F:\Police\PSS\Background & Hiring\hiring forms\BG packets\Background Packet all jobs 2019.docx
NAME:______________________________________
Last First Middle
DATE:__________________
POSITION SOUGHT: _______________________
CHANDLER POLICE
DEPARTMENT
Background Questionnaire
2019
INSTRUCTIONS:
1.
MAKE SINGLE SIDED COPIES ONLY
2.
PRINT LEGIBLY IN BLACK INK IN YOUR OWN HANDWRITING
3.
ONLY THE APPLICANT WILL FILL OUT THIS QUESTIONNAIRE
4.
IF YOU NEED ADDITIONAL SPACE, MAKE A COPY OF THE “FURTHER
EXPLANATIONS” SHEET, UNLESS OTHERWISE DIRECTED (Sections B and C)
5.
SIGN THE QUESTIONNAIRE AND HAVE IT NOTARIZED ON PAGES 3 AND 4.
THE POLICE DEPARTMENT WILL NOT NOTARIZE YOUR SIGNATURE.
6.
PER PAGE 39, ATTACH ALL NECESSARY COPIES
7.
YOU WILL RECEIVE INSTRUCTIONS ON WHEN TO SUBMIT YOUR FULLY
COMPLETED PACKET
ANY OMISSION, DECEPTION, OR FAILURE TO FOLLOW THE INSTRUCTIONS
IN YOUR PACKET COULD DISQUALIFY YOU FROM FURTHER CONSIDERATION.
Chandler Police Department
Professional Standards Section
250 E. Chicago St.
Chandler, AZ 85225
Questions?
CPDrecruiting@ChandlerPD.com OR 480-782-4123
Table of Contents 2
Background Packet
(Table of Contents)
Personal Data…………………………………………………………..Pg. 5-6
Former Residences…………………………………………………….Pg. 7
Employment History…………………………………………………..Pg. 8-12
References……………………………………………………………...Pg. 13
Education/Training……………………………………………………Pg. 14
Arrest/Legal History…………………………………………………..Pg. 15-20
Driving History………………………………………………………..Pg. 21-22
Alcohol/Drug History…………………………………………………Pg. 23-26
Military………………………………………………………………...Pg. 27-28
Financial Status……………………………………………… ……….Pg. 29-30
Social Networking………………………………………………….….Pg. 31
Law Enforcement Experience………………………………….…….Pg. 32-34
Prior Police Applications………………………………….…….…….Pg. 35
General Questions………………………………………….…….……Pg. 36
Summary Statement………………………………………….…..……Pg. 37
Certification/Disclosure…………………………………….….….…..Pg. 38
Reminder/Checklist………………………………………….…..….…Pg. 39
Further Explanation Form………………………………….…...……Pg. 40
Disqualifiers 3
Chandler Police Department DATE:________________
POSITION_______________________ ____________________________
SWORN DETENTION RESERVE CIVILIAN VOLUNTEER
This questionnaire will be used for reference by those who will be considering you for employment or for a commission with the
CHANDLER POLICE DEPARTMENT.
An extensive background investigation will be conducted into your personal history.
Applicants will be required to take a polygraph examination (1) to confirm the information in this questionnaire and (2) to
determine other items of background information.
I understand that I will not receive, and I am not entitled to, a copy of the report or to know its contents. I further understand that
the contents will be used in the evaluation process for employment with the City of Chandler and that no documents submitted by
me will be returned, and no copies of any other reports or documents utilized for or during my application for employment or a
commission will be furnished or given to me. I understand that I WILL NOT BE ADVISED OF THE REASONS FOR NON-
SELECTION.
Where written explanations are required in this form, it is MANDATORY that the information be listed TOTALLY AND
COMPLETELY.
The existence of any of the conditions listed below may result in rejection from the selection process. These areas will be
explored during an extensive background investigation and psychological and polygraph examinations.
NOTE: Appropriate business attire is required for all steps of your processing, including all interviews, polygraph
examinations, psychological evaluations, and employee orientations. Failure to comply may result in removal
from the hiring process. All employees are required to abide by the General Order #B05-100 General
Appearance requirements which states that ALL personnel may not have any visible tattoos that cannot be
covered when working in their official capacity including on-duty, training, court, or outside events representing
the department
CRITERIA STANDARDS FOR DISQUALIFICATION
1.
ANY FELONY CONVICTION (NO TIME LIMIT)
2.
PARTICIPATION IN ANY SERIOUS CRIME
3.
ANY MISDEMEANOR CONVICTION INVOLVING NARCOTIC DRUGS, DANGEROUS DRUGS OR
MARIJUANA
4.
ANY SELLING OF NARCOTICS DRUGS, DANGEROUS DRUGS OR MARIJUANA
5.
ANY RECENT ILLEGAL USE OF MARIJUANA
6.
ANY EXCESSIVE ILLEGAL USE OF MARIJUANA IN YOUR LIFE
7.
ANY RECENT ILLEGAL USE OF NARCOTICS OR DANGEROUS DRUGS
8.
ANY EXCESSIVE ILLEGAL USE OF NARCOTICS OR DANGEROUS DRUGS IN YOUR LIFE
9.
NEGLIGENCE IN MAINTAINING FINANCIAL RESPONSIBILITY
10.
