Pre-Volunteer Personnel File Information Applicants shall be subject to an extensive background investigation and verification of the validity and content of your answers herein. First Name: Middle Name: Last Name: State Other Names Used: Answer all questions completely. If question is not applicable, type "N/A." type "Unknown" only if you do not know the answer and cannot obtain the answer from your records. Illegible or incomplete forms will not receive consideration. It is imperative that all information is accurate and up to date. Information on names, addresses and references must be correct in order to process this application. Your Address: Address City State Zip Phone Number: (include area code) Date of Birth: mm/dd/yyyy Social Security Number: US Citizen: Yes No Place of Birth: Height: Weight: Color of Eyes: Color of Hair: Drivers License #: (or state id) State of Issue: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Date Issued: mm/dd/yyyy Other Types of License Held and Numbers: License TypeLicense Number 1. # 2. # 3. # Personal History:/font> Marital Status: Married Never Married Divorced Separated Wedding Date: mm/dd/yyyy If Divorced or Separated: Former Spouse's Name: Former Spouse's Address: Former Spouse's City: Former Spouse's State: Former Spouse's Zip: As Applicable: Your Wife's Maiden Name: Your Wife's DOB: mm/dd/yyyy Your Husband's Name: Your Husband's DOB: mm/dd/yyyy Spouse's Occupation: Spouse's Employer: Spouse's Employer's Address: Address: City: State: Zip: Children's Name Age Address Date of Birthmm/dd/yyyy Children's Name Age Address Date of Birth mm/dd/yyyy Children's Name Age Address Date of Birth mm/dd/yyyy Children's Name Age Address Date of Birth mm/dd/yyyy Children's Name Age Address Date of Birthmm/dd/yyyy Father's Name: Date of Birth:mm/dd/yyyy Phone: Address: City: State: Zip: Mother's Name: Date of Birth:mm/dd/yyyy Phone: Address: City: State: Zip: Brothers/Sisters Name1: Date of Birth:mm/dd/yyyy Phone: Address: City: State: Zip: Brothers/Sisters Name2: Date of Birth: mm/dd/yyyy Phone: Address: City: State: Zip: Brothers/Sisters Name3: Date of Birth: mm/dd/yyyy Phone: Address: City: State: Zip: Brothers/Sisters Name4: Date of Birth: mm/dd/yyyy Phone: Address: City: State: Zip: ADDRESSES FOR THE LAST 2 YEARS Current Address: From: MM/YYYY To: MM/YYYY Rent / Own If Rented, Landlord: Name Address Phone Previous Address 1: Street City State Zip From: MM/YYYY To: MM/YYYY Rent Own If Rented, Landlord: Name Address Phone Previous Address 2: Street City State Zip From: MM/YYYY To: MM/YYYY Rent Own If Rented, Landlord: Name Address Phone Previous Address 3: Street City State Zip From: MM/YYYY To: MM/YYYY Rent Own If Rented, Landlord: Name Address Phone Character History: During the course of your employment, either past or present, have you been subject to any disciplinary action, demotion or request for resignation? Yes No If yes, please explain. Have you ever been treated for mental illness or counseled by a psychiatrist/mental health professional? Yes No If yes, give the date and explain: Have you ever intentionally physically injured another person? Yes No If yes, give the date and explain: Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group or combination of persons which is totalitarian, Fascist, Communist, or subversive; or which has adopted or shown a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States; or which seeks to alter the form of Government of the United States by unconstitutional means? Yes No If yes, please explain: Have you ever stolen anything from an employer? Yes No If yes, please explain: Have you ever been arrested or charged with a criminal offense? Yes No If yes, please relate circumstances, including arresting agency, date, charges and disposition: Are you now, or have you ever been a plaintiff or defendant in any civil action? Yes No If yes, please explain: Have you ever used any illegal drugs, including marijuana, amphetamines, depressants, tranquilizers, cocaine, etc? Yes No If yes, please explain: Are you now under a doctor's care and presently taking any prescribed medication? Yes No If yes, please explain, and identify the medication you are taking: Do you associate with any person or persons who use illegal drugs, narcotics or marijuana? Yes No If yes, please explain: Do you drink alcoholic beverages? Yes No If yes, to what extent do you use alcoholic beverages? Never Socially Weekly Daily Have you ever received treatment in an alcohol-related program? Yes No If yes, when: Are there any incidents in your life, not previously mentioned in this application which, if known, would disqualify you as an applicant, as outlined in the foregoing advisement, whether or not you were directly involved, which might be discovered by subsequent investigation? Yes No If yes, please describe the incident(s) below and explain in detail: Are you acquainted with any employees of the Durango Police Department? Yes No If yes, please list their names: Do you have any relatives currently employed by the Durango Police Department? Yes No If yes, please list their names & relationship: Why are you applying for a volunteer position in the law enforcement profession? SUPPLEMENTARY: STATEMENT OF ACKNOWLEDGMENT AND CONSENT TO RELEASE INFORMATION State of Colorado ) ss.) County of La Plata ) I, being first duly sworn upon oath, state as follows: I am presently an applicant as a volunteer with the Durango Police Department, Durango, Colorado. I fully understand that the Durango Police Department conducts a background investigation of all applicants (using this application for its beginning point), who are being considered as a volunteer with the Durango Police Department. This investigation includes, but is not limited to, an investigation of my past employment performance, driving records and character. I hereby waive any and all rights that I may have to examine, review, or inspect any documents or information of whatever kind, form or nature, obtained in the course of the background investigation. I hereby authorize any person who is contacted by the Durango Police Department’s personnel to release any information to the Durango Police Department pertaining to the background investigation including, but not limited to, records or information relating to my past employment performance, driving records and character for use by the Durango Police Department in the consideration of my application as a volunteer and for no other purpose. I also understand hereby that this application and any and all papers and other exhibits submitted by me or any person, government agency, former employer, private