Rincon Police Department Chief Jonathon Murrell Name: _________________________________________________ Date Received: ____________________ Position Applied For: Chief: ____________________________ CID: ____________________________ Please fill out completely and attach the following documents: Copy of your Birth Certificate Copy of your Social Security Card Copy of your High School Diploma or GED Certificate Copy of your DD-214 Long Form (if applicable) Copies of any certificates of training in the area of Law Enforcement or security work Copy of your Marriage License and Divorce Decree (if applicable) Certified Driver History for 7 years (must be obtained from Georgia State Patrol at your expense) When you have completed your application and have all copies of all needed documentation, please bring your application to: Rincon Police Department 107 W. 17th Street Rincon, Georgia 31326 WITHOUT THE ABOVE DOCUMENTATION, YOUR APPLICATION WILL NOT BE PROCESSED. Applications will be held for a six month period. IMPORTANT NOTICE IT IS TO YOUR ADVANTAGE TO BE ABSOLUTELY TRUTHFUL IN ANSWERING ALL QUESTIONS IN YOUR INTERVIEWS, ON YOUR APPLICATION, AND PERSONAL HISTORY STATEMENT. A MIS-STATEMENT OF FACT, OR THE OMISSION OF REQUESTED INFORMATION IS GROUNDS FOR AUTOMATIC REJECTION. WE HAVE FOUND IN THE PAST THAT SOME APPLICANTS HAVE BEEN REJECTED BECAUSE OF A MIS- STATEMENT OR OMISSION WHERE THE FACT WHICH THEY ATTEMPTED TO HIDE WOULD NOT HAVE BEEN REASON FOR REJECTION. WE ENCOURAGE YOU TO BE ABSOLUTELY TRUTHFUL IN THESE MATTERS. INSTRUCTIONS AND INFORMATION PLEASE READ CAREFULLY BEFORE BEGINNING 1. An investigation will be conducted by personnel in the Office of Professional Standards based on the information you provided in this application. It is critical that you fill out this application completely, truthfully, and accurately. At any point during the background investigation, or thereafter, it is found that you misrepresented, deliberately omitted, or falsified any information, you will be automatically disqualified from further consideration. It is imperative that you list any convictions to include a finding or a verdict of guilt, a plea of guilty, or a plea of nolo contender in a criminal proceeding, regardless of whether the judgement of guilt or sentence is withheld or not entered thereon. This includes first offenders (OCGA §35-8-7.1). Do not leave blanks in this booklet. If an item does not apply, write N/A. I fully understand what I have read. _____________________________________________ _________________ Applicant Signature Date _____________________________________________ _________________ Notary Public Date _____________________________________________ _________________ Investigator Signature Date 2.Please complete the application in full to include your signatures and required notary sections. 3.If you are a Georgia Certified Police Officer registered with the Georgia Peace Officer Standards and Training Council (POST), please attach a copy of your basic certificate displaying your certification number. 4.The following situations WILL prohibit an applicant from serving as a law enforcement officer: a.Conviction in any court of a felony offense. b.Conviction in any court of a drug related offense. c.Any medical, physical, or mental condition which would prevent an applicant from satisfactorily performing assigned duties or complying with regulation of the Georgia POST Council. 5.The following situations MAY prohibit an applicant from serving as a law enforcement officer: a. Any pending criminal action in court. b. A military discharge other than honorable. c. application. d. Not a citizen of the United States.** An applicant who has received an official pardon or other similar action for any offense or applicable condition as stated above is not obligated to disclose the offense or condition in this application. If, however, during the course of a background investigation, facts are discovered regarding the offense or condition, the applicant may be required to produce proof of such pardon or action to remain in consideration for employment. 6. If you have any questions regarding this application, please contact the Rincon Police Department at (912) 826-5200. 7. The following is a checklist for your convenience. You are urged to use it, as an incomplete application cannot be processed. Upon completion of the application, refer to the checklist to make sure no information has been omitted. ______ All questions answered; those not applicable to be marked N/A. ______ I have attached copies of the following: ______ Birth Certificate ______ High School Diploma ____ ______ Social Security Card ______ DD-214 Long Form (if applicable) showing character of service ______ Application is signed and dated. All forms so noted have been signed in the presence of a Notary Public. These forms MUST bear the signature, stamp, and seal of a Notary Public. PERSONAL INFORMATION 1. Name: _______________________________________________________ 2. Date of Birth: _________________ Place of Birth: _________________________________ 3. Social Security Number: _________________________________ 4. Height: __________________ Weight: _______________________ Hair Color: _______________________ Eye Color: ____________________________ 5. Are