MPD Application - City of Martinsville, Indiana

Personal History

Name

First Middle Last

Social Security Number

Date of Birth

Place of Birth

City, County, State, Country

Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Home Telephone

Cell Phone

Email

Personal Web Page Address

Facebook, etc.

Aliases, Nicknames, Maiden Name, or Other Name Changes

Education

High School

Name, Address, Dates of Attendance, Graduation Date, or Date of GED

College/University

Name, Address, Dates of Attendance, Graduation Date, Degree

Graduate School

Name, Address, Dates of Attendance, Graduation Date, Degree

Vocational School

Name, Address, Dates of Attendance, Graduation Date, Certifications, Degrees

If you have not obtained a degree, please indicate the total amount of college credits you have earned

Military Service

Have 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 forces

While 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 action

Please attach any documentation you have regarding such a procedure.

Employment History

Beginning 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.

List

Name of Employer	Address	Job Title	Supervisor	Start Date	End Date	Final Salary	Reason 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 details

Criminal History

Have 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 outcome

Have 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 explain

Have you ever been charged and/or convicted of a domestic violence related offense, either misdemeanor or felony?

Yes
No

If yes, please explain

Have you ever been the subject of a restraining order?

Yes
No

If yes, please explain

Are you currently involved in any civil actions?

Yes
No

If yes, please explain

Driving Record

Do you currently hold a valid Indiana Driver's License?

Yes
No

Driver's License Number

Expiration Date

Type of License

Endorsements

Restrictions

Has your driver's license ever been suspended or revoked?

Yes
No

If yes, please explain

Date of restoration

List all vehicle accidents you have been involved in over the last five years:

Date	Location	Description

List all traffic citations/warnings you have received in the last three years

Date	Location	Description

Have you ever held a license in another state (including military license)?

Yes
No

If yes, please list the following

State	License Number

Miscellaneous

Are you a graduate of the Indiana Law Enforcement Academy?

Yes
No

If yes, Class and Graduation Date

References

Please 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.

Name	Address	Occupation	Years Known	Home Phone	Cell Phone	Work Phone

Writing Test

In the space provided, please describe the reasons why you wish to become a police officer with the Martinsville Police Department.