Little Elm Fire Department Polygraph Statement

Applicant’s Name______

Date: ______

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01/17 POLYGRAPH STATEMENT

NAME

APPLICANT IDENTIFICATION INFORMATION

NAME: ______Last First Second BIRTH CERTIFICATE NAME: ______ALIAS: ______ADDRESS: ______Number Street Other ______City State Zip Code TELEPHONE: ______Area Code Number Extension SOCIAL SECURITY NUMBER: ______DRIVER’S LICENSE NUMBER: ______State Number Expiration DATE OF BIRTH: ______Month Day Year PLACE OF BIRTH: ______City County State Country EDUCATIONAL: High School: ______Diploma ____ College: Degree Post Graduate: Degree OCCUPATION: ______

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01/17 DEBTS

Answer All Inquiries Yes or No. Except for question 1, explain any yes answers on form provided with same title as above.

______1. Will you be able to meet your current financial obligations with the salary advertised by the Town of Little Elm?

______2. Do you presently owe a debt to any member of The Town of Little Elm, or any person employed by the Town of Little Elm?

______3. Do you currently owe any city, county, state, or federal taxes?

______4. Have you ever had anything repossessed?

______5. Are there any judgments or civil matters pending against you as result of a civil lawsuit?

______6. Have you ever filed for bankruptcy?

______7. Have you ever had a check “bounce” that you did not pay before it was turned in to a county or district attorney for collection?

______8. Have you ever been evicted from a residence for non-payment of rent?

______9. Have you intentionally evaded or avoided paying a debt that you legally owe?

______10. Have you been employed by a governmental agency and your employment was terminated, in part or in whole, because of a financial matter?

______11. Are you in arrears on any court ordered child support payments?

______12. Are you in default of an obligation to repay a student loan(s)?

______13. Regarding your debts, credit and financial affairs, is there a private matter that you believe needs to be discussed with the investigator conducting your background investigation before you submit a polygraph examination?

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01/17 APPLICATIONS WITH GOVERNMENTAL AGENCIES

In the space below, list the name of each city, county, state, or federal agency where you applied for employment, but were not employed: (Include all fire applications)

1. NAME: ______Position Applied For: ______Date Applied: Status: 2. NAME: ______Position Applied For: ______Date Applied: Status: 3. NAME: ______Position Applied For: ______Date Applied: Status: 4. NAME: ______Position Applied For: ______Date Applied: Status: 5. NAME: ______Position Applied For: ______Date Applied: Status:

GOVERNMENTAL AGENCY EMPLOYMENT In the space below, list the name of each city, county, state, or federal agency you have employed by: Be explanative for “Reason” and add additional paper if needed

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01/17 EMPLOYMENT HISTORY List the name of all employers. Do not include the governmental agencies you have already listed.

1. NAME: ______DATES: ______Position Held: ______Salary: ______Reason for Leaving: ______2. NAME: ______DATES: ______Position Held: ______Salary: ______Reason for Leaving: ______3. NAME: ______DATES: ______Position Held: ______Salary: ______Reason for Leaving: ______4. NAME: ______DATES: ______Position Held: ______Salary: ______Reason for Leaving: ______5. NAME: ______DATES: ______Position Held: ______Salary: ______Reason for Leaving: ______

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01/17 WORK RECORD Answer all inquiries Yes or No. Except for question 28, explain any yes answers on form provided with same title as above.

_____ 1. Did you ever knowingly falsify a job application or personal history statement?

_____ 2. Did you falsify the Town of Little Elm job application or personal history statement?

_____ 3. Have you ever been fired, terminated, or forced to resign by an employer?

_____ 4. Has an employer ever suspended you from work?

_____ 5. Has an employer ever issued you a written letter of reprimand?

_____ 6. Have you ever been the subject of an internal affairs investigation?

_____ 7. Have you been reprimanded by an employer for violating a policy?

_____ 8. Have you consumed alcohol in violation of an employment policy?

_____ 9. Have you ingested drugs in violation of an employment policy?

_____ 10. Have you stolen money or anything of physical value where you were previously employed? _____ 11. Have you ever stolen property or merchandise where you were employed?

_____ 12. During the last 2 years, have you violated an employment policy regulating vacations _____, days off _____, sick leave _____, compensatory time _____?

_____ 13. Have you falsified a claim of injury to receive worker’s compensation benefits?

_____ 14. Have you ever lied to a supervisor to protect another employee?

_____ 15. Have you ever knowingly falsified any official documents or records?

_____ 16. Did you ever add, create, alter, or destroy computer data without permission?

_____ 17. Have you ever knowingly violated a person’s constitutional rights?

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01/17 _____ 18. During any internal affairs investigation, did you lie, make false statements, or knowingly withhold information for the purpose of concealing the truth?