you a US Citizen? Yes__________ No__________ Natural Born______________ 6. Have you ever used any other name? Yes___________ No___________ 7. was your former name? ____________________________________________________ 8. Present Address: __________________________________________________________ City: ________________________ State: ______________ Zip: ________________________ 9. Home Phone Number: ________________________________ Work Phone Number: ________________________________ Mobile Phone Number: _______________________________ Email Address: _______________________________________________________ Social Media Accounts (Facebook, Twitter, etc.): a. ___________________________ b. ___________________________ c. ___________________________ d. ___________________________10. How long at present address? ________________________________ Rent: Yes______ No______ Name of Landlord: ______________________ Own: Yes______ No______ Live with Family: Yes______ No______ 11. Previous addresses if less than 10 years beginning with the most current: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ 12. Have you ever filed an application with the Rincon Police Department before? Yes______ No______ If so, when and for what position(s): _______________________________________________ _____________________________________________________________________________ MILITARY SERVICE 13.Complete military service: Branch of service: _____________________Active Guard Reserve (Check applicable) Service number: ______________________ Dates of service: ______________________ Highest Rank attained: _________________ MOS/Rating: _________________________ 14.If member of Reserve or Guard Unit, specify Branch and Unit: _______________________ _________________________________________________________________________ _ 15.Did you ever receive any type of disciplinary action? Yes______ No______ Court Martial? _________ AWOL? __________ Reduction in Rank? _____________Article 15? _________________ Any Other? ______________________________________ 16. Name your last supervisor: ____________________________________________________ Phone Number and Unit: _____________________________________________________ FORMAL EDUCATION 17.Highest grade of school completed: _______________________________________ 18.Did you graduate from high school: __________ Dates attended: ___________________ 19.Name of High School: ______________________________________________________ City/State: _______________________________________________________________ 20.If you did not graduate from high school, do you have a GED certificate? Yes______ No______ Date Obtained: ________________________________ 21.Give names and locations of any Colleges and Universities you have attended, and major course of study: _______________________________________________________________ ______________ ________________________________________________ _______________________________________________________________ _______________________________________________________________ 22.Check highest year of college completed: 1 2 3 4 Degree/Year Obtained: _____________ 23.Graduate School: 1 2 3 4 Degree/Year Obtained: __________________ 24.Do you have any special skills or training that would be helpful to you if you were selected for a law enforcement position? ________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________25. Do you read, write, or speak any foreign languages? Yes______ No______ If so, please list: ________________________________________________________________ 26. If you wear corrective lenses (glasses or contacts) and you lost them during a scuffle with a suspect or inmate, could you still function? Yes______ No______ LAW ENFORCEMENT EMPLOYMENT HISTORY 27. List ALL previous law enforcement employment, starting with the most recent: a. Name/ Address of Agency: _____________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this agency? Yes______ No______ b. Name/ Address of Agency: _____________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this agency? Yes______ No______c. Name/ Address of Agency: _____________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this agency? Yes______ No______ d. Name/ Address of Agency: _____________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this agency? Yes______ No______ e. Name/ Address of Agency: _____________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this agency? Yes______ No______ IF MORE SPACE IS NEEDED ATTACH ADDITIONAL SHEETS. COMPLETE THIS SECTION ONLY IF YOU ARE CURRENTLY OR HAVE BEEN A LAW ENFORCEMENT OFFICER. THIS DOES NOT INLCUDE SECURITY EXPERIENCE. 28. Are you currently a peace officer? Yes______ No______ 29. 