ANY HISTORY OF DISREGARD FOR TRAFFIC LAWS WITH SUCH FREQUENCY SO AS TO
INDICATE A DISRESPECT FOR TRAFFIC LAWS AND A DISREGARD FOR THE SAFETY OF OTHER
PERSONS ON THE HIGHWAY
11.
ANY SEXUAL CONDUCT PROHIBITED BY LAW
PLEASE CONFIRM THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THE AFOREMENTIONED
CONDITIONS AND CRITERIA BY SIGNING BELOW.
_____________________________________
Applicant Signature Date
Subscribed and sworn to before me this
_______ day of _____________________, 20 _____
My commission expires: ______________________
___________________________________________
Notary Public
Release 4
Chandler Police Department
ORI - AZ0070500
AUTHORITY FOR RELEASE OF INFORMATION
Last Name
First Name
Middle Name
Sex
Race
Date of Birth
SSN
City of Birth
County
State
Country
I, _______________________________, do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning myself, by
and to ANY duly authorized agent of the Chandler Police Department, Professional Standards Section, whether said records are of public, private, or
confidential nature.
The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; financial or credit
institutions (including records of deposits, withdrawals, balances of checking and savings accounts, and loans) and also the records of commercial or
retail credit agencies (including credit reports and/or ratings); public utility companies; employment and pre-employment records, including background
reports, efficiency ratings, complaints or grievances filed by or against me, and salary records; real and personal property tax statements and records, and
other financial statements and records wherever filed; records of complaint, arrest, trial, and/or convictions for alleged or actual violations of law,
including criminal, civil, and/or traffic records; the results of any polygraph examinations; records of complaints of a civil nature made by or against me,
wherever located, including the records and recollections of attorneys at law, or of other counsel, whether representing me or another person in any case
in which I presently have or have had an interest.
I reiterate and emphasize that the intent of this authorization is to provide full and unobstructed access to the background and history of my personal life
for the specific purpose of pursuing a background investigation, which may provide pertinent data for the Chandler Police Department to consider in
determining my suitability for employment by that department. It is my specific intent to provide access to personal information, however personal or
confidential it may appear to be, and the sources of information specifically identified herein.
I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly, in whole or in part,
upon this release authorization will be considered in determining my suitability for employment by the Chandler Police Department. I understand that
all materials pertaining to this background investigation become the property of the Chandler Police Department, Professional Standards Section, and
will not be returned to me.
I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims,
damages, losses, and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request. I further understand that
in the event my application is disapproved, the sources of confidential information cannot be revealed to me.
A photocopy of this release form will be valid as an original hereof, even though said photocopy does not contain an original writing of my signature.
MUST BE SIGNED IN THE PRESENCE OF A NOTARY:
Subscribed and sworn to before me this
_________ day of _____________________, 20_____.
My commission expires: ________________________
_____________________________________________
Notary Public
_________________________________________
Applicant Signature Date
_________________________________________________
Street Address City State Zip
Personal Data 5
Note: Where necessary, use a separate page to complete answers throughout this questionnaire.
A. Personal Data Today’s Date: ____________
Full Name ______________________________________________________SSN_________________
LAST FIRST MIDDLE
AKA/Maiden Name ___________________________________________________________________
DL # State________ Gender _____ Marital Status ________ Date of Birth__________
MM/DD/YYYY
Height________ Weight________ Eye Color________ Hair Color________ Race__________
Address _____________________________________________________________________________
NO./STREET APT. # CITY STATE ZIP
Phone (_____) _______________ (_____) __________________ ______________________________
HOME CONTACT EMAIL
1. Have you ever used or been known by any other name other than the one you listed on this
questionnaire (including your maiden name)? Yes No
If yes, list name(s): __________________________________________________________________
2. Have you ever used a social security number other that the one you have listed? Yes No
If yes, list number(s): ________________________________________________________________
3. Have you ever taken a polygraph before? Yes No
Date (MM/YY)
Agency:
Result:
4. Have you ever committed a felony or an offense that would be a felony if committed in Arizona?
Yes No
If yes, explain:
5. Have you driven a vehicle under the influence of alcohol or drugs and not been caught?
Yes No
If yes, explain:
6. Have you ever failed to file an IRS statement? Yes No
If yes, list year(s): _______________ Why? _____________________________________________
Personal Data 6
A. Personal Data Continued
7. Are you currently delinquent with any child support obligations? Yes No
If yes, explain:
8. Have you ever failed to make child support payments you were legally required to make?
Yes No
If yes, explain:
9. Do you have any prejudices against any group? Yes No
If yes, explain:
10. Have you ever had a physical confrontation (i.e. pushed, slapped, punched, property damage, etc.)
with a romantic/intimate partner (i.e. spouse, girlfriend/boyfriend, date)?
No
Yes, on one occasion
Yes, on two or three occasion
Yes, on four or more occasion
If yes, explain:
11. Have you ever been a member of any organization that advocates, advises, or supports the use of
force or other unlawful means to deny other person their rights under the constitution of the United
States? Yes No
If yes, explain:
12. Did you cheat, lie, or commit fraud in any way on your application or evaluation process for this job?
Yes No
If yes, explain:
13. Indicate whether you have been rejected as a job applicant for any of the following reasons:
a. Issues raised by a background investigation? Yes No N/A
b. Issues raised by a polygraph? Yes No N/A
c. Issues raised by an oral board? Yes No N/A
d. Issues raised by a physical agility test? Yes No N/A
e. Other __________________________
If yes, explain:
14. Have you ever failed to successfully complete a probationary period with a law enforcement agency?
Yes No
If yes, explain:
Residences 7
B. Residences
Starting with the present, list all residence addresses and proceed backwards for the past 10 years.
