Colonial Beach Police Department

Employment Application for Police Officer

Applicant __________________________

-B Colonial Avenue
Colonial Beach, VA 22443

Employment Application

INSTRUCTIONS TO THE APPLICANT

This form is to be completed by the applicant and each question answered
accurately. If a question does not apply to you, write N/A (Not Applicable)
as your response to that question. Incomplete and/or inaccurate answers
will substantially extend the time required to process your application and
could result in removal from the process. If the application is incomplete
when submitted, it will be returned to you until it is in compliance.
The information you provide in this application will be used in the
investigation into your background to assist in determining your suitability
for the position for which you have applied. Please fill it out completely and
accurately. Keep in mind that:

. The completion of this application is required in order for you to
receive consideration for appointment;

. All statements are subject to verification;. Deliberate inaccuracies or incomplete statements may be cause for

rejection;. A thorough and complete background investigation will be

conducted, including previous employment verification

It is to your advantage to respond honestly and openly. Intentionally
omitting information or attempting to make a false statement will be an
immediate disqualification for employment.
If additional space is needed for any questions, comments or remarks, a
continuation sheet is provided at the end of this application. Please be sure
to identify each entry with the appropriate section in the application and
question number.

Employment Application

PAPERS/DOCUMENTS REQUIRED

All applicants will be required to submit a copy of the following applicable
documents, to be left with the Colonial Beach Police Department.

. Birth Certificate

. High School Diploma or GED

. College Transcript (if applicable)

. DD-214 (if applicable)

. Court Orders (if applicable)

a. Name change
b. Bankruptcy
c. Marriage/Divorce paperwork

. Credit report

. DCJS training record (if applicable)

Employment Application

Personal Data

Printed Name (Last, First, Middle) Date of Birth
Month Day Year

Current Address Place of Birth
City County State/Country

Height Weight Hair Color Eye Color Visible Tattoos or Scars/Marks

Social Security Number

Cell Phone # E-Mail:

Marital Status

Check one:

Married  Single  Divorced

Widowed  Separated

Do you have any objections with us contacting your
spouse or former spouse as part of your

background?

Yes  No

Spouse

Last, First, Middle Date of Birth Age

Spouse is employed by Company Name/Address/City/State Work Telephone No.

List below the name(s) of each of your children
Name of Child Date of Birth Age Address where child resides

Do you have any dependents other than those listed above? If yes, list them at the end of this
application.

Employment Application

Parents

Name (Last, First, Middle) Phone Number

Father Address (Include street address, city, state & zip)

Place of Birth (City, State) Date of Birth Date of Death (if deceased)

Name (Last, First, Middle) Date of Birth Phone Number

Mother Address (Include street address, city, state & zip)

Place of Birth (City, State) Date of Birth Date of Death (if deceased)

Military Service

Branch of Service Dates of Service Officer/Enlisted Primary MOS/AFSC

Highest Rank Attained Type of Discharge (Honorable, Dishonorable, Medical, etc.)

Were you ever subject to any disciplinary actions while in the Armed Forces? (Article 15, etc.,)

Reserve Service?
Yes  No

Dates of Membership Officer/Enlisted Branch

Financial

Do you now or have you ever had any wage garnishments on your salary? (If yes, briefly explain)
Yes  No

Have you ever been found delinquent on income or other tax payments? (If yes, briefly explain)
Yes No
Have you ever had a court-ordered financial judgement against you? Do you have one pending?
Yes  No
Have you ever had any property repossessed? (If yes, briefly explain)
Yes  No

Have you ever filed for or declared bankruptcy? If yes, what chapter? (7, 13, etc.,)
Yes  No

Employment Application

References

Give the data requested below on three (4) references who:

a. Are not related to you by blood or marriage
b. Are not former employees & are not mentioned elsewhere on this form
c. Are responsible adults of reputable standing in their community, and
d. Have known you well for at least five (5) years.

These references may include but not limited to: teachers, counselors, property owners or
members of clergy, business people, etc.

A.
Name (Last, First, Middle) Years known

Occupation Place of Employment

Phone Number

B.
Name (Last, First, Middle) Years known

Occupation Place of Employment

Phone Number

C.
Name (Last, First, Middle) Years known

Occupation Place of Employment

Phone Number

D.
Name (Last, First, Middle) Years known

Occupation Place of Employment

Phone Number

Personal History

Education

Provide the information requested below on all schools you have attended since the 9th
grade, beginning with the most recent. Be sure to include college, universities, military,
business/trade schools and anything relevant to the position for which you are applying.
Name of School Address (street address, city, state & zip)

Dates Attended Highest Grade
completed

Did you graduate?


