APPLICATION FOR EMPLOYMENT Step 1 of 5 20% Today's Date(Required) MM slash DD slash YYYY APPLICANT INFORMATIONInformation provided in this section is used for identification purposes.Name(Required) First Middle Last Which of the following are you applying as? New Officer Experienced Officer Dispatcher List any other names or aliases you have used for work-related purposes (include maiden name, if applicable): Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Are you a U.S. Citizen or are you authorized to work in the U.S.?(Required)SelectYesNoHave you ever been convicted of a felony?(Required)SelectYesNoAre you a full-time Police Officer?(Required)SelectYesNoHow long have you been a full-time Police Officer?(Required) Are you currently on Probation?(Required)SelectYesNoDo you have any tattoos?(Required)SelectYesNoPlease list the location of each tattoo on your body:(Required) EDUCATION & SKILLSHigh School(Required) Name City State Did you graduate?(Required)SelectYesNoCollege/University Name City State Degree Major/Minor Degree received, if any: College/University Name City State Degree Major/Minor Degree received, if any: If you have not yet obtained a degree, how many credit hours do you have towards a Criminal Justice-related field? List any other schools attended (trade, voicemail, business, etc.).(Required)Give names and dates of attendance, course of study, certificate received, and any other pertinent information.Were you ever expelled or suspended from any school?(Required)SelectYesNoList other formal education beyond high school you may have, including special training courses:(Required)List any professional licenses or certificates you hold or have held:(Required) EMPLOYMENT HISTORYBeginning with your present or most recent job, list all employment since the age of 18, including part-time, temporary, or seasonal employment. Include all periods of unemployment.1. Employer Name Address Phone Job Title Start Date End Date Duties: Reason for Leaving: 2. Employer Name Address Phone Job Title Start Date End Date Duties: Reason for Leaving: 3. Employer Name Address Phone Job Title Start Date End Date Duties: Reason for Leaving: 4. Employer Name Address Phone Job Title Start Date End Date Duties: Reason for Leaving: 5. Employer Name Address Phone Job Title Start Date End Date Duties: Reason for Leaving: 6. Employer Name Address Phone Job Title Start Date End Date Duties: Reason for Leaving: **INDICATE, BY NUMBER, ANY OF THE ABOVE EMPLOYERS WHOM YOU DO NOT WISH FOR US TO CONTACT** SPECIAL QUALIFICATIONS AND SKILLSList any special license you hold (such as paramedic, pilot, radio operator, scuba, etc.) Show licensing authority, original dates of issue, and date of expiration.(Required)List any specialized machinery or equipment that you are trained to operate:(Required)State why you want to work as a police officer for the City of Centralia. You should also state any special talents you would bring to the position.(Required)Signature(Required) I agree.I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the statements and answers I have provided in this application. I am fully aware that any such willful misrepresentation, omissions, or falsifications may be grounds for immediate rejection of my application for employment or termination of employment whenever such misrepresentation, omission, or falsification is discovered.Signature(Required)Date of Signature(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS(Required) I agreeI do hereby authorize a review of all records concerning myself to any duly authorized agent of the Centralia Police Department, whether the said records are of a public, private or confidential nature, including, but not limited to, applicant background information. I authorize you to furnish the Centralia, Illinois Police Department with any and all information that you have concerning my: work record, salary, attendance, reputation, medical records, criminal history, credit history, loan history, driving history, and military service records. Information of a confidential or privileged nature may be included. Your reply will be used to assist the Centralia Police Department in determining my qualifications and fitness for the position I am seeking with the department. 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 Centralia Police Department. I understand that all materials pertaining to this background investigation become the property of the Centralia Board of Fire & Police Commissioners and will not be returned to me. I hereby release you and your organization from any and all liability or damages which may result from furnishing the information requested. I further release the Centralia Police Department, and its agents, from any and all liability which may be incurred or as a result from the collection of such information. I further understand that in the event my application is disapproved, the sources of confidential information cannot be revealed to me.Name(Required) First Last Signature(Required)Date of Signature(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenURL Δ