Include school, military, and personal residences. ACCOUNT FOR ALL TIME. DO NOT LEAVE ANY
TIME FRAME BLANK. LIST EVERYTHING IN PROPER SEQUENCE. If you need additional space,
copy this blank page and attach as Page 6(a).
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
From (MM/YY)
To (MM/YY)
Number and Street
City
State/County
Zip Code
Employment History 8
C. Employment History
List all places of employment. Begin with most recent employer and go backwards. List periods of
school, military service, and unemployment in the past 10 years. Do not omit any employers. If you
need additional space, copy this page before completing, and attach copy as Page 8(a).
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State,
Zip
Phone
Describe your duties:
Reason for leaving:
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
Employment History 9
C. Employment History Continued
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
From (MM/YY)
To (MM/YY)
Job Title
Name of Employer
Supervisor
Ending Salary
Address of Employer
Street, City, State
Zip
Phone
Describe your duties:
Reason for leaving:
Employment History 10
C. Employment History Continued
1. Have you ever been terminated or asked to resign from any employment? Yes No
If yes, complete the following:
Employer’s Name: _________________________________________ Phone: __________________
Explanation:
2. Have you ever resigned from a job to avoid being fired or terminated? Yes No
If yes, name of employer: ________________________________________________________
Explanation:
3. Are you currently employed? Yes No
4. If your work performance has been evaluated in the past, what is the latest evaluation you received?
Exceptional
Above average
Average
Below average
Never been evaluated
5. Have you been tardy or late for work because of circumstances within your control?
Yes No
If yes, how often? _________________ Last time: __________________
Explanation:
6. During the past year, have you falsified sick time by calling in sick when you were not ill?
Yes No If yes, when? _________________________________________________________
Explanation:
7. Have you been unemployed anytime during the past three years? Yes No
If yes, when? ______________________________________________________________________
Explanation:
Employment History 11
C. Employment History Continued
8. Have you ever been written up, counseled, or disciplined in any manner, by any of your employers for
failure to comply with required rules or regulations, or for any other reason?
Yes No
If yes, explain:
9. Have you ever been suspended or served an “Intent to terminate” by any employer?
Yes No
If yes, explain:
10. Have you ever quit a job without giving notice required by an employer? Yes No
If yes, explain:
11. Would you be eligible to be rehired by all your former employers (assuming there was a job
available)? Yes No
If no, explain:
12. Did you ever work without reporting it (even on the side) while collecting unemployment benefits?
Yes No
If yes, explain:
13. Have you ever taken merchandise or goods that you were not authorized to take from a company
where you worked?
No, never
Yes, items with a total value of less that $25
Yes, items with a total value of between $26 to $99
Yes, items with a total value of between $100 to $499
Yes, items with a total value of $500 or more
14. Have you ever taken money that you were not authorized to take from a company where you have
worked? Yes No
If yes, how much? ________
How many times? ________
Last time: ______________
Explanation:
Employment History 12
C. Employment History Continued
15. Have you ever purposely taken anything from a fellow employee that you were not authorized to take?
Yes No
If yes, what? ________________________________________When?_______________________
Explanation:
16. Have you ever taken anything from a job site or crime scene that you were not authorized to take?
Yes No
If yes, what? ________________________________________When?_______________________
Explanation:
17. While employed, have you ever been involved with another employee or outside person in a scheme
to defraud your employer? Yes No
If yes, explain:
18. Has an employer ever accused you of being dishonest? Yes No
If yes, explain:
19. Have you ever been bonded? Yes No
20. If yes, was it canceled? Yes No
If yes, explain:
21. Did you ever sell or give confidential information you received through your employment to anyone
for financial gain or for any other reason? Yes No
If yes, explain:
22. Have you ever or are you now making payments to any employer or bonding company for
merchandise taken, stolen, or lost? Yes No
If yes, explain:
Personal References 13
D. References_
1. List at least five (5) references (not relatives or romantic partners) who are responsible adults and
who have known you well during the past five (5) years. You must provide complete address
including zip code, current telephone number, and email.
Name
Residence Address:
Relationship
City, State, Zip
How long acquainted?
Phone: (H) (C)
Occupation:
Email Address:
Name
Residence Address:
Relationship
City, State, Zip
How long acquainted?
Phone: (H) (C)
Occupation:
Email Address:
Name
Residence Address:
Relationship
City, State, Zip
How long acquainted?
Phone: (H) (C)
Occupation:
Email Address:
Name
Residence Address:
Relationship
City, State, Zip
How long acquainted?
Phone: (H) (C)
Occupation:
Email Address:
Name
Residence Address:
Relationship
City, State, Zip
How long acquainted?
Phone: (H) (C)
Occupation:
Email Address:
2. Are you acquainted with any employees of this department or any employees of the City of
Chandler? Yes No
If yes, list them: ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Arrest History 14
E. Education and Training
1. List all schools you have attended (high schools, trade schools, colleges, and universities).
List GED if it applies
From
MM/YY
To
MM/YY
Name and city/state
Credit
Hours
Graduate?