Yes  No
From (Mo/Yr) To (Mo/Yr)
Name of School Address (street address, city, state & zip)

Dates Attended Highest Grade
completed

Did you graduate?


Yes  No
From (Mo/Yr) To (Mo/Yr)
Name of School Address (street address, city, state & zip)

Dates Attended Highest Grade
completed

Did you graduate?


Yes  No
From (Mo/Yr) To (Mo/Yr)
Name of School Address (street address, city, state & zip)

Dates Attended Highest Grade
completed

Did you graduate?


Yes  No
From (Mo/Yr) To (Mo/Yr)
Name of School Address (street address, city, state & zip)

Dates Attended Highest Grade
completed

Did you graduate?


Yes  No
From (Mo/Yr) To (Mo/Yr)
Name of School Address (street address, city, state & zip)

Dates Attended Highest Grade
completed

Did you graduate?


Yes  No
From (Mo/Yr) To (Mo/Yr)
Did you graduate from High School & receive a
diploma?  Yes  No

Did you pass a G.E.D (General Education
Development Test)?  Yes  No

Have you ever been dismissed or expelled from any school or college for any academic or
disciplinary reason?
Yes  No If yes, briefly explain: __________________________________________________

Personal History

Employment Data

List below your work history, starting with your most current position. Be sure to list all periods
of active military duty and all periods of employment. Please note: Your answers will be subject to
verification
A.

Name & Address of Employer

Date(s) Employed
(Mo/Day/Yr)

U.S./State Agency?
Yes  No
Secret Clearance

Your Salary
(Annual)

$

Check applicable box:
Full Time  Part Time
Temporary  Volunteer
Seasonal  Unemployed

Job Title Work Phone Number Name of Supervisor Supervisor’s Phone No.

Briefly describe your duties and responsibilities:

Reason for Leaving:
B.

Name & Address of Employer

Date(s) Employed
(Mo/Day/Yr)

U.S./State Agency?
Yes  No
Secret Clearance

Your Salary
(Annual)

$

Check applicable box:
Full Time  Part Time
Temporary  Volunteer
Seasonal  Unemployed

Job Title Work Phone Number Name of Supervisor Supervisor’s Phone No.

Briefly describe your duties and responsibilities:

Reason for Leaving:

Personal History

Employment Data, cont’d.

C.
Name & Address of Employer Date(s) Employed

(Mo/Day/Yr)

U.S./State Agency?

 Yes  No
Secret Clearance

Your Salary
(Annual)

$

Check applicable box:

Full Time  Part Time 
Temporary  Volunteer 
Seasonal  Unemployed

Job Title Work Phone Number Name of Supervisor Supervisor’s Phone No.

Briefly describe your duties and responsibilities:

Reason for Leaving:
D.

Name & Address of Employer Date(s) Employed
(Mo/Day/Yr)

U.S./State Agency?

 Yes  No
Secret Clearance

Your Salary
(Annual)

$

Check applicable box:

Full Time  Part Time
Temporary  Volunteer
Seasonal  Unemployed

Job Title Work Phone Number Name of Supervisor Supervisor’s Phone No.

Briefly describe your duties and responsibilities:

Reason for Leaving:

Personal History

Employment Data, cont’d.

E.
Name & Address of Employer

Date(s) Employed
(Mo/Day/Yr)

U.S./State Agency?
Yes  No
Secret Clearance

Your Salary
(Annual)

$

Check applicable box:
Full Time  Part Time
Temporary  Volunteer
Seasonal  Unemployed

Job Title Work Phone Number Name of Supervisor Supervisor’s Phone No.

Briefly describe your duties and responsibilities:

Reason for Leaving:
F.

Name & Address of Employer

Date(s) Employed
(Mo/Day/Yr)

U.S./State Agency?
Yes  No
Secret Clearance

Your Salary
(Annual)

$

Check applicable box:
Full Time  Part Time
Temporary  Volunteer
Seasonal  Unemployed

Job Title Work Phone Number Name of Supervisor Supervisor’s Phone No.

