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City of Bastrop
Police Department

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Employment Application
Equal access to programs, services and employment is available to all persons.
Those applicants requiring accommodation to the application and /or interview process should contact the Bastrop Police Department at 321-5550.
Please type in, print and mail completed form and original signature to:
Bastrop Police Department, 104 Grady Tuck Lane, Bastrop, Texas 78602

PERSONAL HISTORY STATEMENT

A. APPLICANT IDENTIFICATION - Information provided in this section is used for identification purposes only.


1. NAME    		 LAST FIRST MIDDLE
2. ADDRESS NUMBER & STREET CITY
  STATE ZIP CODE
3. TELEPHONE (HOME) (WORK) 4. SOCIAL SECURITY NUMBER
5. DRIVER'S LICENSE # STATE 6. DATE OF BIRTH
7. PLACE OF BIRTH 8. MAIDEN NAME, NICKNAMES, OR OTHER NAMES BY WHICH YOU HAVE BEEN KNOWN
9. HEIGHT 10. WEIGHT 11. COLOR OF EYES 12. COLOR OF HAIR

B. RESIDENCES - List all addresses where you have lived durIng the past 10 years, beginning with present address. List date by month and year. Add attachment with additional addresses if necessary.

FROM TO ADDRESS

 

 

C. WORK HISTORY - Beginning with your present, or most recent job, list employment since the age of 17,
including part-time, temporary, or seasonal employment. Include all periods of unemployment. Attach extra sheets if needed.

1. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

2. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

3. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

4. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

5. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

6. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

7. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

8. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE
DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

9. EMPLOYER ADDRESS
FROM TO PHONE NUMBER JOB TITLE

DUTIES SUPERVISOR
NAME OF CO-WORKER
REASON FOR LEAVING

D. MILITARY RECORD

1 . BRANCH DATES TO 2. SERVICE NUMBER
RANK 3. TYPE OF DISCHARGE
4. DISCIPLINARY ACTIONS RECEIVED (Describe in full)

E. EDUCATIONAL HISTORY

HIGH SCHOOLS ATTENDED CITY/STATE FROM TO GRADUATED
YES NO
YES NO
YES NO

COLLEGE/UNIVERSITY CITY/STATE
DATES TO GPA UNITS/SEMESTER HOURS COMPLETED
MAJOR/MINOR DEGREE(S) RECEIVED

COLLEGE/UNIVERSITY CITY/STATE
DATES TO GPA UNITS/SEMESTER HOURS COMPLETED
MAJOR/MINOR DEGREE(S) RECEIVED

COLLEGE/UNIVERSITY CITY/STATE
DATES TO GPA UNITS/SEMESTER HOURS COMPLETED
MAJOR/MINOR DEGREE(S) RECEIVED


LIST OTHER SCHOOLS ATTENDED (Trade, Vocational, Business, etc.)

SCHOOL CITY/STATE
SUBJECT MATTER DATES TO
DIPLOMAS/CERTIFICATES RECEIVED

SCHOOL CITY/STATE
SUBJECT MATTER DATES TO
DIPLOMAS/CERTIFICATES RECEIVED

SCHOOL CITY/STATE
SUBJECT MATTER DATES TO
DIPLOMAS/CERTIFICATES RECEIVED

F. SPECIAL QUALIFICATIONS AND SKILLS

LIST ANY SPECIAL LICENSES YOU HOLD
(Pilots, Radio Operator, Scuba, etc.)
Show licensing authority, date of issue and date of expiration.
LIST ANY SPECIALIZED MACHINERY OR EQUIPMENT YOU CAN OPERATE



LIST SPECIAL ACCOMPLISHMENTS, PUBLICATIONS, AWARDS
(exclude information which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

List any foreign language(s) you know and check the boxes that describe your skill level.
Language 1: Speak some Speak fluently Read Write
Language 2: Speak some Speak fluently Read Write
Language 3: Speak some Speak fluently Read Write
Language 4: Speak some Speak fluently Read Write

G. ARRESTS, DETENTIONS, AND LITIGATION
(Include all felonies, misdemeanors, except minor traffic violations)
CHARGE
AGENCY
DATE
DISPOSITION

 

LIST ALL CIVIL LITIGATIONS IN WHICH YOU HAVE BEEN INVOLVED AS A PARTY OR WITNESS
(Except those involving Worker's Compensation)

H. TRAFFIC RECORD
LIST ALL TRAFFIC CITATIONS YOU HAVE RECEIVED

CITY/STATE MONTH/YEAR CHARGE DISPOSITION

LIST ALL TRAFFIC ACCIDENTS IN WHICH YOU HAVE BEEN INVOLVED

CITY/STATE MONTH/YEAR AT FAULT DRIVER/PASSENGER
YES NO
YES NO
YES NO
AUTO INSURANCE COMPANY
POLICY NUMBER

If your driver's license has ever been suspended or revoked, attach an extra sheet and give date, state, and reason for action.

I. MARITAL AND FAMILY HISTORY

1. MARITAL STATUS SINGLE ENGAGED MARRIED SEPARATED DIVORCED WIDOWED
2. IF MARRIED, NAME OF SPOUSE MAIDEN NAME OF WIFE (If Applicable)

3. IF EVER SEPARATED, DIVORCED OR WIDOWED: DATE OF MARRIAGE CITY & STATE
SPOUSE'S NAME
PHONE
 PRESENT ADDRESS  

 

 

J. REFERENCES
List three persons, other than relatives or employers, who know you well enough to give detailed information about you.