Yes No
Type of
Degree
2. List all professional societies, organizations, licenses (date and number), registrations (date), special
skills, knowledge, or abilities.
_____________________________________________________________________________________
_____________________________________________________________________________________
3. Do you speak, read, or write a language other than English? Yes No
If yes, what language? _________________ How well? _______________________
4. Have you ever received any law enforcement training? Yes No
Name of organization: _______________________________________________________________
Month and year you attended: _________________________________________________________
What type of training? _______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
F. Conviction Record
1. Have you ever been convicted (pled guilty or no contest) of any offense, domestic violence, or violation
of any statute, ordinance, law, or regulation by any civil or military authority, either in this country or
any other country? (Include detentions as a juvenile or minor by court adjudication of guilt. Include
all situations, even if expunged) Yes No
If yes, explain:
Arrest History 15
G. Arrest History
1. Have you ever been arrested (convicted or not) for any offense or violation of any statute, ordinance,
law, or regulation by any civil or military authority, either in this country or any other country?
(Include detentions as a juvenile or minor by court adjudication or guilt.)
Yes No
If yes, explain:
2. Explain all "yes" answers in detail in the space for additional information below (including any
incidents as a juvenile). Include any traffic stops.
a. Yes No Have you ever had any contact with a police officer?
b. Yes No Have you been warned for anything by a police :
c. Yes No Have you ever been detained by a police officer?
d. Yes No Have you ever been accused of a crime?
e. Yes No Have you ever been charged with a crime?
f. Yes No Have you ever been arrested (this includes criminal citations)?
g. Yes No Have you ever been convicted of any crime?
h. Yes No Have any of your relatives ever been convicted or imprisoned?
i. Yes No Have the police ever been called to your home for any reason?
If yes to any, explain:
Legal History 16
H. Legal History
1. Have you ever been questioned as a suspect in a crime? Yes No
If yes, explain:
2. Have you ever been connected with a criminal investigation of any kind? Yes No
If yes, explain:
3. How many times have you been arrested (held in police custody, cited and released, etc.) for any
reason? ______
4. How many times have you been convicted of, pled guilty to, or plead no contest to misdemeanor
charges? ______
5. How many times have you been convicted of, pled guilty to, or pled no contest to felony
charges?______
6. Have you ever had a warrant issued for your arrest? Yes No
If yes, explain:
7. Have you ever been on court-ordered probation? Yes No
If yes, explain:
8. Have you ever had to appear before a juvenile court for an act that would have been a crime if
committed as an adult? Yes No
If yes, explain:
9. Have you ever applied for a permit to carry a concealed weapon? Yes No
If yes, explain:
10. Have you ever stolen or taken without permission any property from a business or other people. (i.e.
shoplift or switched price tags)?
No, never
Yes, items with a total value of less than $25
Yes, items with a total value between $25 - $99
Yes, items with a total value between $100 - $499
Yes, items with a total value between $500 or more
11. When was the last time you stole or took, without permission, any property from a business or other
person? ___________ Age: ______
Explain:
Legal History 17
H. Legal History Continued
12. Did you ever buy anything that you suspected was stolen? Yes No
If yes, explain:
13. Did you ever sell anything that you knew was stolen? Yes No
If yes, explain:
14. Are you now in possession of any stolen property? (i e., on person, at residence, in car, etc.)
Yes No
If yes, explain:
15. Have you ever paid, or been paid, to participate in any sexual act? Yes No
If yes, explain:
16. Have you ever sought out or viewed child pornography, including via the Internet?
Yes No
If yes, explain:
17. In the next section mark ALL ANSWERS THAT APPLY to you, including incidents as a juvenile.
Be sure to mark at least one response for each offense. Even if you were in the military and the
offenses under the UCMJ, make sure you include these offenses.
If you have been questioned by police about one of these offenses or have been named in a police
report concerning one of these described offenses, mark the box for that offense(s) and any other box
that might apply for that offense.
a. ARSON – Intentionally setting a fire to destroy something or cause damage.
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
b. FORGERY – Signing another person’s name to a document without their permission.
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
Legal History 18
H. Legal History Continued
c. EMBEZZLEMENT – Theft of money or valuables entrusted to you.
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
d. RAPE OR ATTEMPTED RAPE – A forcible sex act other than child molest, including sexual
abuse.
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
e. SEXUAL CHILD ABUSE OR MOLEST
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
f. ASSAULT, RESISTING ARREST, HOMICIDE
I have been accused of it. Which crime(s)? ________________________
I have committed it. Which crime(s)? ________________________
I have been arrested for it. Which crime(s)? ________________________
I have been tried in court for it.
I have been convicted (or pled guilty or no contest).
I have been a victim.
None of the above.
g. BURGLARY, THEFT, BREAKING AND ENTERING
I have been accused of it. Which crime(s)? ________________________
I have committed it. Which crime(s)? ________________________
I have been arrested for it. Which crime(s)? ________________________
I have been tried in court for it.
I have been convicted (or pled guilty or no contest).
I have been a victim.
None of the above.
h. CRIMINAL DAMAGE (VANDALISM/GRAFFITI)
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
Legal History 19
H. Legal History Continued
i. ROBBERY (ARMED/STRONG ARMED)
I have been accused of it. Which crime(s)? ________________________
I have committed it. Which crime(s)? ________________________
I have been arrested for it. Which crime(s)? ________________________
I have been tried in court for it.
