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  • App 07

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    yu

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    41 vues17 pages

    App 07

    Transféré par

    Meghan Puryear
    yu

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PDF ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 17
    REGION XI SELECTION CENTER Personal History Questionnaire LE C] co WILLFULLY OR KNOWINGLY FALSIFYING THIS APPLICATION WILL RESULT IN. DISQUALIFICATION FROM THE SELECTION CENTER PROCESS OR IF DISCOVERED DURING OR AFTER TESTING CANMWILL RESULT IN TERMINATION OF THE ‘SELECTION CENTER PROCESS. Photo - Must have been rio more than sik ‘months prior fo submitting this application Note: This application must be printed ~ not typed — using a ballpoint pen by the applicant Make en Omar Mic Sdigus LAST NAME FIRST NAME MIDDLE NAME ‘ALIAS (S), Maiden Name, Nickname, or other changes in name, Include offic HAO NW Doves CT ‘STREET ADDRESS APARTMENT NUMBER document(s) MAILING ADDRESS IF DIFFERENT THAN STREET ADDRESS Pork SLlucs USA Pu Bus CITY COUNTY STATE ZIP CODE CATO UBL -9AZLS Ogorw2es HOME PHONE/CELL PHONE SOCIAL SECURITY NUMBER ONvatyal se@ Yuhoo com WAG-8G New Mork EMAIL DATE OF BIRTH PLACE OF BIRTH ETHNIC ORIGIN: White Asian or Pacific Islander CHispanic Black, non-Hispanic UAmerican Indian or Alaskan Native COther CITIZENSHIP: U.S. CITIZEN afES NO Naturalized Certificate No. de Country of Origin 1 Date, Place and Court mg HeicHT: 5'\O_weicHt: S__cororor eves: Slack coLor or Hair: _ “Black SCARS, TATTOOS, ANDIOR DISTINGUISHING MARKS: MARITAL STATUS: ingle Married Engaged Separated Divorced If married, are you living with your spouse? Yes 0No( If not, state reasons, Updated 9727105, Name of Fiancée or Gitl/Boy Friena Employer's Name Name Address. Telephone # Date of Birth and Address Wha Via vila nia hig Information concerning marriages: (List all marriages) Where 7 Date Performed (City | Spouse's Complete Name (include Married & State Maiden Name) DOB Soc. Sec # We Ala WIA lA nls | nig \a WA IA lA ws wle MA ywiA WL Name and Address of Spouse(s) if divorced or separated. (ATTACH COPI IES OF DIVORCE) Name Address State) Date of order or decree where Issued (Court & Phone Number &SS# “LA Wa nv A WA wlA wl nlf F List all your children, natural or adopted, to include step children, and give the following information: | Name. DOB. POB. Address | Living With | Supported'by WA wk | NiA Nik WIA WA A\R [wie | NIA NiA NLA ALTA wih [Nia | Nik | NTA NiA ALLA NA Evia | ty Nige wi | WA OTHER DEPENDENTS: If you claim income tax exempti spouse and childs provide the following information: Are you now supporting all natural, adopted and stepchildren Yes 1) No 0 If not, give details: 1s for support of dependents other than your Name Address | etationship | prove [wil NIA UTA WIA LNA Mi MIA Updated 9127105 FAMILY: a close relationship existed or exists List in the order given, al family members even though deceased. Include any others you have resided with or with whom Relationship Name, Present Address Phone. Birthday Occupation ner ISeddique [YIONW Dover CH foraceres | 121215 | Chncaiccd Mvior MOAT | ale [S4 | Cosmotolayish Sedboevy, S90 Fe" [elisiss | student Marian ae 22139 Mary 4 Le jintgo — RESIDENCES: List all residences, beginning with your present address. List the name, address and hone number of present and prior landlords, if applicable. To: Cugeat Own Rent 0 Port sh Luci? Se HeiR ‘Own/Rent Your Address, Include Street, City, | Landlord's Name, Street Address, City, County, State & Zip Code Gounty, State & Zip Code From: 2. co YOQONW