30. Certification Type: _______________________________________________________ 31. Certification Date: ________________________ Name and Location of Police Academy: ______________________________________________ ______________________________________________________________________________ 32. How many years of law enforcement do you have? __________________ 33. Have you ever been the subject of an internal investigation? Yes______ No______ 34. Has disciplinary action ever been taken by your certifying agency (POST)? Yes______ No______ 35. Have you ever qualified with a weapon? Lethal: ________________________________________________________________________ Less Lethal: ____________________________________________________________________NON-LAW ENFORCEMENT EMPLOYMENT HISTORY 36. List previous employment for the past ten (10) years or to your 18th birthday, whichever is the longer, beginning with the most recent. a. Name/ Address of Employer: ______________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this employer? Yes______ No______ b. Name/ Address of Employer: ______________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this employer? Yes______ No______c. Name/ Address of Employer: ______________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this employer? Yes______ No______ d. Name/ Address of Employer: ______________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________ Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this employer? Yes______ No______ e. Name/ Address of Employer: ______________________________________________________ ___________________________________________________________________________ Dates of Employment: ________________________________________________________Reason for Leaving: __________________________________________________________ Name and phone number of immediate supervisor: ________________________________ __________________________________________________________________________ Job Title and Duties: _________________________________________________________ __________________________________________________________________________ May we contact this employer? Yes______ No______ IF MORE SPACE IS NEEDED ATTACH ADDITIONAL SHEETS. CRIMINAL RECORD (PLEASE CHECK APPROPRIATE RESPONSES) 37. Have you ever been arrested, charged, indicted, or convicted of a felony offense? Yes______ No______ 38. Have you ever been arrested, charged, indicted, or convicted of a firearms or explosives charge? Yes______ No______ 39. Have you ever been arrested, charged, indicted, or convicted of any offenses related to alcohol or drugs (including DUI)? Yes______ No______ 40. Are there currently any charges pending against you for any criminal offense? Yes______ No______ 41. Have you ever been arrested, charged, indicted, or convicted of any type of offense (including traffic citations, warrants, or misdemeanors)? Yes______ No______ 42. Have you ever been arrested, charged, indicted, or convicted of a domestic violence offense? Yes______ No______43. Have you ever been named as a defendant in a Protective Order from any court? Yes______ No______ Date of Offense Offense Law Enforcement Authority/Court ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ IF MORE SPACE IS NEEDED ATTACH ADDITIONAL SHEETS. DRIVING RECORD 44. Can you operate a motor vehicle? Yes______ No______ 45. 46. Has your license ever been suspended or revoked? Yes______ No______ ber: _______________________ State: __________________ For what reason: _____________________________________________________________ Was it restored: Yes______ No______ 47. Have you ever been refused a license by any state? Yes______ No______48. Give details of any motor vehicle accidents you have been involved in. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ IF MORE SPACE IS NEEDED ATTACH ADDITIONAL SHEETS. PERSONAL REFERENCES 49. Personal References (other than family members and former employers/supervisors) a. Name: ____________________________________________________________ Occupation: ________________________________________________________ Address: ___________________________________________________________ Phone Number: _________________________ Years Known: _______________ b. Name: ____________________________________________________________ Occupation: ________________________________________________________ Address: ___________________________________________________________ Phone Number: _________________________ Years Known: _______________ c. Name: ____________________________________________________________ Occupation: ________________________________________________________ Address: ___________________________________________________________ Phone Number: _________________________ Years Known: _______________CREDIT REFERENCE 50. Credit References a. Name: ____________________________________________________________ Address: ___________________________________________________________ Type of Account: ____________________________________________________ Phone Number: ________________ Contact Person: _______________________ b. Name: ____________________________________________________________ Address: ___________________________________________________________ Type of Account: ____________________________________________________ Phone Number: ________________ Contact Person: _______________________ c. Name: ____________________________________________________________ Address: ___________________________________________________________ Type of Account: ____________________________________________________ Phone Number: ________________ Contact Person: _______________________ BACKGROUND INFORMATION 51. Marital Status: Single: ______ Married: ______ Separated: ______ Divorced: ______ Widowed: ______ 52. 53. 54. _________________ Place of Birth: ___________________________ 55. 56. 