I have been convicted (or pled guilty or no contest).
I have been a victim.
None of the above.
j. CHILD ABUSE
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
k. CHILD NEGLECT
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
l. SEXUAL CRIMES – i. e. self-exposure, obscene phone calls, peeping tom, sex in a public place,
bestiality (sex with animals), etc.
I have been accused of it. Which crime(s)? ________________________
I have committed it. Which crime(s)? ________________________
I have been arrested for it. Which crime(s)? ________________________
I have been tried in court for it.
I have been convicted (or pled guilty or no contest).
I have been a victim.
None of the above.
m. DRIVING UNDER THE INFLUENCE OF ALCOHOL OR DRUGS
I have been accused of it.
I have committed it.
I have been arrested for it.
I have been tried in court for it.
I have been convicted
(or pled guilty or no contest).
I have been a victim.
None of the above.
18. Have you ever observed, been present, participated in, or concealed the commission of any crime?
Yes No
If yes, explain:
19. Have you had the police to your residence for any reason? Yes No
If yes, explain:
Legal History 20
H. Legal History Continued
20 Have you ever been the subject of a court order of protection or injunction prohibiting harassment?
Yes No
If yes, explain:
21. Have you ever been the subject of an investigation by child protective services (child welfare
agency)? Yes No
If yes, explain:
22. Have any of your relatives (including your spouse) or your spouse’s relatives, ever been convicted or
imprisoned for a crime? Yes No
If yes, please list name and relation: ___________________________________________________
Charge: _________________________________________________________________________
23. List all criminal actions in which you were a defendant. ALL INCIDENTS MUST BE
EXPLAINED IN GREAT DETAIL.
Date
Original Charge
Charge Reduced To
Court Disposition
Police Agency Concerned
If you answered yes to any of the questions above, describe in detail the situation and the end result.
Make a copy of the further explanations page attached at the back of this packet if needed.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature: _________________________________
Date:_________________________________
Driving History 21
I. Driving History
1. Have you ever had a driver’s license cancelled, refused, revoked or suspended? Yes No
If yes, explain in detail:
2. If yes, how many times did you drive while your license was suspended or revoked? ____
3. Have you ever attended a driver improvement school? Yes No
If yes, explain in detail:
4. Do you currently have an Arizona Driver’s License? Yes No
License #_____________________ Restrictions: _________________________________________
5. Do you have, or have you ever had, a driver’s license from another state or country?
Yes No If yes, where? ________________________________________________________
6. How many automobile accidents have you been involved in as a driver? _________
Date
PD
called?
Location
(City, State)
Citation
Yes/No
7. Have you ever been a driver or passenger in an accident where injuries or damage occurred and you
left the scene of the accident (hit and run)? Yes No
If yes, explain:
8. Have you ever falsified information on an accident report or given police false information during a
traffic stop or accident investigation? Yes No
If yes, explain:
9. Have you ever been involved in a “road rage” situation? Yes No
If yes, explain:
10. Have you ever had a warrant issued for your arrest for failure to pay a citation or failure to appear in
court? Yes No
If yes, explain:
Driving History – Alcohol and Drugs 22
I. Driving History Continued
11. Do you have any outstanding warrants for your arrest right now? Yes No
If yes, what state issued? ____________
If yes, explain:
12. Do you currently have automobile insurance as mandated by the state? Yes No
If no, explain why not:
13. Has your insurance ever been canceled? Yes No
If yes, explain:
14. Has your insurance ever been placed under a “high risk” status? Yes No
If yes, explain:
15. List every traffic citation and warning you have received within the last 10 years. List in
chronological order beginning with the most recent.
Date
Agency
Violation
Ticket or Warning
16. Have you ever been charged with driving under the influence of alcohol or drugs?
Yes No
If yes, explain:
J. Alcohol and Drugs
1. Do you drink alcohol? Yes No
2. How often during the week do you drink alcohol? ________________________________________
3. Have you ever had difficulty within your family due to your alcohol consumption?
Yes No
If yes, explain:
Alcohol and Drugs 23
J. Alcohol and Drugs Continued
4. Have you ever possessed, used, purchased, or sold marijuana? Yes No
If yes, explain:
5. What form was the marijuana? (joint, bong, edible with cannabis oil, etc.)
6. When estimating your total marijuana usage, remember that once a month for a year is 12 times, once
a week for a year is about 52 times, and almost every day for a year is about 365 times.
Never
1 to 5 times
6 to 10 times
11 to 20 times
21 to 25 times
26 to 50 times
51 to 100 times
More than 100 times
7. When was the last time you used marijuana? Date last used:_______________
Age at time of use: ___________
8. Since the age of 21, how many times have you used marijuana? _____
9. Are you currently using marijuana for any reason? Yes No If yes, explain:
__________________________________________________________________________________
10. Have you ever possessed, used, purchased or sold cocaine in any form? Yes No
If yes, explain:
11. How many times?
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times.
12. When was the last time you used cocaine in any form?
Date last used:____________ Age at time of use: ___________
13. Since the age of 21, how many times have you used cocaine in any form? _____
14. Are you currently using cocaine in any form? Yes No
15. Have you ever illegally possessed, used, purchased or sold prescription drugs (i.e., OxyContin
®
,
Fentanyl, Soma, morphine, etc.)? Yes No
If yes, explain:
16. How many times?
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times.