_____ 19. Have you ever committed perjury?

_____ 20. Have you ever used unnecessary and excessive force on anyone?

_____ 21. Have you ever engaged in any sexual activity with a person in custody?

_____ 22. Have you ever “blackmailed” anyone?

_____ 23. Have you ever “bribed” anyone?

_____ 24. Have you ever accepted a “bribe”?

_____ 25. Without proper authority and consent, did you inform a person of a pending police action? _____ 26. Do you have an ulterior motive in mind for wanting this job?

_____ 27. If employed by the Town of Little Elm, do you have any future plans that may cause you to leave, or require time off within the next 12 months?

_____ 28. If employed by the Town of Little Elm, do you know a person that resides within the city limits of the Town of Little Elm or works within the city limits?

_____ 29. Are you related (by blood or marriage) to a member of the Town of Little Elm Fire Department or other department?

_____ 30. Regarding your work record, is there a private matter you need to discuss with the investigator conducting your background investigation before you submit to a polygraph examination?

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01/17 Arrests Answer all inquiries Yes or No. Explain any yes answers on form provided with same title as above.

_____1. Have you ever been notified that a warrant has been issued for your arrest? _____2. To your knowledge has a warrant ever been issued for you arrest?

_____3. Have you ever been arrested?

_____4. Have you ever been incarcerated (placed in jail)?

_____5. Have you ever been taken to a police station and questioned with regards to committing a criminal offense?

_____6. Have you ever evaded law enforcement to avoid being arrested?

_____7. Have you ever lied to any law enforcement to keep from being arrested for committing a criminal offense?

_____8. Are you presently wanted for questioning by any city, county, state, or federal authorities?

_____9. Are you presently wanted for questioning by any foreign country?

_____10. Are you presently wanted for questioning under an alias or assumed name?

IN THE SPACE BELOW, LIST ALL ARRESTS

Title of Arrest City/State Date / How long? ______

______

______Page 8 of 18

01/17 CONVICTIONS Answer all inquiries Yes or No. Explain any yes answers on form provided with same title as above.

_____ 1. Has anyone ever file a criminal charge against you with a city, county, or district attorney?

_____2. Has a criminal charge against you ever been presented to a Grand Jury?

_____3. Have you ever been convicted in a federal court in the United States?

_____4. Have you ever been convicted in any state district court?

_____5. Have you ever been convicted in any district, county or municipality court?

_____6. Have you ever been convicted of a Class “C” misdemeanor, in any Justice of the Peace Court, or City/Municipal Court?

_____7. Have you ever been tried and acquitted in a court of law?

_____8. Were you ever placed on probation?

_____9. Have you ever been placed on adjudicated probation?

_____10. Have you ever been placed on a non adjudicated probation?

_____11. Have you ever been sentenced to confinement in a city, county, state, or federal detention facility?

In the space below, list all convictions:

Title of Conviction City/State Date

______

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01/17

Law violations Answer all inquiries Yes or No. Explain any yes answers on form provided with same title as above.

_____ 1. Have you ever committed any felony criminal law violations?

_____ 2. Have you ever committed a homicide?

_____ 3. Have you ever committed a burglary?

_____ 4. Have you ever committed a robbery?

_____ 5. Have you ever committed a theft over the value of $1500.00?

_____ 6. Have you ever committed an aggravated assault?

_____ 7. Have you ever committed a motor vehicle theft?

_____ 8. Have you ever committed arson?

_____ 9. Have you ever committed fraud?

_____ 10. Have you ever committed forgery?

_____ 11. Have you ever possessed stolen property?

_____ 12. Have you ever illegally possessed a handgun _____, automatic weapon _____, bomb _____, explosives _____, explosive device _____, armor piercing ammunition _____, incendiary device _____, silencer _____, assault knife _____, brass knuckles _____, club _____, or other illegal weapon _____?

_____ 13. Have you ever intentionally damaged property belonging to another?

_____ 14. Have you used a credit card without the credit card holder’s permission?

_____ 15. Have you illegally used an electronic listening-viewing device?

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01/17 _____ 16. Have you ever committed a sexual assault?

_____ 17. Have you ever violated a law that regulates the starting of fires?

_____ 18. Have you ever caused the death of a person?

_____ 19. Have you amputated or disfigured any part of a person’s body?

_____ 20. Since your 18th birthday, have you engaged in a sexual act of any kind with a person who was under the age of 17?

_____ 21. Have you intentionally exposed your genitals to a person in a public place?

_____ 22. Have you engaged in an act of incest?

_____ 23. Have you engaged in acts of window peeping?

_____ 24. Have you engaged in a sexual act with an unconscious person?

_____ 25. Have you engaged in a sexual act with a mentally retarded person?

_____ 26. Have you illegally touched a person for sexual reasons that were not aware of your motives? _____ 27. Have you ever registered as a sex offender with any city, county, or state?

_____ 28. Have you ever physically or sexually abused a child?

_____ 29. Have you ever stalked a person?

_____ 30. Have you married a person while still legally married to another?

_____ 31. Have you engaged in a sexual act with a prostitute?

_____ 32. Have you ever forced anyone to have sex with you against his/her will?

_____ 33. Have you ever illegally used a controlled substance regulated by state and/or federal statutes (includes marijuana)? _____ 34. Have you ever illegally sold a controlled substance regulated by state and/or federal statutes? Page 11 of 18

01/17 _____ 35. Have you illegally possessed a controlled substance regulated by state and/or federal statutes?