business, or any other individual or group of individuals become upon submission to the Durango Police Department, the property of the City of Durango, State of Colorado, and can not and will not be returned to me under any circumstances whatsoever and will not be disclosed to me. I authorize the Durango Police Department to release any information or documents collected during the application process to any person or entity lawfully empowered to obtain this information or documents. I further agree to release and hold harmless any person releasing such information to the Durango Police Department from any and all liability or claims that I may have against that person arising out of the release of such information. I further agree to release and hold harmless the City of Durango, its elected officials, officers, agents and employees from any and all liability or claims which I may have arising out of the disclosure of such information to the Durango Police Department for use by the Durango Police Department in the consideration of my application as a volunteer, and the disclosure or release of any information or documents by the Durango Police Department or agents thereof collected during the application process to any person or entity lawfully empowered to obtain such information or documents. This authorization for the release of information shall be valid for a six (6) month period from the date hereof. Any release of claim or liability set forth herein shall survive the termination of the agreement. I further certify hereby that all statements made by me in the completion of this application are, to the best of my knowledge and recollection, accurate and true and I understand that any false answer (deceitfully made) or any fraud whatsoever, constitutes a basis for automatic rejection of this application, or if I am accepted and fraud and/or deceit is subsequently discovered, such fraud and/or deceit will become grounds for my immediate dismissal from the Durango Police Department. Date: Signature: This document will not be "signed" in the sense of a traditional paper document. To verify the contents of this form, the signatory must enter any combination of alpha/numeric characters that has been specifically adopted to serve the function of the signature, preceded and followed by the forward slash (/) symbol. Acceptable "signatures" could include: /john doe/; /jd/; and /123-4567/. For example: if your name is John Miller, you could type /John Miller/ below. Select One This form can be submitted via email to the City This form can be submitted to a PDF that you may print and mail to the cityAdobe Acrobat is Required <-- Back to Volunteer Information
SUPPLEMENTARY:
STATEMENT OF ACKNOWLEDGMENT AND CONSENT TO RELEASE INFORMATION
State of Colorado ) ss.) County of La Plata )
I, being first duly sworn upon oath, state as follows:
I am presently an applicant as a volunteer with the Durango Police Department, Durango, Colorado.
I fully understand that the Durango Police Department conducts a background investigation of all applicants (using this application for its beginning point), who are being considered as a volunteer with the Durango Police Department. This investigation includes, but is not limited to, an investigation of my past employment performance, driving records and character. I hereby waive any and all rights that I may have to examine, review, or inspect any documents or information of whatever kind, form or nature, obtained in the course of the background investigation.
I hereby authorize any person who is contacted by the Durango Police Department’s personnel to release any information to the Durango Police Department pertaining to the background investigation including, but not limited to, records or information relating to my past employment performance, driving records and character for use by the Durango Police Department in the consideration of my application as a volunteer and for no other purpose.
I also understand hereby that this application and any and all papers and other exhibits submitted by me or any person, government agency, former employer, private business, or any other individual or group of individuals become upon submission to the Durango Police Department, the property of the City of Durango, State of Colorado, and can not and will not be returned to me under any circumstances whatsoever and will not be disclosed to me.
I authorize the Durango Police Department to release any information or documents collected during the application process to any person or entity lawfully empowered to obtain this information or documents.
I further agree to release and hold harmless any person releasing such information to the Durango Police Department from any and all liability or claims that I may have against that person arising out of the release of such information.
I further agree to release and hold harmless the City of Durango, its elected officials, officers, agents and employees from any and all liability or claims which I may have arising out of the disclosure of such information to the Durango Police Department for use by the Durango Police Department in the consideration of my application as a volunteer, and the disclosure or release of any information or documents by the Durango Police Department or agents thereof collected during the application process to any person or entity lawfully empowered to obtain such information or documents.
This authorization for the release of information shall be valid for a six (6) month period from the date hereof. Any release of claim or liability set forth herein shall survive the termination of the agreement.
I further certify hereby that all statements made by me in the completion of this application are, to the best of my knowledge and recollection, accurate and true and I understand that any false answer (deceitfully made) or any fraud whatsoever, constitutes a basis for automatic rejection of this application, or if I am accepted and fraud and/or deceit is subsequently discovered, such fraud and/or deceit will become grounds for my immediate dismissal from the Durango Police Department.
Date: Signature:
This document will not be "signed" in the sense of a traditional paper document. To verify the contents of this form, the signatory must enter any combination of alpha/numeric characters that has been specifically adopted to serve the function of the signature, preceded and followed by the forward slash (/) symbol. Acceptable "signatures" could include: /john doe/; /jd/; and /123-4567/. For example: if your name is John Miller, you could type /John Miller/ below.
