Butler Township Police Department
An Equal Opportunity Employer
The Butler Township Police Department does not discriminate based on race, color, religion, national origin, gender, age, or disability. All qualified applicants are given an equal opportunity and selection decisions are based on job-related factors.
The applicant must answer each question fully and accurately. All information will be subject to verification by polygraph or Computer Voice Stress Analysis and interviews. If a question does not apply to your particular circumstance, write “DNA” in that blank. Insert the full date when answering questions that require dates. Partial dates or month-year responses are unacceptable. You must provide complete address information. Partial address information is unacceptable.
The Police Department will take no action on this application until you have answered all questions completely and honestly. Use a sheet of blank paper if you need additional room to answer a question. PLEASE PRINT LEGIBLY. In reading and answering the questions, none of the questions are intended to imply illegal preferences or discrimination based upon non-job related information. WARNING We caution applicants to answer every question truthfully and without evasion. The Ohio Revised Code provides penalties for making a false statement of a material fact, or for practicing any fraud or deception in obtaining or attempting to obtain employment. Such penalties include rejection for appointment or discharge after appointment and/or prosecution under Ohio Revised Code, section 2921.13.
AUTHORITY TO RELEASE INFORMATION
1 To Whom It May Concern:
I hereby authorize any Butler Township Police Officer / Employee bearing this release or copy thereof within one (1) year of its date, to obtain any information in your files or within the personal knowledge of you, your employees and associates, pertaining to my employment, military service, or educational records, including but not limited to academic achievement, attendance, athletic, personal history, and disciplinary records, medical records, and credit records, and other such information that may be useful in determining my suitability for employment with the Butler Township Police Department. Consent is granted for the Butler Township Police Department to furnish such information as is described above to third parties in the course of fulfilling its official responsibilities.
I am advised that, with limited exceptions, the reports, documents, and other information in written form, learned about me, will be subject to public disclosure under R.C. 149.43, the Ohio Open Records Act.
I hereby release you, as the custodian of such records or knowledge, any school, college, university, or other educational institution, hospital, or other repository of medical information, credit bureau, lending institution, consumer reporting agency, or retail business establishment including its officers, employees, or related personnel, both individually and collectively, from any and all liability, for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance, or attempt to comply with this authorization and request to furnish information. I am furnishing my social security number on a voluntary basis with the understanding such is not required by statute or regulation. I have been informed that the Butler Township Police Department will utilize this number to facilitate the location of employment, military, credit, educational or other records concerning me in conjunction with this application.
Signature: ______Date: ______
Print / Type Name: ______
Date of Birth: ______
County of ______State of ______
Signed and sworn to before me, in my presence, by ______this ______day of ______, 20______.
______Notary Public
BUTLER TOWNSHIP POLICE DEPARTMENT
2 APPLICATION QUESTIONNAIRE
(PLEASE PRINT CLEARLY. USE BLACK INK. ANSWER ALL QUESTIONS TRUTHFULLY)
Name: ______Last First Middle
Other Names Used: Maiden, Aliases, Nicknames, etc.
______
Current Address: ______
Business Address: ______
Telephone Numbers: Home: ______Business: ______
Cellular Phone: ______Alternative: ______
Social Security Number: ______Date of Birth: ______
Place of Birth: ______City State County
Drivers License Number: ______Number State Type Exp.