Dares cr nA From: +003 God NS Stor BO UN To: 235 2 ae PU BASSI j_Own & Rent 0 Pork Sew t Fro Fa No aaa pe epgentea To: Own Rent Bin” Rent 0 os From: 1352 \ase ote Sine Rent _| We* Skt EO From: | | | \ From: To: Own _Rent 0 From: To: Own O Renta Updated 9127105, Rent Rent o From: To: Own 0_Rent 5. From: To: Own Rent) From: To: Own Rent From: To: Own Rent 3 From: To: OwnO Rent o List Neighbors Dates Name, Street Address; City, State & Zip Code Telephone No. Present Neighbor Bowe Cee cM NW ASHI Wom, Pork ok Cocrt Ce 34927 Qiavys14-eom | ANeighbor within 4-3 years ago Me Anne Coa SR ow al Lr BC Sse Or 5-05t] | A Neighbor within 4.8 years ago John Upde Grast ar he Greater uN Paik SH uci! FL MN brds7e-ous ANeighbor within 7-40 years ago orig Lynch, Mie Te Greatly, OL Faasin Bands FL 62D 61-4736 Updated 9127105, EDUCATION: List all elementary, junior high, and high schools attended: (Attach copies of high school, GED Diploma & Scores) NOTE: IF HOME SCHOOLED YOU MUST HAVE GED SCORES. Dates Attended radustoa:] Full Name. Complete Address Years } _ conpiees_| Yes_|_No Maries Cora, Sao Fa A Adath Vecchione Genet Abn sey yn ey Sak PL 7 v Mern Comm | LBO1S Kannel Woy 4 Wrgk Grr | sivek LL | Z seas More [S95 Georgy al Y Scheoe\ gimee BO saa rose! I Soate mee LY© SE Mourns d [Midde et | oy Shue BVAEV HIGHER EDUCATION: List information below for all colleges or universities attended: (Attach copies of transcripts and/or diploma) (YOU ARE RESPONSIBLE FOR HAVING TRANSCRIPTS SENT TO IRCG’S ADMISSIONS OFFICE) Name and Location of College or University Credit Hours | _& Yearit was Received Degree Received College (TRE) Tadian Riser Coemunt AS cae ousnice Other schools or training (trade, vocational, business, specialized, or military): Give the name, location, dates attended, subjects studied, certificate, and any other pertinent data. (Attach copies of certificates) Dates Name of School and Location (Complete Addresses) ‘Courses Studied iA LA Wk FOREIGN LANGUAGE: Do you speak, read, write or understand any ie information below. y foreign languages? Yes Noo Reading [Speaking Understan’ ding oot | rar | exe, | Good | Fate YAW EDUCATION CONTINUED: P,ease answer the following questions. If you answer “yes”, provide details at the bottom of this page. Yes [NO- 7 Were you ever suspended or expelled from an education facility? | Were you ever subject to disciplinary action while in school? 7 2 3 Were you ever held back a school year? a "| Did you ever receive any awards or honors in school? (attach copies) _ Have you had any specialized training or courses? (attach copies) Do you have any special skilis? 7 | Are you currently enrolled in school? 5 6 7 Can you operate any special equipment? @ 9 7 Can you type? (if yes, how many words por minute?) 70 [ Do you have any computer experience? VW Words per WAC Updated 9/27/05 MILITARY - (Attach your DD214 with separation codes) Have you ever gered in a military or Naval organization of the United States? Yes No 2. Branch of Service Company Ship 3. Highest Rank Held 4, How many periods of active military service have you had? 5. List all medals and decorations awarded to you as a member of the armed forces. 