Little Elm Fire Department Polygraph Statement Applicant’s Name_________________________________ Date: ____________________________________________ Page 1 of 18 01/17 POLYGRAPH STATEMENT OF 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: _________________________________________________ Page 2 of 18 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? Page 3 of 18 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 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: ____________________________________________________ _____________________________________________________________________ Page 4 of 18 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: ____________________________________________________ _____________________________________________________________________ Page 5 of 18 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? Page 6 of 18 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? Page 7 of 18 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