Sex: ______Race: ______Height: ______Weight: ______
Hair color: ______Eye Color: ______
Marital Status: ______Date Marriage Performed: ______
City & State Marriage Performed: ______
Name of Present Spouse: ______Last First Middle
Other Names Used by Spouse: ______If Divorced or Annulled, List prior Marriages in order of occurrence:
3 Name of Former Spouse: ______Last First Middle
Address of Former Spouse: ______
Grounds for Divorce or Annulment: ______
Amount of Alimony Ordered: ______Current: Yes or No
Amount of Child Support Ordered: ______Current: Yes or No
Title of Court Issuing Order: ______
Location of Court Issuing Order: ______
Date of Final Divorce: ______
Name of Former Spouse: ______Last First Middle
Address of Former Spouse: ______
Grounds for Divorce or Annulment: ______
Amount of Alimony Ordered: ______Current: Yes or No
Amount of Child Support Ordered: ______Current: Yes or No
Title of Court Issuing Order: ______
Location of Court Issuing Order: ______
Date of Final Divorce: ______
CHILDREN:
4 Name Address Date of Birth Place of Birth Natural or step child
RELATIVES: (List relatives including, parents, brother, sister, step-mother, step- father, step-brother, step-sister, in-laws)
Name Address Relation Age Phone
Military Service Information: (include all military service dates)
Branch of Service: ______Serial Number: ______
Military Active Duty Dates: From: ______To: ______Highest Rank Held: ______Type of Separation per DD214: ______Total Months of Combat Duty: ______Total Overseas Duty: ______Military Reserve Status: Ready: _____ Standby: _____ None: ____
5 Were you ever disciplined while in the military service? (If yes, explain below) ______
EDUCATION:
List each grammar, junior high, high school, trade, part-time, business college, and UNIVERSITY that you have attended. Begin with the most recent school attended.
Name of School Location of Attendance Graduate Degree School Dates Yes or No
Please describe any special skills, knowledge or ABILITIES that you have based on your education and experience:
______
FINANCIAL INFORMATION:
This section pertains to your indebtedness involving you, your spouse or ex- spouse:
6 Whom Owed Address Date Incurred Amount / Amount Owed Monthly Payment
BANKING INFORMATION:
Name of Bank Checking Account # Savings Account #
PRESENT VEHICLE INFORMATION:
Year Make Model Registration
7 Do you presently own or rent your home? ______Date Purchased: ______Owner or landlord’s name: ______Financial Institution with mortgage: ______Monthly mortgage or rent payment: $______Are you current on payments? Yes or No
EMPLOYMENT HISTORY:
Have you ever applied with another agency for a police officer position: Yes or No
Agency Name Date Applied Accepted If No, Reason
Begin with your most recent job and list your complete work history in chronological order, including part-time jobs, for the past 10 years.
From Date To Date Name of Employer Job Title
Salary Employer Address Immediate Supv. Telephone #:
Reason for Leaving Duties
From Date To Date Name of Employer Job Title
Salary Employer Address Immediate Supv. Telephone #:
Reason for Leaving Duties
From Date To Date Name of Employer Job Title
8 Salary Employer Address Immediate Supv. Telephone #:
Reason for Leaving Duties
From Date To Date Name of Employer Job Title
Salary Employer Address Immediate Supv. Telephone #:
Reason for Leaving Duties
Have you ever been discharged or asked to resign from a job? Yes or No If yes, please explain: ______
Have you ever reported for work in a condition unsuitable to perform your duties? Yes or No
If yes, please explain: ______
REFERENCES: (Name 3 references, no co-workers or relatives)
Name Address Telephone No. Relationship Occupation
CONTINUATION SHEET
9 Please use this section to explain or further add to answers from this questionnaire. Indicate section and page number in the columns before writing your answer. Your answers must be clear in meaning. Explain all facets of the particular question.
Section name Page number Explanation
Interview Worksheet / Employment Questionnaire
10 If you answer yes to any question, please provide a detailed explanation in the space provided. Use additional paper if needed.
1. Have you ever used or been known by a different name?
2. What is your current address?
3. Have you ever used a date or place of birth different from either listed on your birth certificate?
4. Have you ever lied about your name, age, or address?
5. Have you ever used a different social security number?
6. Have you ever been asked to resign from any job or position?
7. Have you ever resigned while under investigation or resigned in lieu of being terminated for any reason?
8. Have you ever been fired from any job?
11 9. Have you ever quit any job without giving notice?
10. Why did you leave the last job you had?
11. Have you ever been disciplined, reprimanded, or counseled at any job for any reason?
12. Have you any racial, ethnic, religious, sexual or other prejudices that will affect your performance?
13. Have you ever been warned, counseled, or otherwise spoken to about comments you made regarding someone’s race, gender, religion, nationality, or sexual preference?