Alcohol and Drugs 24
J. Alcohol and Drugs Continued
17. When was the last time you used illegal prescription drugs in any form?
Date last used:____________ Age at time of use: ___________
18. Since the age of 21, how many times have you used illegal prescription drugs in any form?______
19. Are you currently using illegal prescription drugs in any form? Yes No
20. Have you ever possessed, used, purchased or sold any hallucinogens (i.e., LSD, mescaline, peyote,
acid, mushrooms, angel dust, PCP, etc.)? Yes No
If yes, explain:
21. How many times?
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times.
22. When was the last time you used hallucinogens in any form?
Date last used:____________ Age at time of use: ___________
23. Since the age of 21, how many times have you used hallucinogens in any form? _____
24. Are you currently using hallucinogens in any form? Yes No
25. Have you ever illegally possessed, used, purchased or sold opiates or dangerous drugs (i.e.
opium, morphine, heroin Ecstasy, GHB, etc.)? Yes No
If yes, explain:
26. How many times?
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times.
27. When was the last time you used opiates or dangerous drugs in any form?
Date last used:____________ Age at time of use: ___________
28. Since the age of 21, how many times have you used opiates or dangerous drugs in any
form?______
29. Are you currently using opiates or dangerous drugs in any form? Yes No
Alcohol and Drugs 25
J. Alcohol and Drugs Continued
30. Have you ever illegally possessed, used, purchased or sold amphetamines (i.e., meth, Dexedrine,
speed, crank, crystal meth, ice, glass, cross tops, etc.)? Yes No
If yes, explain:
31. How many times?
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times.
32. When was the last time you used amphetamines in any form?
Date last used:____________ Age at time of use: ___________
33. Since the age of 21, how many times have you used amphetamines in any form? ____
34. Have you ever illegally possessed, used, purchased or sold illegal steroids? Yes No
If yes, what kind:
Explain the type of cycle followed:
35. How many times?
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times.
36. When was the last time you used illegal steroids in any form?
Date last used:____________ Age at time of use: ___________
37. Since the age of 21, how many times have you used illegal steroids in any form? ______
38. Prior to 1994, how many times did you use illegal steroids in any form? ______
39. Since 1994, how many times have you used illegal steroids in any form? ______
40. Are you currently using illegal steroids in any form? Yes No
41. Have you ever used any other substance (legal or not), for the purpose of getting high? (salvia, spice,
whip its, paint, bath salts, etc) Yes No
If yes, explain:
42. Have you ever illegally possessed, used, purchased or sold depressants or tranquilizers such as
barbiturates, Valium, Quaaludes, etc.? Yes No
If yes, explain:
Alcohol and Drugs 26
J. Alcohol and Drugs Continued
43. How many times? (Use the same timetable as the above as guideline)
Never
1 to 5 times
6 to 10 times
11 to 15 times
16 to 20 times
More than 21 times
44. When was the last time you illegally used depressants or tranquilizers in any form?
Date last used:____________ Age at time of use: ___________
45. Since the age of 21, how many times have you illegally used depressants or tranquilizers? _______
46. Have you ever used another person’s prescription, or given your prescription to another?
Yes No
If yes, explain:
47. Have you ever illegally possessed or used any other controlled drug besides those already described?
Yes No
If yes, explain:
How often?
Last time:
48. How many times in your life have you driven a vehicle after using any illegal or controlled drug?
Never
1 to 2 times
3 to 4 times
5 times or more
49. When was the last time you provided any illegal or controlled drug to friends or others in exchange for
money or in trade for goods?
Never.
Most recent time: ________________
50. Have you ever grown, manufactured, or processed any controlled substance? Yes No
If yes, explain:
51. With the exception of marijuana, how many times have you used any illegal substance since the age
of 21? _________
52. Do you know of any relatives or close friends that are currently using illegal drugs?
Yes No
If yes, explain:
53. Are you aware that the employment environment within this agency is a DRUG-FREE
ENVIRONMENT, and any violation of that policy can lead to termination? Yes No
Organizational Membership - Military Experience 27
K. Organizational Membership
1. 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 shows 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 the State of
Arizona or which seeks to alter the form of Government of the United States or the State or Arizona
by any unlawful or unconstitutional means? Yes No
If yes, explain:
2. Have you ever been a member of any crime group or gang? Yes No
If yes, explain:
L. Military Experience
1. Have you ever registered with the Selective Service (the draft)?
No, although I was legally required to do so.
No, I was not required to do so (females).
Yes, in __________________________ (State)
IF YOU HAVE NO MILITARY EXPERIENCE, MARK THE “N/A” BOX AND GO TO THE
NEXT SECTION
N/A
2. Have you ever served in the Army, Navy, Marine Corps, Air Force, Coast Guard, R.O.T.C., or any
other military or para-military organization? Yes No
Branch of Service
Serial #
Date Entered
Date Separated
3. If yes, give type of separation:_____________________________
4. How long were you in the military, on active duty: _____ years ______ months
5. What type of discharge did you receive (check all that apply):
Honorable
Honorable with hardship reasons
General
Less than honorable
Retirement length of service ______
Still on full-time active duty
Still on reserve status
Other: ____________________
Military Experience 28
L. Military Experience Continued
6. Did you ever fail to complete any term of enlistment for any reason? Yes No
If yes, explain:
7. How many times did you receive any disciplinary action in the military such as Court Martial, Article
15, Captain’s Mast, Company Mast, Company punishment, reduction in rank, etc.?