NAME ADDRESS PHONE YEARS KNOWN

K. FINANCIAL HISTORY
List all sources of income including wages, tips, interest, commissions, etc.

SOURCE AMOUNT FREQUENCY
TYPE REAL ESTATE OWNED VALUE
LOCATION
VALUE OF STOCKS, BONDS OWNED

BANKING INSTITUTIONS IN WHICH YOU MAINTAIN ACCOUNTS
NAME/LOCATION TYPE ACCOUNT AVE. BALANCE


 

 

 

 

 

 

FINANCIAL OBLIGATIONS

CREDITOR / LOCATION ITEM(S) PURCHASED BALANCE MO. PAYMENT

LIST ALL PAYMENTS IN WHICH YOU ARE 30 DAYS OR MORE IN ARREARS

CREDITOR NO. MONTHS IN ARREARS AMOUNT IN ARREARS

LIST ANY ALIMONY OR CHILD SUPPORT PAYMENTS

NAME TO WHOM PAID FREQUENCY PAYMENT STATUS
CURRENT ARREARS
CURRENT ARREARS
CURRENT ARREARS
CURRENT ARREARS
CURRENT ARREARS

L. MEMBERSHIP IN GROUPS, CLUBS, AND ASSOCIATIONS
List name, address, type of organization (Professional, Fraternal, Social, etc.) and dates of participation.

NAME / ADDRESS TYPE OFFICES HELD FROM TO

 

M. PERSONAL DECLARATIONS

POSITION APPLIED FOR:
REFERRAL SOURCE:
 
MAY WE CONTACT YOU AT WORK?  
WORK NUMBER AND BEST TIME TO CALL:  
IF YOU ARE UNDER 18, CAN YOU PROVIDE A WORK PERMIT?    
HAVE YOU FILLED AN APPLICATION HERE BEFORE? YES
HAVE YOU EVER BEEN EMPLOYED HERE BEFORE?
IF YES, GIVE DATES:  
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THIS COUNTRY?
(Proof of U.S. citizenship or immigration status will be required upon employment.)
TYPE OF EMPLOYMENT DESIRED:
  		PART-TIME 
  SEASONAL
ARE YOU ON LAY-OFF AND SUBJECT TO RECALL?
WILL YOU RELOCATE IF YOUR JOB REQUIRES IT?   YES
WILL YOU TRAVEL IF YOUR JOB REQUIRES IT?
ARE YOU ABLE TO MEET THE ATTENDANCE REQUIREMENTS OF THIS POSITION?  
WILL YOU WORK OVERTIME IF REQUIRED?  
HAVE YOU EVER BEEN BONDED?  
1. DESCRIBE IN YOUR OWN WORDS THE FREQUENCY AND EXTENT OF YOUR PRESENT USE OF ALCOHOLIC BEVERAGES.

 

 

 

2. DESCRIBE THE LEVEL, FREQUENCY, AND CIRCUMSTANCES SURROUNDING ANY PRESENT USE OF MARIJUANA OR ILLEGAL USE OF DRUGS NOT PRESCRIBED BY A PHYSICIAN.


3. DESCRIBE, IN DETAIL, ANY INCIDENT IN WHICH YOU SOLD OR FURNISHED ANY MARIJUANA, ILLEGAL DRUGS, OR NARCOTICS TO ANYONE.

4 DESCRIBE ANY BELIEFS OR PRECEPTS YOU HAY HAVE WHICH WOULD PREVENT YOU FROM TAKING A HUMAN LIFE IN THE COURSE OF YOUR LAW ENFORCEMENT DUTIES IF REQUIRED TO DO SO.


5. DESCRIBE ANY BELIEFS OR PRECEPTS YOU MAY HAVE WHICH WOULD PREVENT YOU FROM FULLY PERFORMING THE DUTIES OF A LAW ENFORCEMENT OFFICER, INCLUDING WORKING WEEKENDS, HOLIDAYS, EVENINGS, OR AT NIGHT.


6. LIST ALL LAW ENFORCEMENT AGENCIES WITH WHICH YOU HAVE EVER APPLIED.

AGENCY DATE POSITION SOUGHT

7. LIST ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO CONSIDER:



I HEREBY CERTIFY THAT THERE ARE NO WILLFUL MISREPRESENTATIONS, OMMISSIONS, OR FALSIFICATIONS IN THE FOREGOING STATEMENTS AND ANSWERS TO QUESTIONS. I AM FULLY AWARE THAT ANY SUCH WILLFUL MISREPRESENTATIONS, OMMISSIONS, OR FALSIFICATIONS MAY BE GROUNDS FOR IMMEDIATE REJECTION OR TERMINATION OF EMPLOYMENT.

SIGNATURE OF APPLICANT __________________________________________DATE


 

 

Affirmative Action Voluntary Information
(Completion of information below is voluntary)


We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other legally protected status.
To be completed by applicant. Not for interview purposes. To be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or as necessitated by another federal law or regulation.

As required, we comply with government regulations including Affirmative Action obligations where they apply.
In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.
Please be advised that this survey is not a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.
Position(s) applied for: date:
Referral Source:
 Govt. Employment Agency Walk-in Relative
Employee Private Employment Agency School Other
Advertisement - Source:
 Name of person who referred you (if applicable):
Applicant Information:

Name: Last:

First: Middle:
Telephone and area code: Address: Street:
City:
State: Zip Code:
Gender: male female
Please check one of the following Equal Employment Opportunity Identification Groups:
White Black (not of Hispanic origin) American Indian/Alaskan Native
Hispanic Asian/Pacific Islander  
Special Notice
To Vietnam Era Veterans, Disabled Veterans and Individuals with physical and mental disabilities:

Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam era and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential. Refusal to provide this information will not adversely affect your consideration for employment.

If you so wish to be identified, please check if any of the following are applicable.

Vietnam era Veteran (served between 1964 - 1975) Disabled Veteran Individual with a disability

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