14. Have you ever used drugs or drank alcoholic beverages while on the job anywhere?
15. Have you ever called in sick because you were too hung over or drunk to go to work?
16. Have you ever called in sick to work when you were not sick?
12 17. Have you ever used a company vehicle for personal use in violation of the employer’s rules?
18. Have you ever intentionally violated any employer’s rule(s) but not been caught?
19. Have you ever stolen any money from an employer?
20. Have you ever been accused of stealing any money from an employer whether you did it or not?
21. Have you ever been refused a job because of your work history?
22. What places where you once worked would refuse to rehire you and why?
23. Have you ever sexually harassed another employee?
24. Have you ever used your position for personal gain in any way?
13 25. Have you ever had any system or plan from stealing from an employer?
26. Have you ever done anything to harm, insult, or frighten another person because of that person’s race, gender, sexual preference, nationality, or religion?
27. To what other law enforcement agencies have you applied?
28. What other law enforcement agencies have rejected you and why?
29. Are you now or have you ever been employed as a police officer, sheriff, deputy sheriff, correctional officer, or any other law enforcement agency?
30. Have you ever been the subject of a disciplinary investigation at work, at a volunteer or other unpaid position, in the military, or in school?
31. Have you ever been suspended from employment or school for any reason?
32. How are you rated on your evaluations?
14 33. Have you ever received a “less than satisfactory” evaluation?
34. Have you ever had any traffic accidents with any employer’s vehicle?
35. Have you ever been interviewed by an employer’s internal affairs, quality control, loss prevention, or other disciplinary investigation unit?
36. Have you ever fired a handgun either purposely or accidentally?
37. Have you ever fired a rifle either purposely or accidentally?
38. Have you ever fired a shotgun either purposely or accidentally?
39. Have you ever taken a polygraph or voice stress analysis examination?
40. Do you have a relative who is employed by Butler Township?
41. Have you ever lied concerning your actions as an employee?
15 42. Where you ever in any branch of the US Armed Forces?
43. What were your dates of service?
44. What was your MOS or military job?
45. What type of discharge(s) did you receive?
46. What was the highest rank you attained?
47. What disciplinary action did you face in the military?
48. Are you currently in the reserves or National Guard?
49. Have you ever served in the armed forces of another nation?
50. Have you ever been denied entrance to the armed forces for any reason?
16 51. Have you ever intentionally written a bad check?
52. Have any of your debts been turned over to a collection agency?
53. Are any creditors demanding payment?
54. Have you ever filed for or declared bankruptcy?
55. Have any judgments ever been filed against you?
56. Are you currently more than 30 days behind payment to any creditor?
57. What is the balance of your financial indebtedness as of this date?
58. Describe your current financial situation:
59. Have you ever had any delinquent federal or state income tax?
17 60. What outstanding student loans do you have?
61. What liens have been placed against you?
62. Have you ever had your wages attached?
63. Have you ever had anything repossessed?
64. Have you ever been sued?
65. Have you ever been evicted?
66. Have you ever broken a lease agreement?
67. From what High School did you graduate?
68. What colleges or universities have you attended?
18 69. Have you ever been suspended, expelled, or placed on academic probation at any school?
70. Have you ever been requested to transfer to another school?
71. Have you ever misrepresented your educational level?
72. Has your spouse or domestic partner ever called the police on you for any reason?
73. Has your spouse or domestic partner ever accused you of battery in a report or discussion with anyone else?
74. Has anyone ever claimed that you have beaten, abused, mistreated, or sexually assaulted a child no matter the relationship or non-relationship of the child to you?
75. How many times have you been married?
76. How many times have the police been called to your home, no matter who called the police?
19 77. Have any members of your family ever been arrested?
