Obligation

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USE OF ALCOHOL OR DRUGS

43. Do you drink alcoholic beverages? *

If yes, to what degree? *

43. Have you ever used marijuana? *

If yes, what were the circumstances? *

When was the last time? *

45. Have you ever used any illegal drugs including but not limited to, opiates, heroin, cocaine, crack, LSD, etc? *

If yes, what were the circumstances? *

When was the last time? *

46. Have you ever used prescription drugs other than under the supervision of, or as prescribed by a physician? *

If yes, what were the circumstances? *

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CRIMINAL OFFENSE AND DISCIPLINARY ACTIONS

NOTE: Include all offenses other than minor traffic offenses. The following are not minor traffic offenses and must be listed below: OWI (Alcohol or Drugs), failure to stop in the event of an accident, driving while license barred, suspended or revoked, and eluding.

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 shouldanswer “Yes.” You should answer “No” only if you have never been arrested or charged, or your record was expunged by a judge’s court order.

47. Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense? (The term "charged" includes being issued a criminal citation or summons.) *

If yes, give details below:

A. Offense Charged

Law Enforcement Agency

Date

Disposition of Case

B. Offense Charged

Law Enforcement Agency

Date

Disposition of Case

C. Offense Charged

Law Enforcement Agency

Date

Disposition of Case

48. Have you ever had a Domestic Assault Protection Order issued against you? *

Date of Issuance:

County of Issuance:

Name of Plaintiff:

Date of Expiration:

49. Under Federal law you may be disqualified to receive or possess a firearm if you meet any of the following conditions:

Currently under Indictment or Information in any court for a crime punishable by imprisonment for a term exceeding one year.
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.
Are a fugitive from justice.
Are an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or any other controlled substance.
Have been adjudicated from the Armed Forces under dishonorable conditions.
Are illegally in the United States.
Have renounced his/her 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 Iowa.

Based on the above information are you disqualified to recieve or possess any firearms under any of the above provisions of federal law? *

If yes, explain:

50. Have you ever 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, committed by a current or former spouse, parent, or guardian of the victim by a person with who the victim shares a child in common, be a person who is cohabitating with or has cohabitated with the victim as a spouse, parent, or guardian or by a person similarly situated to a spouse, parent, or guardian or the victim. (Domestic Violence Offense)? *

Offense Charged:

Law Enforcement Agency:

Date:

Disposition:

51. Have you ever been charged with a felony? *

If yes, give details:

52. Have you ever been placed on probation? *

If yes, give details:

53. Have you ever been required to pay a fine in excess to $50? (This does not include court costs.) *

If yes, give details:

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54. Can you operate a motor vehicle? *

55. Do you possess a valid driver's license in the state of Iowa? *

Driver's License Number: *

Year Issued: *

56. Do you possess a driver's license issued by any other state other than Iowa? *

Driver's License Number:

Year Issued:

57. Was your license ever suspended or revoked? *

If yes, state which and give reasons:

58. Was your license ever restored? *

If yes, when?

59. Have your driving privileges ever been restricted? *

If yes, give details:

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CAREER OBJECTIVES

60. Briefly explain your reasons for applying to this position: *

61. List any special skills, training, fields of work or study for which you are licensed, registered, or certified, and hobbies which may be useful in the performance of the duties of the position for which you have applied. *

62. What are your feelings about the use of deadly force if it became necessary in the performance of official duties? *

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REFERENCES

Please give names of five responsible persons, other than relatives or past employers, who could provide information about your character, abilities, experience, and other qualities

Name *

Address *

Phone Number *

Name *

Address *

Phone Number *

Name *

Address *

Phone Number *

Name *

Address *

Phone Number *

Name *

Address *

Phone Number *

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STATE OF IOWA: DALLAS COUNTY

I herby certify that each and every statement made on this form is true and complete and understand that any misstatement or omission of information will subject me to disqualification or dismissal. I also acknowledge that I have a continuing duty to update all information will subject me to disqualification or dismissal. I will report to the employing agency any additional information which occurs after the signing of this document.

Signature *

Clear Signature

Date *

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