Briefly describe your duties and responsibilities:

Reason for Leaving:

Personal History

Employment Data, cont’d.

Have you: Yes No

a. Ever been discharged from employment (fired) for any reason?  

b. Ever resigned (quit) after being informed that your employer intended  
to discharge (fire) you for any reason?

c. Ever resigned (quit) after being informed that your employer intended  
to take any form of disciplinary action against you?

If you answered “Yes” to any of the above three questions, give full details in the space below.
Include the name(s) and addresses of the employer, approximate date(s) and the circumstances in
each case.

Law Enforcement Experience

THE INFORMATON IN THIS SECTION RELATES ONLY TO THOSE
INDIVIDUALS THAT HAVE PREVIOUS LAW ENFORCEMENT EXPERIENCE.
IF YOU HAVE NO PREVIOUS EXPERIENCE, SKIP THESE QUESTIONS AND
MOVE TO THE NEXT SECTION OF THE APPLICATION

Are you now or have you ever been a member of a law enforcement agency?

…………………………………………………………………………………Yes No

IF YES, WAS THE LAW ENFORECMENT AGENCY:

Federal

State

City Police

County
Police County Sheriff

Other

LIST THE NAME OF THE AGENCY AND THE DATES YOU WERE EMPLOYED
THERE:

AGENCY DATES (FROM/TO)

LIST YOUR LAST THREE PRIMARY DUTIES:

Are you a certified Police Officer in Virginia?

…………………………………………………………………………………. Yes No

DATE OF CERTIFICATON ACADEMY ATTENDED:

Are you a certified Police Officer in another state?

…………………………………………………………….  Yes  No

IF YES:

STATE
LEVEL OF
CERTIFICATION YEAR

During your tenure in Law Enforcement, were you ever subject to an Internal Affairs
Investigation? ………………………………………………………………. Yes  No

IF YES, EXPLAIN:

During your tenure in Law Enforcement, did you receive any disciplinary actions, as
a result of an IA or otherwise? …………………………………………… Yes  No

IF YES, EXPLAIN:

PLEASE LIST CONTACT INFORMATION FOR YOUR LAST IMMEDIATE
SUPERVISOR:

NAME RANK PHONE NUMBER

Personal History

Driving Record

Indicate below all traffic violations or citations (excluding parking tickets) that you have
received. Include in your response, but do not limit it to, such violations such as: Speeding,
Reckless Driving, Changing Lanes w/o Caution, Defective Equipment, Stop Sign Violations
& Red-Light Violations. Give the following data for each violation:

Date Violation City & State Agency Disposition Points

Provide the information requested below on all drivers’ licenses which are now or have been
issued to you from any state (regardless of status).

Issuing State License Number Expiration Date Type of License

Is your driver’s license now or has it ever been:

a. Denied or refused?  Yes  No
b. Suspended?  Yes  No
c. Revoked?  Yes  No
d. Subject to any other similar penalty or action?  Yes  No

If you answered “Yes” to any of the questions above, please explain in detail below:

Personal History

Driving Record, cont’d

Have you ever been involved in a vehicle accident?
If answered “Yes”, give complete details below. Include date, place, fault, charges, injuries
and the name of the Law Enforcement Agency that made the report.
Enter the following information concerning any motor vehicle(s) owned or operated by you:

Vehicle No. 1 Vehicle No. 2
Make Make
Model Model
Year Year
License Plate No. License Plate No.
State Registered State Registered
Name & Address of Owner (or ‘Self’)

Name & Address of Owner (or ‘Self’)

If there is anything you wish to state about your driving record, please use the space below:

Personal History

Arrest/Conviction Data

Have you ever been:
a. Arrested?

Yes No

b. Charged by any law enforcement agency/authority?
c. Convicted of any offense against the law?
d. Subjected to forfeiture of collateral in connection with an arrest?
e. Place on probation?
f. Required to appear before a juvenile court for an act which would

have been a crime if committed by an adult?

g. Fingerprinted for any reason?
h. Investigated or questioned for any reason by any law enforcement

agency/authority?

i. Involved as a plaintiff or defendant in any civil court action?
Are you now: Yes No

a. Charged with an offense by any law enforcement agency?
b. Presently on bail or out on personal recognizance or other

conditional release?

c. On probation of any type?
If you answered “Yes” to any questions above, give complete details below.
At a minimum include: date of offense, charge(s), city & state, name of law enforcement
agency involved and final disposition. If additional space is needed, use the “Remarks” page
in the final section of this application.