_____ 36. Have you transported drugs from one location to another?

_____ 37. Have you manufactured drugs?

_____ 38. Have you financed a drug transaction?

_____ 39. Did you ever “launder” any drug money?

_____ 40. Have you ever been paid by a drug dealer for services rendered?

_____ 41. Have you ever been a member of a drug cartel?

_____ 42. Have you used a prescription drug for a reason other than its prescribed use?

_____ 43. Have you furnished alcohol to a minor?

_____ 44. Have you committed any illegal act related to the possession, use, manufacture, transportation, distribution, or delivery and sale of drugs?

_____ 45. Regarding drugs, is there a private matter you believe needs to be discussed with the investigator conducting your background investigation before you submit to a polygraph examination?

_____ 46. Are you now, or have you ever been, a member of an organization that advocates violence and terrorism?

_____ 47. Did you ever plan to commit, threaten to commit, or commit an act of violence or terrorism?

_____ 48. Are you now, or have you ever been a member of an organization that advocates non compliance with any city, county, state, or federal laws?

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01/17 _____ 49. Did you ever plan to commit, threaten to commit, or commit an act of terrorism at/against any: airport _____, public transportation carrier _____, school or educational facility _____, church or religious organization _____, Semitic or other ethnic group or organization _____, public utility _____, political figure _____, or public servant _____?

_____ 50. Did you ever plan to commit, threaten to commit, or commit an act of violence or terrorism against property belonging to a city, county, state, or federal government?

_____ 51. Did you ever commit an act of domestic violence?

_____ 52. Regarding violations, is there something you believe needs to be discussed with the investigator conducting your background investigation before you submit to a polygraph examination?

Theft In the space below, list all money, property and items you have stolen Money-Property-Item Stolen Owner City/State Date of Theft

______

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01/17 Drugs In the space below, identify the type of illegal drugs you have used, ingested or experimented with: Type/Name of Illicit Drug Used Last Use: Month/Year

______

In the space below, identify the type of illicit drugs you have sold: Add more paper if needed Type/Name of Illicit Drug Sold Last Sale: Month/Year

______

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01/17 Traffic and driving record Answer all inquiries in the spaces provided: Except for question 1-5 and 10, explain any yes answers on separate paper with same title as above

_____ 1. List all states that have issued you a driver’s license: A. ______B. ______C. ______D. ______

_____ 2. List the total number of traffic tickets you have been issued: ______

_____ 3. List the number of traffic tickets you have been issued during the last 3 years: ______4. List the total number of motor vehicle accidents you have had while driving: ______5. List the number of motor vehicle accidents you have had in the last 3 years: ______6. Has your driver’s license ever been suspended?

_____7. Have you been arrested or convicted for driving while intoxicated?

_____ 8. Have you ever been arrested or convicted for driving while under the influence of drugs?

_____ 9. Have you ever failed to appear in court on a traffic ticket you were issued?

_____ 10. Do you have required liability insurance on all your motor vehicles?

_____ 11. Did you ever run from the police (evade an arrest)?

_____ 12. Did you ever commit a “hit and run” motor vehicle accident?

_____ 13. Is there any action pending against you that may cause your driver’s license to be suspended?

_____ 14. Whether you were arrested or not, during the last 5 years, have you driven a motor vehicle on a public highway while you were under the influence of alcohol?

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01/17 Military service (Documentation may be required) Answer the following two inquiries Yes or No in the space provided:

_____ 1. Have you ever applied for military service?

_____ 2. Have you been a member of the military service?

If applicable, fill in the blanks in the space provided:

What branch of the military were you a member of: ______Enlistment dates (month/year to month/year): ______

Type of discharge: ______Highest rank held: ______Military occupational specialty (MOS): ______Last permanent duty station: (City/State/Country) ______If any disciplinary or punitive action was taken against you by the military, please explain: ______

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01/17 Use this form to explain any “Yes” responses as directed.

Question # Response DEBTS

______

WORK RECORD ______

ARREST ______

CONVICTIONS ______

LAW VIOLATIONS ______

TRAFFIC AND DRIVING RECORD ______

** Use additional sheets if needed, using same format. Page 17 of 18

01/17 Declaration

I, ______, as witnessed by my signature, on my oath declare and state:

I am the person that answered all questions and other inquiries contained in the Town of Little Elm Polygraph Statement;

I did not withhold any information requested;

I did not use deception of any kind or type; and,

Without any mental evasion of mind, I answered all questions, inquiries, forms, and requested information truthfully to the best of my knowledge and ability.

______Signature

Notary Public

This instrument was acknowledged before me on the _____ day of ______, 20____

______Notary Public, State of Texas

My commission expires the _____ day of ______(Year) ______

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01/17