6. Type of discharge? Honorable (i General () Medical Honorable Conditions 1) Other 0 Dishonorable 0 7. Give date and location of entrance to active duty. @k no Military Service, give reason: \Naski) to slay close Senily 9. Give period or periods of active military service: From: TO: From: From: TO: From: 10. Are you now or were you ever on active or inactive duty of any branch of the United States Reserve Forces Yes] No State which: Active 0 Inactive 0 41. Are you now or were you ever a member of the Nation Guard Yes = No 1 State Regiment Unit Rank From: To: Type of Discharge 12. What is your present draft classification Date of classification: Selective Service Number Draft Board number and location 13. Were you ever court-martialed, tried on charges, or were you the subject of a summary court, deck court, captain’s mast or company punishment, or any other disciplinary action while a member of the Armed forces. Yes No UI If Yes please explain. 14.List any disciplinary action taken against you in the Nation Guard or other reserve unit: 15. List any other information pertaining to military not requested above: Updated 2727105 AFFIDAVIT NO MILITARY SERVICE state of _Flaridex County of SA. Lvete ih Ona Nick GaN , do hereby swear (or affirm) that | have never served in any branch of the Armed Forces of the United States of America. © eliy[oy Signature Date aa 2OG7? H Sworn to (or affirmed) before me this [4 day of one by MS Mak, ; who is personally known to me or has produced _f- Locida, \Dr were License as identification. (Type of identification) “KENNETH MACDOUGALL Notary Pubic» Stato of ida Comission Expres Sop 25,2010 } ‘Commission # 00 598535) q| “MiREA Bonded By National Notary Assn Yrennellr etl (Name of Notary typed, printed or stamped) (SEAL ABOVE) j€ - State of Florida Updated 912705 EMPLOYMENT: 1. Were you ever discharged, terminated, fired or forced to resign because of misconduct or unsatisfactory service (except military) Yes ENo (1 If yes, explain, giving name and address of employer, approximate date, and reasons in each case on a separate paper. 2. Have your employers always treated you fairly: Yes & No 10 If no, please explain: 3. Do you object to wearing a uniform? Yes CN 4. Do you object to working nights? Yes 0 Nor 5. Have you experience with shift work? Yes‘ No 0 6. Have you ever received unemployment insurance or other federal, state, local benefits or assistance? Yes D No Type of Assistance Local Office. Address For How Long? Type of Assistance Local Office, Address For How Long? Type of Assistance Local Office, Address For How Long? 7. List all jobs, positions, and employers you EVER had to include part-time, temporary, seasonal and voluntary jobs, placing your present or most recent job FIRST. Include military service in proper sequence and also all periods of unemployment and if you were self-employed, provide copies of tax returns. If additional space is required please attach additional sheets. _ FROMDATE | NAME OF EMPLOYER PARTTIME FULL-TIME | JOB THLE 7 loloe Megha Correchonal Ta o Cormtion’ Aus TO DATE ‘STREET ADDRESS x DESCRIPTION OF DUTIES | TELEPHONE NUMBER 6. 3 SW Mr Bp _—_ | Famnke cones = Useless _| i(5e_ Su Allagatids RO [Some Go cn 109 597-3 4 SALARY BEGIN | CITY, STATE, ZIP CODE G21 Sivek \ndurwr .F NAME OF SUPERVISOR FAX NUMBER SALARY END, | REASON FORLEAVING wry Pamisve\ FROM DATE — | NAME OF EMPLOYER ~] PART-TIME FULL-TIME JOB TITLE oe ONG o Seles aysececkee TO DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER ttfob BelGNW Federel hwy Closmg stock 1 1DU42~1sBEe ‘SALARY BEGIN | CITY, STATE, ZIP CODE Tyneleins Cus Yona" S [NAME OF SUPERVISOR | UHSECN | Sansan Beech £L Merapcot SALARY END | REASON FOR LEAVING FAX NUMBER eats Aco _ J FROMDATE | NAME OF EMPLOYER PARTTIME FULL-TIME | JOB TITLE yates \ol\iskar Qo Sales asserick(, TO DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER ora FB NW Fedecad they \natans cusees lQryCe-ne ‘SALARY BEGIN | CITY, STATE, ZIP CODE Folds dems | NAME OF SUPERVISOR | GAS doason Cela Qasr |S Von [EERE [MANERA ca ux shots PNB Updated 9127/05, 9 FROM DATE | NAME OF EMPLUYER