57. ____________________________________________ 58. 59. 60. Date of Marriage: ______________________________________ 61. Is your spouse in favor of you becoming a law enforcement officer? Yes______ No______ 62. Closet Living Relative: _________________________________________________________ 63. Are you supporting all living children born to you or adopted by you? Yes______ No______ 64. Are you related to any City of Rincon employee? Yes______ No______ What department do they work for? ______________________________________________ 65. Do you know any employees of the City of Rincon? Yes______ No______ ______________________________________________________________________________ OTHER INFORMATION 66. This position may require you to: Wear a uniform Do you object to doing so? Yes______ No______ Work rotating shifts Do you object to doing so? Yes______ No______ Work overtime Do you object to doing so? Yes______ No______ 67. Have you ever experienced shift work? Yes______ No______ 68. If you have ever been fingerprinted by a police agency other than for an arrest, give details below. Your answer will be checked with the FBI and other agencies. Agency Date Purpose ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 69. Do you drink alcoholic beverages? Yes______ No______ 70. Have you ever used marijuana? Yes______ No______ 71. Have you ever used any other illegal drugs, opiates, pills, etc? Yes______ No______ ______________________________________________________________________________ ______________________________________________________________________________ 72. Do you know now, or have you ever associated with anyone that used illegal drugs? Yes______ No______ 73. Have you ever been fired or permitted to resign from employment for a breach of trust, embezzlement, theft, or other crime? Yes______ No______ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 74. Have you ever been fired or permitted to resign from employment for abuse of authority, insubordination, or ANY other disciplinary reason? Yes______ No______ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 75. If it became necessary in the course of law enforcement duties to take a human life, would you have any reluctance to do so because of religious or other beliefs? Yes______ No______ ______________________________________________________________________________ ______________________________________________________________________________ 76. In the space provided below, give a brief biography or history of yourself. Begin with your past, bringing yourself into the present, and project yourself into the future. Tell where you were born, where you grew up, significant experiences and accomplishments in your life. Tell individuality. Also, describe your reasons for applying for a position with the Rincon Police Department. If you need additional space, attach a separate page to this application. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Rincon Police Department Chief Jonathon Murrell FAIR CREDIT REPORTING ACT AUTHORIZATION TO OBTAIN INFORMATION In undertaking this agreement, I understand that I have certain rights under the Fair Credit Reporting Act which include but are not limited to the following: You must be told if information in your file has been use against you. You can find out what is in your file. You can dispute the inaccurate information with the CRA. Inaccurate information must be corrected or deleted. You can dispute inaccurate items with the source of information. Out-dated information may not be reported. Your consent is required for reports that are provided to employers or reports that contain medical information. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. You may seek damages from violators. Being knowledgeable of my rights under the Fair Credit Reporting Act, I hereby authorize the Rincon Police Department to order and obtain a Consumer Report to be used for employment consideration. __________________________________________ ________________________ Printed Full Name Date __________________________________________ Signature __________________________________________ Department Witness CRIMINAL JUSTICE EMPLOYMENT RELEASE WAIVER FRO NEW APPLICANTS CONSENT TO BACKGROUND INVESTIGATION: DRUG TESTING AND PHYSICAL AND PSYCOLOGICAL TESTING TO: Rincon Police Department P.O. Box 232 Rincon, GA 31326 RE: Name: _________________________________________________________________ SSN: _________________________ DOB: ___________________________ Address: ________________________________________________________________ City, State, Zip: ___________________________________________________________ Sex: ____________ Race: ____________ HGT: _____________ WGT: ____________ Accept this instrument as my personal request and authorization to conduct a comprehensive personal background investigation, including pending charges of any description, a complete traffic history, criminal history (including first offender status, if applicable), credit history report, medical records, full and complete disclosure of the records of educational institutions, financial statements and records, wherever filed; Veterans administration; employment and re-employment records, including background reports, polygraph examinations or reports, efficiency