78. Have you ever been the victim of a crime?
79. Has any member of your family ever been the victim of a crime?
80. In what state are you currently licensed to drive?
81. How long have you been a licensed driver?
82. Has your license ever been suspended, refused, revoked, or cancelled for any reason?
83. Have you ever used another person’s driver’s license for any reason?
84. Have you ever allowed another person to use your driver’s license for any reason?
85. How many outstanding traffic tickets do you currently have in any jurisdiction?
20 86. Do you have exclusive use to any vehicle that is not currently registered to you?
87. Have any registration for any vehicle owned by you ever been cancelled, refused, suspended, or revoked for any reason?
88. Have you ever used registration plates on any vehicle when those plates were registered to another vehicle?
89. With what company do you currently have automobile insurance?
90. Has your automobile insurance ever been cancelled, refused, suspended, or revoked for any reason?
91. Have you ever been involved in a hit and run accident?
92. Have you ever been sued as a result of a traffic accident?
93. Have you ever lied in court about any traffic ticket you ever received?
21 94. Have you ever lied to any insurance company about any traffic ticket you ever received?
95. Have you ever driven a motor vehicle when you thought you had drank too much of any alcoholic beverage?
96. When was the last time you drove a motor vehicle when you thought you had drank too much of any alcoholic beverage?
97. Have you ever been stopped, questioned, or arrested for driving while intoxicated, driving while impaired, or driving under the influence of alcohol or any controlled substances whether you were arrested or not?
98. Have you ever taken another persons vehicle without permission, whether you knew the person or not?
99. Have you ever committed a crime involving a motor vehicle in any way?
100. How many alcoholic beverages do you drink in an average week?
22 101. When was the last time you were intoxicated?
102. How many times in the last month were you intoxicated?
103. How many times in the last six months were you intoxicated?
104. How many times in the last year were you intoxicated?
105. Has there been a period in your life where you felt you abused alcoholic beverages?
106. Have you ever had any contact with any law enforcement officer because you had been drinking?
107. Have you ever been in a fight or argument with anyone because you had been drinking?
108. Have you ever done anything while under the influence of alcohol that you would not have done if you had been sober?
23 109. Have you ever been arrested for any drug violation?
110. How many times have you ever used marijuana?
111. When did you last use marijuana?
112. When was the last time you used marijuana that was treated with another chemical or drug?
113. How many times have you ever used LSD?
114. When was the last time you used LSD?
115. How many times have you ever used PCP?
116. When was the last time you used PCP?
117. How many times have you ever used cocaine in powder form, crack, or any other form?
24 118. When was the last time you used cocaine in any form?
119. How many times have you used heroin in any form?
120. When was the last time you used heroin in any form?
121. How many times have you ever used amphetamine in any form?
122. When was the last time you used amphetamine in any form?
123. How many times have you ever used barbiturates in any form?
124. When was the last time you used barbiturates in any form?
125. How many times have you used steroids, other than those prescribed by a doctor, in any form?
126. When was the last time you used steroids, other than those prescribed by a doctor, in any form?
25 127. How many times have you used any other type of drug, other than a drug prescribed by a doctor, in any form?
128. When was the last time you used any other type of drug, other than a drug prescribed by a doctor, in any form?
129. How many times have you used a prescription medication that was prescribed for someone else?
130. When was the last time you used a prescription medication that was prescribed for someone else?
131. How many times have you ever sold any kind of narcotic, dangerous drug, or marijuana?
132. When was the last time you ever sold any kind of narcotic, dangerous drug, or marijuana?
133. How many times have you ever bought any kind of narcotic, dangerous drug, or marijuana?
26 134. When was the last time you ever bought any kind of narcotic, dangerous drug, or marijuana?
135. Have you ever purchased alcoholic beverages for a minor?
136. Describe the date, location, charge, police agency and disposition of any time that you have ever been arrested as an adult or juvenile:
137. Where you ever adjudicated a delinquent?
138. Did you ever run away from home?
139. Have you ever received a criminal or civil summons to appear as an accused or defendant?
140. Have you ever been interviewed by the police as a witness in any case?
141. Have you ever been interviewed by the police as a suspect in any case?
27 142. What is the greatest amount of money you have ever stolen at any one time?