PARY-TIME FULL-TIME JOB TITLE 2 a Ules Nicrrdyon W2Ad Cohn To DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER | Slos VHVS US Vidor Gee Case] Avy ap Castor, NI TYNAN = ISG ‘SALARY BEGIN | CITY, STATE, ZIP CODE Wledfing Fac | NAME OF SUPERVISOR Ae Pork Proree hoary Ay cole SALARY END | REASON FOR LEAVING. “(ace FAX NUMBER [ FROM DATE | NAME OF EMPLOYER PAREATIME FULL-TIME JOB TITLE OU bs Weloerory a Coohi’ TO DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER oul ust Tay oe Cursor] 070) §15- 0453 ‘SALARY BEGIN | CITY, STATE, ZIP CODE 4 NAME OF SUPERVISOR ants Qo SeQuew Lo | WloKsy Prems Meso SALARY END | REASON FOR LEAVING FAX NUMBER FROM DATE | NAME OF EMPLOYER PART, TIME FULL-TIME JOB TITLE o§ jot Chic fils a Cashes |coolk TO DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER | Aes 327 3 NW Colnvel Hoy coriews (07D 2-232. SALARY BEGIN | CITY, STATE, ZIP CODE, agiy Up CujContv' | NAME OF SUPERVISOR 1.80 Vingua Bevel FC NeXber Beer = SALARYEND | REASONFORLEAVING 37) [uallege FAX NUMBER | FROM DATE | NAME OF EMPLOYER PART-TIME FULL-TIME JOBTITLE Oslo Golds Gan 0 0 Dlooe Witdror TO DATE STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER \\oS, L80 NW Paacock Bl) Mery Sure gave SALARY BEGIN | CITY, STATE, ZIP CODE equien ah wey NAME OF SUPERVISOR E88 150 | Pork Seok Lever’ Le lseakecest ACen) [SALARKEND [REASON FORLEAVING ea FAX NUMBER "FROM DATE — | NAME OF EMPLOYER “PART-TIME FULL-TIME JOB TITLE og a TO DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER ‘SALARY BEGIN | CITY, STATE, ZIP CODE NAME OF SUPERVISOR /SALARYEND | REASON FOR LEAVING _ FAXNUMBER FROMDATE | NAME OF EMPLOYER "| PART-TIME FULL-TIME JOB TITLE a D | TO DATE ‘STREET ADDRESS DESCRIPTION OF DUTIES | TELEPHONE NUMBER) ‘SALARY BEGIN | CITY, STATE, ZIP CODE NAME OF SUPERVISOR ‘SALARY END | REASON FOR LEAVING | FAX NUMBER | Uptisted 9/27/05, 10 VEHICLE OPERATOR'S LICENSE: the purpose of the following questions is to determine general driving ability. Ifyou answer "Yes" to any of the below questions, give details at the end of this section, ves | No 4. Have you ever been refused a driver's license by any State? 2. Has your driver's license ever been revoked or suspended? 4 3. Was your driver's license ever restored? [7 4.__| Have you ever received a trafic citation? | 5.__| Have you ever been involved in a motor vehicle accident? Y Have you ever had any accident while operating an emergency vehicle? 7. ___| Do you have any traffic citations, which you failed to pay? NIN 8.__| Do you have any parking tickets you failed to pay? ir i 9. | Have you ever had automobile insurance withdrawn or revoked, or have you ever been refused automobile insurance? 10. | Have you ever been charged with driving a motor vehicle while under the influence of alcoholic beverages, chemical substances, or controlled substances? | 11. | Have you ever refused to submit to a breath, blood, or urine test to determine the Have you ever been licensed to drive in another state? Yes 0 No @—~ If “Yes” please give state and Driver's License Numbers. State: Driver's License Number (You must submit a copy of your driving record from the other state) influence of alcoholic beverages, chemical substances, or controlled substances: INN If "yes" to any accident question, give details for each accident whether collision, non- collision or hit and run. | Location: ‘Cause of Accident (for example ran red ~~) Who was charged with accident and light, careless driving etc.) . Investigation Yes 0 | court disposition? We deisek of Awe ihide Ws nol — dre er we war ia XWP ParKimg tok Whi? € arse * we Injury O The persen paling Or Non-injury 57 o [ Date: