Police Applicant

Pre-Polygraph

INTEGRITY

Questionnaire
Information contained in this booklet is to be reviewed only by
authorized personnel.

Applicants Name:_____________________________ Date:__________________

Applicants Address:____________________________ DOB:__________________

Have you taken a polygraph examination before? Yes No

If yes, answer the following:

When was it taken?

Where was it taken?

For what department?

Who was the examiner?

Note: Failure to accurately and truthfully complete this questionnaire in it’s entirety will
be cause to disqualify the applicant from further consideration for employment.

Revised 10/02
 EMPLOYMENT STATUS

1. How many jobs have you had?

Past year?_________ Past two years?_________ Past five years?________

2. Have you ever been fired from a job? Yes No

Explain:

3. Have you ever been asked to resign from a job? Yes No

Explain:

4. Have you ever quit a job to avoid being fired for any reason? Yes No
Explain:

ARMED FORCES

1. Have you ever served in the Armed Forces? Yes No

If yes, please answer A through H.

A. Branch of Service: __________________________

Dates of Service (month and year): From ___________ To ____________

Type of Discharge: ______________________

Rank when discharged: ___________________

Reason for discharge:_______________________________________________

_______________________________________________

B. Have you ever been AWOL? Yes No

Remarks:

C. Were you ever given a judicial punishment? Yes No

Remarks:

D. Were you ever confined to the brig, guardhouse or stockade? Yes No

Remarks:

Integrity Questionnaire Revised 10/02 2

 E. Were you ever reduced in rank? Yes No
Remarks:

F. Were you ever given a court martial or had any type of disciplinary
action taken against you? Yes No
Remarks:

G. Did you ever sell anything on the black market? Yes No

Remarks:

H. Did you ever convert any government property to your own

use or sell any property? Yes No
Remarks:

2. Are you currently a Maine Resident? Yes No

If yes, how long:

CREDIT INFORMATION

1. Do you have a house, mortgage or rent? Yes No

Payment per month?_______________

2. Do you owe any school loans? Yes No

If yes, please explain:

3. Do you have any doctor or hospital bills? Yes No

If yes, please explain:

4. Have you ever declared bankruptcy? Yes No

If yes, please explain:

5. Have you ever had anything repossessed? Yes No

If yes, please explain:

Integrity Questionnaire Revised 10/02 3

 6. Have you ever had unsatisfactory credit? Yes No
If yes, please explain:

7. Do you have any accounts past 30 days due? Yes No

If yes, please explain:

DRIVING RECORD

1. Type of license:___________________________ State:_______________

Restriction Code: _________________ License Number:__________________

Address on License: ________________________________________________

2. Do you hold any other state licenses? Yes No

If yes, please list the following: state, license # and expiration.

3. Have you ever had your license revoked or suspended? Yes No

If yes, please explain:

4. Have you ever received a warning or safety notification letter? Yes No

If yes, please explain:

5. How many citations have you received in the past year? _______ Two years?______
Remarks (what was the violation(s)):

6. Total number of citations you have ever received? _________

Remarks (what was the violation(s):

7. How many accident have you had in the past year? ________ Two years?_______
Total number of accidents you have ever been in?__________
Were there any injuries?

8. Have you ever operated any motor vehicle while under the influence of drugs or
alcohol, drove recklessly, or driven while under suspension? Yes No
If yes, for what violation and explain:

Integrity Questionnaire Revised 10/02 4

 DRUG USE

1. Have you ever smoked marijuana? Yes No

Explain:

2. When was the first time you smoked marijuana? ____________________________

Remarks:

3. When was the last time you smoke marijuana? _______________________________

Remarks:

4. How many times have you smoked marijuana in the last twelve months?___________
Remarks:

5. How many times have you smoked marijuana in your entire life? ________________
Remarks:

6. Have you ever injected, or had injected, any illegal drugs into
your body? Yes No
Remarks:

7. Have you ever used:

A. Hashish? Yes No G. Uppers? Yes No

B. Heroin? Yes No H. Downers? Yes No

C. Acid/LSD? Yes No I. Crack? Yes No

D. Cocaine? Yes No J. Quaalude? Yes No

E. Speed? Yes No K. Hallucinogenic? Yes No

F. Inhalants? Yes No J. Magic Mushrooms Yes No

If yes, indicate number of usage’s and when last usage occurred:

Integrity Questionnaire Revised 10/02 5

 8. Have you ever misused or illegally used prescription drugs? Yes No
Explain:

9. Have you illegally used any of the following:

A. Zanax Yes No F. Ritilan Yes No

B. Percocet Yes No G. Percoden Yes No

C. Dilaudid Yes No H. Oxycontine Yes No

D. Oxycodine Yes No I. Methadone Yes No

E. Valium Yes No J. Steroids Yes No

10. Have you ever been present when any of the following were used,
but you did not use them? Yes No
Explain:

11. Have you ever purchased marijuana or any other type of illegal or
prescription drug not prescribed to you? Yes No
Explain:

12. Have you ever sold marijuana or any other type of illegal or
prescription drug? Yes No
Explain:

13. Have you ever bought an illegal drug or a prescription drug for
someone else? Yes No
Remarks:

14. Have you ever grown, harvested, packaged, stored or transported

any type of illegal drugs? Yes No
Explain:

15. When was the last time you used or possessed any illegal drug?

Integrity Questionnaire Revised 10/02 6

 FIRE

1. Have you ever illegally started a fire? Yes No

Explain:

2. Have you ever intentionally set fire to anything? Yes No

Explain:

FISH AND GAME

1. Have you ever been convicted of a Fish and Game violation? Yes No
Explain:

2. Have you ever hunted or fished without a license? Yes No

Explain:

3. Have you ever night hunted illegally? Yes No

Explain:

4. Have you ever committed any fish and game violation(s) Yes No
Explain:

ILLEGAL AND IMMORAL ACTIVITIES

1. Have you ever sexually fondled a child since you’ve been grown? Yes No
Explain:

2. Have you ever committed an indecent exposure or held the urge to do

so? Yes No
Explain:

3. Have you ever accepted or given any money for the act of prostitution? Yes No
Explain:

Integrity Questionnaire Revised 10/02 7

 4. Have you ever given someone a drug before engaging in sex
with them? Yes No
Explain:

5. Have you ever forced someone to have sex with you, (rape)? Yes No
Explain:

6. Have you ever possessed or produced child pornography? Yes No

Explain:

7. Have you ever accessed child pornography on the Internet? Yes No

Explain:

CRIMINAL / CIVIL RECORD

1. Are you presently involved in any litigation: criminal or civil? Yes No

Explain:

2. Have you ever been convicted of a misdemeanor or a felony? Yes No

Explain:

3. Have you ever been arrested or detained? Yes No

Explain:

4. Have you ever stolen any money from a place where you work(ed)? Yes No
Explain:

5. Have you ever stolen any property or merchandise form a place where
you work(ed)? Yes No
Explain:

6. Have you ever been with someone when they stole something from a
store? Yes No
Explain:

Integrity Questionnaire Revised 10/02 8

 7. Have you, in the past five years, stolen anything from a store? Yes No
Explain:

8. Have you ever broken into a house or business not under your control? Yes No
Explain:

9. Have you ever engaged in any type of fraud over the Internet? Yes No
Explain:

10. What is the most serious crime in which you were involved?____________________
_________________________________________________________________
_________________________________________________________________

11. Have you been completely truthful on your application for employment and during
the entire hiring process for the agency, you are currently seeking employment with?

12. If selected to continue in the hiring process, you will be required to take a polygraph
examination. Part of the polygraph examination process will be to verify whether or
not you have been completely truthful and honest with your prospective employee
throughout the hiring process, including this Integrity Questionnaire.

Have you accurately and truthfully completed this questionnaire? Yes No

Integrity Questionnaire Revised 10/02 9