143. Have you ever shoplifted anything in your life?
144. What is the greatest amount of property you have shoplifted at any one time?
145. Have you ever switched price tags or labels on any merchandise at any time in you life?
146. Did you ever buy anything that you knew was stolen?
147. Did you ever buy anything that you suspected was stolen?
148. What have you stolen from any place where you worked?
149. Have you ever stolen a gun or weapon of any kind?
28 150. Have you ever committed a crime with a gun or weapon whether you were arrested or not?
151. Did you ever steal, or help someone else steal any kind of vehicle?
152. Did you ever ride in a stolen car?
153. Did you ever ride in a car you suspected to be stolen?
154. Have you ever forced entry into any room, building or residence of any kind in your life?
155. Where you ever with someone who forced entry into any room, building, or residence of any kind in your life?
156. Have you ever robbed anyone?
157. Where you ever with someone else who robbed someone?
158. Have you ever snatched a purse?
29 159. Where you ever with someone who has snatched a purse?
160. When was the last time you were involved in a fight?
161. Have you ever injured someone in a fight?
162. Have you ever been involved in or witnessed any kind of murder or other type of killing?
163. Have you ever been involved in or been accused of being involved in an incident of child molestation?
164. Have you ever been involved in or been accused of any forced sexual act?
165. Have you ever forced anyone to have sexual intercourse with you?
166. Have you ever forced anyone to kiss, touch, or have any other type of sexual contact with you?
30 167. Have you ever committed a crime for which you were not caught?
168. Since your 18th birthday, have you ever had sexual contact with another person under the age of 18?
169. Have you ever committed or been involved in vandalism?
170. Have you ever committed or been involved in bestiality?
171. Have you ever committed or been involved in fraud?
172. Have you ever committed or been involved in forgery?
173. Have you ever committed or been involved in telephone misuse?
174. Have you ever committed or been involved in a weapons violation?
175. Have you ever committed or been involved in any illegal gambling?
31 176. Have you ever committed or been involved in cruelty to animals?
177. Have you ever committed or been involved in arson?
178. Have you ever committed or been involved in bribery?
179. Have you ever committed or been involved in extortion?
180. Have you ever committed or been involved in prostitution?
181. Have you ever committed or been involved in a theft offense?
182. Have you ever committed or been involved in making false alarms?
183. Have you ever committed or been involved in embezzlement?
184. Have you ever committed or been involved in illegal eavesdropping or wiretapping? 185. Have you ever committed or been involved in impersonation of a law enforcement officer?
32 186. Have you ever been on parole or probation for any reason?
187. How long do you expect to be employed by the Butler Township Police Department?
188. Did you receive a copy of the Butler Township Police Department Applicant Disqualifying Criteria?
33 I certify that all information provided in this Employment Application / Questionnaire is true and complete. I understand that any false or intentionally misleading or excluded information may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.
I authorize and agree to cooperate in a thorough background investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, driving record, and criminal history.
I understand that if I am selected for employment, my employment is conditioned upon passing a pre-employment physical and drug examination and successfully passing a background check.
I understand information discovered during the background process is subject to public records release as allowed by law.
I understand if I am employed, I may be required to work day shift, evening shift, night shift, and weekends and / or be called into work and be required to work mandatory overtime.
I understand and accept if employed my continued employment is conditioned upon my maintaining a valid operator’s license in the State of Ohio and my ability to obtain and maintain Ohio LEADS access.
I understand that this employment questionnaire or subsequent employment processes does not create a contract of employment nor guarantee employment for any definite period.
I have read this employment application / questionnaire and understand its contents. I represent and warrant I have read and fully understand the prior and seek employment under these conditions.
Applicant Signature: ______Applicant’s printed name: ______Date: ______
County of ______State of ______
Signed and sworn to before me, in my presence, by ______this ______day of ______, 20______.
______Notary Public
34