Location: Cause of Accident (for example ran red Police ‘Who was charged with accident and light, careless driving etc.) Investigation Yes U | court disposition? Noo Injury 0 Non-injury 3 | Updated 9127105 a List all traffic citations you have received: (include parking tickets) Location (Street, City, & State) ‘Approximate | Date Nature of Violation Penalty or Disposition AL vl WwliA 4 \ \ | | \ T List all vehicles that you currently own or operate: YEAR MAKE MODEL COLOR TAG NUMBER: OWN [at_| menda Reta Fel TOT 1 Do you presently have automobile Liability insurance Yes won List the following informatio NAME OF POLICY NAME OF ADDRESS and DATES OF | company | NUMBER AGENT PHONE NUMBER COVERAGE p S08 364 | Sys HEQBACH [M1508 394 | Shy ele, ; _ From; 2664 ENC. \ 1192) 210-3349 To: Cucrent From: L To: If No, Give details: If you have been insured by the above company (ies) for less than three years, list the revious insurance company: NAME OF POLICY NAME OF ADDRESS and TYPE OF company | NUMBER | AGENT PHONE NUMBER COVERAGE & DATES mi From: nih | | | to \ t vem To: Updated 9127105, 12 ARREST, DETENTION, AND LITIGATION: INCLUDE TRAFFIC ARREST Ifyou answer "yes" to any of the below questions, you must submit Arrest reports and/or details. Lyes | No] 1. Have you ever been arrested or charged or received a notice or summons to appear for any criminal violation or detained by ANY law enforcement agency? (Provide court S copies for any arrest and arrest where records were expunged including juvenile records.) 2. Have you ever been advised of your Miranda rights? I 3. Have you ever been the subject of a criminal police investigation? 7 “4. Have you ever been convicted of a crime? 5. Have you ever been required to pay a fine? (other than traffic) AK 6. Have you ever been reported as a missing person? y pe 9 P ww 7. Have you ever been fingerprinted by a law enforcement agency for criminal reasons? | 8, Have you ever been questioned as a suspect for any crime? N Have you ever had any records sealed or expunged? 0. Have you ever been placed on probation? ASIA IC | Pr Have you ever committed a criminal offense, However never been Caught? 12. Has any members of your immediate family ever been arrested for or convicted of a criminal offense? 13. Have you or any members of your immediate family ever been a victim of a crime? 14. Do you know of anyone who is an enemy or who might try fo harm you in any way? 15. Have you ever had to call the police to your home? GIG 16. Has a neighbor ever had to call the police on you or one of your family members? Ifany of the above questions resulted in a court case please provide copies of the court case disposition. CIVIL, ya 4. Have you or your spouses ever sued anyone (civil court plaintiff}? Yes (1 No 2. Have you or your spouses ever been sued by anyone (civil court defendant)? Yes (1 No & POLYGRAPH EXAMINATION 1, Have you ever had a polygraph examination? Yes (1 No (If "yes" please submit detail below. Date Examiner's Name Location Purpose NOTE Criminal records ordered sealed under Section 943.058, Florida Statutes, are available from the FCIC System for inspection by a criminal justice agency for purposes of criminal justice employment. The applicant is to be advised that applicant may not lawfully deny arrests or convictions, notwithstanding adjudication being withheld or the sealing or expunged of arresticonviction records. The applicant is being advised that a misdemeanor arrest or conviction may not necessarily disqualify applicant. Updated 9127105 13 FINANCIAL INFORMATION: (ATTACH CREDIT REPORT) Name of Bank City & State a. Savings Account b. Checking Account