Personal History

Miscellaneous

Do you belong to any organization and/or adhere to any belief which
would in any way:

a. Limit or prohibit your use of weapons or firearms?

Yes No

b. Restrict or prohibit you from working on particular days off?
c. Restrict you from conforming to departmental standards of

appearance and/or grooming which my from time to time be set?

If you answered “Yes” to any of the above, explain in the “Remarks” page in the final section
of this application.
Do you now, or have you in the past, used, tried or experimented with:

a. Marijuana?
b. Narcotics of any kind?
c. Dangerous drugs of any kind?
d. Any other illegal drug?

If you answered “Yes” to any of the above, explain in the “Remarks” page in the final section
of this application.
Are you, or have you ever been, a member of or advocated the beliefs of:

a. A group or organization that aims to achieve their objectives
through the use of both non-violent and violent direct action, rather
than through policy reform?

b. A group or organization that to your present knowledge, seeks the
overthrow of the constitutional form of government of the United
States of America by force or violence, or other unlawful means?

If you answered “Yes” to any of the above, explain in the “Remarks” page in the final section
of this application.
Have you ever been issued a permit or license to carry a handgun or other
weapon on your person? If “Yes”, please give details below.

If you have never been issued a permit or license to carry a handgun, have
you ever discharged your weapon (other than at an approved range), or
been the subject of an investigation regarding the discharge of your
weapon? If yes, give details below.

Personal History

Miscellaneous, cont’d.

List any special skills that you possess that you believe may be applicable to the position for
which you are applying (skills with machines, public speaking experience, membership in a
professional, scientific, community or other such organizations, etc.)

a. Is this the first time that you have applied with the Colonial Beach
Police Department?

Yes No

b. Have you ever applied for a position with any Federal, State or
Local Law Enforcement agency

c. Have you ever applied for a position with any Federal, State or
Local Law Enforcement agency for which a background
investigation was initiated?

d. Have you ever been denied employment by an organization
covered in questions “a” or “b” above?

e. Have you had any prior law enforcement training or experience?
If you answered “Yes” to any of the above five questions ( ‘a’ thru ‘e’), provide complete
details in the space below with regard to all such positions applied for. Be sure to include the
full name of each organization applied to, the position(s) applied for, the date(s) of your
application(s), and the reason(s) you were denied employment. If additional space is needed,
please use the “Remarks” page in the final section of this application.

Remarks Section – Continuation Sheet

Identify each question to which a response is being provided.
Page Number Segment

Remarks Section – Continuation Sheet

Identify each question to which a response is being provided.
Page Number Segment

Personal History

Signature Page

If information should surface during the stages of this investigation which would disqualify
you from further consideration, the investigation will be terminated immediately and you will
be notified accordingly.
Please be advised that each statement given in this application will be investigated and any
inaccurate, untruthful or misleading answer will be cause for rejection.
I hereby certify that all the answers are accurate and true to the best of my knowledge.
_____________________________________________________________________________________
Date Signature

Personal History

Town of Colonial Beach
Police Department

-B Colonial Avenue
Colonial Beach, Virginia 20176

(804) 224-7612

AUTHORIZATION TO RELEASE INFORMATION

This is to certify that I, _______________________________, am an applicant for
the position of _________________________________with the Colonial Beach Police
Department and that I do hereby authorize the release of any and all information to the
Colonial Beach Police that they may request from whomever they may deem it
necessary to make such a request, from any of my records, military records, police
records (including juvenile records), arrest records, court records, attendance records,
traffic records, confidential records, educational records & transcripts, etc. I also release
all persons from any liability which could result from furnishing said information to the
Colonial Beach Police.

***
I further understand that in the event my application is disapproved, the sources of
confidential information cannot be revealed to me.

***

I further understand that in the event my application is disapproved, the sources of
confidential information cannot be revealed to me.

***

___________________________________ __________________________________________
Date Signature
__________________________________________
Address
City/County of ___________________________ Commonwealth of Virginia
Sworn to and subscribed before me this______day of ___________________,_____.
Witness my hand and official seal.
_________________________________________ _______________________________________
Notary Public My Commission Expires