Never
1
2
3 or more
8. If you were ever subject to any disciplinary action, explain whether it was a General, Special, or
Summary Court Martial, Captain’s Mast, Article 15, or other and the reason for the separation type:
9. While in the military, were you ever incarcerated (brig or guardhouse)? Yes No
If yes, explain:
___________________________________________________________________________
10. Were you ever UA, AWOL, missing from formation or ship movement? Yes No
If yes, explain:
11. Do you still possess any military equipment that you are not authorized to have? Yes No
If yes, explain in detail:
12. Are you currently a member of a U.S. Reserve or National Guard? Yes No
If yes, what unit? ____________________________________
Commander’s Name: _________________________________
Contact Number: _____________________________________
Financial Status 29
M. Financial Status
1. Are you currently able to pay all of your bills on time? Yes No
2. Have you ever been referred to a collection agency? Yes No
If yes, explain:
3. Do you presently have any debts in collections? Yes No
If yes, explain:
4. Have you ever had anything repossessed? Yes No
If yes, explain:
5. Are you purposely avoiding any creditors?
Yes No
If yes, explain:
6. Have you ever had your wages garnished regarding any of your financial obligations? Yes No
If yes, explain:
7. Have you had any issues, or do you currently have any unresolved issues with the Internal Revenue
Service or any revenue department in any state? Yes No
If yes, explain:
8. Have you ever made false or exaggerated claims on insurance policies? Yes No
If yes, explain:
9. Have you ever had a bad credit rating? No
If yes, explain:
10. Have you ever filed for bankruptcy? Yes No
If yes, when? __________ Court: __________________ Chapter 7 11 13 (circle one)
Explain:
Financial Status 30
M. Financial Status Continued
11. Did you ever write a check with the intentions of cheating someone, or cash a check you knew was
bad? Yes No
If yes, explain:
12. How many times in the past year have you had a check returned for insufficient funds? ___________
13. Has a landlord ever served you with an eviction notice? Yes No
If yes, explain:
14. Have you ever been sued in court for anything? Yes No
If yes, give date, court, and disposition:
15. List ALL present outstanding loans, mortgages, credit card debt, etc. (including bills in collections)
Company
Type of loan/debt
Monthly Payment
Debt balance
17. Are you a co-signer of someone’s outstanding loan? Yes No
If yes, explain:
18. If employed, do you anticipate income other than salary? Yes No
If yes, explain:
19. Can you keep up with your present financial obligations on what you will earn here?
Yes No
If no, explain:
20. Do you gamble? Yes No
21. Do you owe any gambling debts? Yes No
If yes, explain:
Law Enforcement Experience 31
N. Social Networking
1. Have you ever been a member of a social networking site of any kind? This includes hosting, posting,
or visiting any network under your real name, assumed name or moniker used in connection with the
site. Yes No
2. List the social network and your user name(s) for each
Name of social network:
User name:
3. List all email addresses you have ever used.
4. Have you ever posted any comments or pictures on a social networking site, whether yours or another
person’s, that may contain material considered inappropriate based on race, color, sex, religion,
national origin, age or disability? Yes No
If yes, explain:
5. Have you ever posted any comments, sexually explicit pictures, or pictures of conduct that may be
considered publicly embarrassing on a social networking site, whether yours or another person’s?
Yes No If yes, explain:
6. Have you ever posted or viewed pictures or images of juveniles engaged in any activity that is
unlawful? Yes No
If yes, explain:
7. Did you clean your site in preparation for this interview or job search, and if so, what material was
removed and why? Yes No
If yes, explain:
Law Enforcement Experience 32
O. Law Enforcement Experience
IF YOU HAVE NEVER SERVED IN ANY CAPACITY WITHIN A LAW ENFORCEMENT ENTITY,
MARK THE “N/A” BOX AND GO TO THE NEXT SECTION.
N/A
1. Indicate whether you have any of the following law enforcement experience: (answer each question)
a. Sworn/commissioned weapon carrying officer Yes No
b. Police reserve Yes No
c. Military police officer Yes No
d. Corrections/detention Yes No
e. Civilian job title: ______________________________
2. Number of years experience as a sworn police officer: ____
3. How many law enforcement agencies have you worked for as a sworn police officer? ____
4. How many law enforcement agencies have you worked for as a civilian? ____
5. How many citizen complaints have been filed against you? _____
If any, explain:
6. How many of these complaints were sustained or found to be true? _____
If any, explain:
7. How many reprimands (written or oral) have you received? ____
Explain and list dates:
8. How many times have you been suspended, demoted, or dismissed? ______
Explain and list dates:
9. Were you ever the subject of a civil or criminal prosecution (lawsuit)? Yes No
If yes, explain:
10. Other than while on training status, have you ever had any unsatisfactory personnel ratings?
Yes No
If yes, explain:
Law Enforcement Experience 33
O. Law Enforcement Experience Continued
11. As a sworn officer, have you ever violated any controlled substance (illegal narcotic) laws?
Yes No
If yes, explain:
12. Have you ever used illegal drugs while on duty? Yes No
If yes, explain:
13. Have you ever used illegal drugs while employed with a law enforcement agency?
Yes No
If yes, explain:
14. Have you ever consumed alcohol while on duty? Yes No
If yes, explain:
15. Have you ever lied or distorted the facts in a police report? Yes No
If yes, explain:
16. Did you ever cover up a violation for a fellow officer or fellow employee? Yes No
If yes, explain:
17. Did you ever lie or commit perjury in court testimony or any official proceeding, including an internal
affairs investigation? Yes No
If yes, explain:
18. Have you ever been terminated or forced to resign from a law enforcement position during the
probation period? Yes No
If yes, explain:
19. Have you ever been terminated or forced to resign from a law enforcement position after the
probation period? Yes No
If yes, explain:
20. Have you ever been involved, in any manner, with an Internal Affairs investigation?
Yes No
If yes, explain:
Law Enforcement Experience 34
O. Law Enforcement Experience Continued
21. Have you ever falsified information regarding damage to departmental equipment/vehicles?
Yes No
If yes, explain:
22. Have you ever failed to report damage to departmental equipment/vehicles you were responsible for?
Yes No
If yes, explain:
23. Have you ever used “excessive force” or more force than was necessary to affect an arrest?
Yes No
If yes, explain:
24. How many on-duty traffic collisions have you been involved in? ____
In how many of those were you either cited and/or deemed out of policy? ___
25. While on duty or on work premises, have you engaged in any type of sexual activity? Yes No
If yes, explain:
26. Did you ever accept a gratuity in violation of your department’s policy? Yes No
If yes, explain:
27. Have you ever converted items of evidence or property to your personal use in violation of your
department’s policy? Yes No
If yes, explain:
28. Do you know of any crimes committed by other officers that have not been discovered?
Yes No
If yes, explain:
Prior Applications 35
P. Prior Applications
Please list the names of any law enforcement agencies where you have applied for any position within the
last five (5) years.
Name of Agency:
City/State:
Position:
MM/YY applied:
Status:
Name of Agency:
City/State:
Position:
MM/YY applied:
Status:
Name of Agency:
City/State:
Position:
MM/YY applied:
Status:
Name of Agency:
City/State:
Position:
MM/YY applied:
Status:
Name of Agency:
City/State:
Position:
MM/YY applied:
Status:
General Questions 36
Q. General Questions
1. Do you enjoy inflicting pain on humans or animals? Yes No
If yes, explain:
2. Did you ever offer anyone a bribe? Yes No
If yes, explain:
3. Did you give any answers on this background questionnaire that you know are false?
Yes No
If yes, explain:
4. Are you concealing any information, which would prevent you from being employed by this
department? Yes No
If yes, explain:
5. Have you made application to this department at the request of any subversive organizations?
Yes No
If yes, explain:
6. Have you had any other involvement in illegal activities or committed any crimes that have yet to be
disclosed? Yes No
If yes, explain:
Summary Statement 37
R. Summary Statement
1. Do you have any knowledge or information, in addition to that specifically called for in the preceding
questions, which is or which may be relevant, directly or indirectly, in connection with an
investigation or your eligibility or fitness for the position for which you are applying? This includes,
but is not limited to, knowledge or information concerning your character, physical and mental
condition, temperance, habits, employment, education, subversive activities, family, association,
criminal record, traffic violation, residency, or otherwise.
Yes No
If yes, explain:
Certification/Disclosure 38
DISCLOSURE OF INTENTION TO OBTAIN A CREDIT REPORT
In accordance with the Fair Credit Reporting Act, § 604(b)(2)(A), the Chandler Police Department
may obtain a credit report on all individuals who apply for new employment or promotions.
Signature of Applicant: _____________________________________ Date: _______________
POLICE OFFICER AND DETENTION OFFICER
APPLICANTS ONLY
If, during the course of your duties as a police officer (detention officer), a situation arose whereby you were
faced with the lawful and necessary taking if a human life, would you be able to do so?
Yes ______ No ______ If No, explain: ________________________________
____________________________________________________________________
____________________________________________________________________
CERTIFICATION
I hereby certify, under penalty of A.R.S. 13-2701 and 39-161, that the entries on this questionnaire are true,
complete, and correct to the best of my knowledge and belief. These entries are made in good faith. I understand
that knowingly and willfully making a false statement on this form constitutes a violation of the law and is cause
to initiate action to suspend or revoke certified peace officer status.
Signature________________________ Date _____________________________
Required Docs 39
S. Required documents
Initial each Box
Make copies of all the documents listed below and attach them to the back of this
packet
You will later need to bring originals of all documents if you are invited to a
background interview
1. Birth certificate
2. Driver license
3. Social security card
4. High school diploma or GED
5. Proof of citizenship if a naturalized citizen
6. Marriage certificate(s) or divorce decree(s), if applicable
7. Military Service Record Form DD214 (Must be Copy 4), if applicable
8. College diploma(s), if applicable
9. Bankruptcy papers, if applicable
IF you cannot locate a required document, list on the further explanations page what
first step you have taken to reacquire that document.
I certify that the above entries are true, complete, and correct to the best of my knowledge and belief and
are made in good faith. I understand that knowingly and willfully making a false statement on this form
constitutes cause to revoke, refuse, or suspend employment with the City of Chandler.
Signature of Applicant: _____________________________________ Date: _______________
Revised 1/29/2019
T. Further Explanations
Make additional copies of this page as necessary to completely answer each question.
Page #
Question #
Explanation