Wishiates Nek. Pork shlace CO Ic. Investments (stocks and Bonds, etc) Wa @_ Home Mortgage Invested Amount, nls Monthly payment , Other Real Estate ~marcate pe or realestate} a TA ¥. Automobile Payments an Vehicle #1 { Make. Year Tag # 1 WL Invested Amt. \onthiy Payment Vehicle #2 | Make Year Tag # Invested Mat Nonthiy Payment | @. List Name & Address of Firms from ‘Type of Date Original | Amount which you have or have had charge Business | Closed Amount Owed Purpose accounts or borrowed money Owed wl | If you answer "yes" to any of the below listed questions, please give Yes [No Details details. 1. Have you ever been refused credit? ._ Have you ever been refused a surety bond? _Do you have any investments (stocks, bonds, ete.)? Do you own a home? Do you own an automobile? Do you have any overdue bills? WAEINVSN lo for fm feo In Have you ever been a party to any civil action (lawsuit)? Have you ever had any accounts placed in the hands of a collection agency? 9, Have you ever filed for bankruptcy? : | \ 10. Do you pay child support? ‘1, Have your creditors treated you fairy? YL | Updated 927105 4 MEDICAL a. Are you presently under doctor's care? Doctor's Name & Address b. Are you taking a prescribed medicine? Prescriptions Wo c. Past and Present Personal Health History (check if applicable) __ Diseases of the heart and arteries ___ Diabetes __ High Blood Pressure ___ Anemia ___ Angina Pectoris (chest Pain) Epilepsy ___ Other lung Disease ___ Asthma ___ Orthopedic or muscular problems ___ Stroke ___ Abnormal Chest x-ray ___ Cancer __ Tried to Commit Suicide __ Smoker DRUG USAGE in order to detect illegal drug use, a drug test is conducted on all applicants. _If you answer "Yes" to any of the following questions put the date of use in the yes column and qive details below. Have you ever experimented, used, sold, transported, delivered, or possessed any of the following substances. If prescribed by a physician for a period exceeding 30 days, check "Yes" and explain. PUT DATE(S) IN THE BOXES a T Circle the exact drug you experimented, No | Yes used, sold, transported, delivered or possessed | (Reminder - honesty is the best policy) Used Sold Transported Delivered Possessed HALLUCINOGENIC DRUG - LSD, PCP, Ecstasy, Hallucinogenic Mushrooms, reer (Gannabis (marijuana)) phencyclidine, ete STIMULANTS - Amphétamines, Methamphetamines, crank, phentermine, cocaine, crack etc. S \ NARCOTICS, heroin, morphine, oxycodone, hydrocodone, hydromorphone, opiates, codéines, etc. Depressants/Tranquilizers, Barbiturates, Valium, librium, Quaalude, rohypnol, | benzodiazephines, etc. Steroids. Misused a prescription drug I | Obtained a prescription drug through fraud i | On prescribed drug for over 30 days | | List any drug that is not above Explanation if your answer is Yes Updated 9127105, 15 PERSONAL DATA Are you acquainted with any members of the Region X! law enforcementicorrectional agencies or Region XVI Correctional Agencies? (Region XI consist of law enforcementicorrectional agencies in Indian River, Okeechobee, St. Lucie and Martin Counties and Region XVI are all State Correctional Agencies in the four county area) Yes 0 No If so, list who and what agency: Name of Officer Agency's Name, Past and/or present membership in organizations: Type office/ Date Name Address Phone # position held To From MA ASSESSMENT INFORMATION A. Have yout previously submitted an application for employment with any Law Enforcement/Corrections agency? Yes 1 No C1_if yes, please fill in the following information. Approx. Name of Agency Position | bate VWrrsey | Dept af Conectians

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