MPD Application Personal HistoryName First Middle Last Social Security Number Date of Birth MM slash DD slash YYYY Place of Birth City, County, State, CountryAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home TelephoneCell PhoneEmail* Personal Web Page Address Facebook, etc.Aliases, Nicknames, Maiden Name, or Other Name Changes EducationHigh School Name, Address, Dates of Attendance, Graduation Date, or Date of GEDCollege/University Name, Address, Dates of Attendance, Graduation Date, DegreeGraduate School Name, Address, Dates of Attendance, Graduation Date, DegreeVocational School Name, Address, Dates of Attendance, Graduation Date, Certifications, DegreesIf you have not obtained a degree, please indicate the total amount of college credits you have earned Military ServiceHave you served in the United States Military? Yes No Branch of Service Unit What is your military service or selective service number? Highest rank held Periods of active military service Type of Discharge Please list any medals and/or decorations your were awarded as a member of the armed forcesWhile in the military service, were you ever the subject of any court martial, summary court, deck court, captain's mast, company punishment, or any other form of disciplinary action, including an Article 15? Yes No N/A If yes, please provide the circumstances and the findings of such an actionPlease attach any documentation you have regarding such a procedure.Max. file size: 128 MB.Employment HistoryBeginning with your current or most recent employer, list all full and part time employment within the last ten years. Please account for all periods of unemployment which exceed three months. Use additional sheets if necessary.ListName of EmployerAddressJob TitleSupervisorStart DateEnd DateFinal SalaryReason for Leaving Have you ever been counseled, reprimanded, suspended, or terminated from an employment position? Yes No Have you ever been asked, or given the opportunity to resign from an employment position? Yes No If you answered yes, please provide detailsCriminal HistoryHave you ever been a witness, suspect, or the subject of a police investigation? Yes No If yes, please explain in detail, the charge, the jurisdiction, the date, and the outcomeHave you ever been arrested, indicted, convicted, or pled no contest to any violation of the law, ordinance, or traffic violation? Yes No If yes, please provide all pertinent details including costs, fines, convictions, probation, jail or prison sentence (including those in the military). Please include the date, the charge, the jurisdiction and the outcome Have you ever committed a criminal offense? Yes No If yes, please explainHave you ever been charged and/or convicted of a domestic violence related offense, either misdemeanor or felony? Yes No If yes, please explainHave you ever been the subject of a restraining order? Yes No If yes, please explainAre you currently involved in any civil actions? Yes No If yes, please explainDriving RecordDo you currently hold a valid Indiana Driver's License? Yes No Driver's License Number Expiration Date MM slash DD slash YYYY Type of License Endorsements Restrictions Has your driver's license ever been suspended or revoked? Yes No If yes, please explainDate of restoration MM slash DD slash YYYY List all vehicle accidents you have been involved in over the last five years:DateLocationDescription List all traffic citations/warnings you have received in the last three yearsDateLocationDescription Have you ever held a license in another state (including military license)? Yes No If yes, please list the followingStateLicense Number MiscellaneousAre you a graduate of the Indiana Law Enforcement Academy? Yes No If yes, Class and Graduation Date ReferencesPlease list three references who are not related to you and who have personally known you and been in contact with you for at least five years. Additional references may be requested if we cannot reach one or any of the references listed below.NameAddressOccupationYears KnownHome PhoneCell PhoneWork Phone Writing TestIn the space provided, please describe the reasons why you wish to become a police officer with the Martinsville Police Department.