ratings, complaints or grievances filed by or against me. Furthermore, I voluntarily, FULLY CONSENT TO UNDERGO PHYSICAL, PSYCOLOGICAL, PSYCHOMETRIC, AND DRUG SCREEN TESTING. I FURTHER UNDERSTAND AND ACKOWLEDGE THAT DRUG SCREEN TESTING MAY REQUIRE ME TO PROVIDE BLOOD, BREATH, URINE OR OTHER BODILY SUBSTANCE FOR COMPLETE DRUG SCREEN TESTING. I am fully aware, and consent that the information gathered in this screening process, be made known to the officers and employees of the Rincon Police Department, as well as the officers and employees of the City of Rincon Personnel Department and the Georgia Peace Officer Standards and Training Counsel. I am aware that such information is required for application for POST certificate as a law enforcement officer, and for employment with the Rincon Police Department. I certify that if any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. Therefore, I AGREE THAT THE INFORMATION ACQUIRED IN THIS INVESTIGATION BE USED FOR EMPLOLYMENT, TERMINATION, OR DISCIPLINARY DETERMINATIONS, and that such information becomes a matter of public information and is accessible to the public under existing state laws. In consideration of making application for employment, and in complete understanding of the foregoing facts and possible results, I agree to hold to all elements of this release waiver, and further agree TO HOLD HARMLESS, THE CITY OF RINCON AND ITS EMPLOYED AND ELECTED OFFICIALS FROM ANY CIVIL LIABILITY OF ANY KIND OF DESCRIPTION AND INCLUDING ANY ACT OF OMISSION OR COMMISSION. This declaration is made freely and voluntarily without fear of punishment, of promise, or reward, and with full and complete understanding of the terms and consequences of my action. A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature. This _______________ day of _______________________. 20_____ _____________________________________ Legal Signature Sworn in the presence of _______________________________ Notary Public Rincon Police Department Chief Jonathon Murrell Georgia Bureau of Investigation Georgia Crime Information Center I hereby authorize the RINCON POLICE DEPARTMENT history information as part of my application for criminal justice employment, or for use relative to the performance of my official duties with this agency. __________________________________________________________ Full Name (Print) _____________ ___________________ __________________________________ License Number __________________________________________________________ Signature ______________________________ Date Rincon Police Department Chief Jonathon Murrell INFORMED CONSENT RELEASE AND HOLD HARMLESS FOR PRE-EMPLOYMENT BACKGROUND INVESTIGATION I fully recognize that under Georgia law, individuals must clearly demonstrate their personal, medical, and psychological fitness to serve in the position of peace officer. I further recognize that an employing agency has both a legal and moral obligation to make every reasonable effort to ensure that any person employed by them as a peace officer will conform to the very highest standards. I understand that I am authorizing an intensive investigation into all aspects of my personal, medical, and psychological fitness, and that such investigation will include contacting persons and/or organizations who have information relating to my fitness, including if I am or have been a peace officer in Georgia. I understand that those persons and/or organizations may feel inhibited, intimidated, or otherwise reticent about furnishing information concerning my fitness unless authorized to do so and held harmless for cooperating in this process. I hereby authorize the Rincon Police Department (RPD) and any agent or representative thereof, including officers on its police force, within one year of the date hereof, to obtain any information pertaining to me from any individual or entity, including any physician or medical provider, court, present or former employer, records custodian, credit bureau, property manager, financial institution, educational institution, or law enforcement agency. The information that I authorize to be obtained includes but is not limited to medical records, employment and disciplinary records, records regarding eligibility for rehire, and records and information relating to my job performance and behavior. I hereby release and hold RPD and its police officers, agents, employees, and representatives and all persons providing the information described herein to RPD from any and all liability to me of whatever kind or nature which may result from compliance or attempts to comply with this authorization, or which results from providing the information described in this harmless any present or former employer from any and all liability for disclosing complete and accurate employment -related information about me, including records or personnel files that relate to my performance or behavior while employed by such employer. I have had adequate time to review this form, I understand its meaning and purpose, and I have been furnished a copy of it. Date this _________________ day of _____________________, 20______ in the County of Effingham , State of Georgia. ____________________________________ ____________________________________ Applicant Signature Witness Signature
