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Personal Information

First Name*
Last Name*
Middle Name*
Street Address*
City*
State*
Zip Code*
Phone Number*
Email Address
Driver's License Number*
Driver's License State*
Driver's License Type
Are you eligible to work in the United States?*
1. Yes
2. No
Are you or will you be 21 years of age at the time of hire per the requirements of KSA 74-5605?*
1. Yes
2. No
Has your driver's license ever been suspended?*
1. Yes
2. No
If yes, explain
Have you ever been in a traffic accident while you were driving?*
1. Yes
2. No
If yes, explain
Have you ever been employed by the Norton Police Department or any other law enforcement agency?*
1. Yes
2. No
If yes, explain
Have you ever been dismissed or asked to resign from employment?*
1. Yes
2. No
If yes, explain
Have you ever been convicted of a domestic violence offense?*
1. Yes
2. No
If yes, explain
Have you ever been the subject of a Protection from Abuse or Protection from Stalking Order?*
1. Yes
2. No
If yes, explain
Were you dishonorably discharged from any branch of the U.S. Armed Forces?*
1. Yes
2. No
If yes, explain
Do you know of any reason why you would not pass a background check?*
1. Yes
2. No
If yes, explain
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Position Information

Position applying for*
How did you hear about the position?
Would you accept a position that would require evening, night, and/or weekend shifts?*
1. Yes
2. No
Type of employment desired*
1. Full Time
2. Part Time
Desired Salary*
Hours per week desired*
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Military Service

Are you currently or have you been in the Armed Forces?*
1. Yes
2. No
Military Branch
From
To
Rank Upon Discharge
Are you claiming veterans preference?
1. Yes
2. No
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Education

High School*
Address*
Did you graduate?*
1. Yes
2. No
3. No, I have a GED or equivalent
College
Address
Did you graduate?
1. Yes
2. No
Degree
Other School
Address
Did you graduate?
1. Yes
2. No
Degree
List any training you feel especially qualifies you for the position for which you are apply
Foreign languages spoken or read
Clerical skills
Typing(wpm)
Professional or Trade Licenses
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Employment History

(Starting with the Most Recent)
Company*
Position*
Address*
Supervisor*
Phone Number*
Salary
Employed From*
Employed To*
Responsibilities
May we contact your previous supervisor for a reference?*
1. Yes
1. No
Company*
Position*
Address*
Supervisor*
Phone Number*
Salary
Employed From*
Employed To*
Responsibilities
May we contact your previous supervisor for a reference?*
1. Yes
1. No
Company
Position
Address
Supervisor
Phone Number
Salary
Employed From
Employed To
Responsibilities
May we contact your previous supervisor for a reference?
1. Yes
1. No
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References

Please list three references.
Full Name*
Relationship*
Phone Number*
Email
Full Name*
Relationship*
Phone Number*
Email
Full Name*
Relationship*
Phone Number*
Email
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Disclaimer & Signature

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.
I expressly authorize without reservation, the employer, it’s representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, it’s agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand the employer does not lawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law.
I understand this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer and wish to be considered for employment, I will be necessary to reapply and fill out a new application.
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.
Do not sign until you have read the above applicant statement.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Applicant Signature*
Date*
Date

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Norton Police Department Officer Application

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Personal Information

Position Information

Military Service

Education

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References

Disclaimer & Signature