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Personal Information Name Physical Address City State Zip Code Permanent Address City State Zip Code Email Address Phone Number Secondary Phone Number Referred By Employment Date You Can Start Are You Currently Employed? Yes No If So, May We Contact Your Employer? Yes No Are You Legally Authorized To Work in the U.S.? Yes No Have You Applied with the Town of Pulaski Before? Yes No If So, When? Have You Worked for the Town of Pulaski Before? Yes No If So, When? Reason for Leaving How Did You FInd Out About This Position? Education History High School Name of School Years Attended Did You Graduate? Yes No Subjects Studied College Name of School Years Attended Did You Graduate? Yes No Subjects Studied Trade, Business or Correspondence School Name of School Years Attended Did You Graduate? Yes No Subjects Studied Subject of Special Study/Research Work
Special Training, Certifications, Licenses Special Skills, Foreign Languages, Etc. Military Service Record Have You Ever Served in the U.S. Armed Forces? Yes No Branch of Service Discharge Date Rank Former Employers (List your last three places of employment, starting with the most recent) Name of Present or Last Employer Address City State Zip Code Starting Date Leaving Date Job Title May We Contact Your Supervisor? Yes No Name of Supervisor Supervisor's Title Phone Number Description of Work
Reason for Leaving
Name of Previous Employer Address City State Zip Code Starting Date Leaving Date Job Title May We Contact Your Supervisor? Yes No Name of Supervisor Supervisor's Title Phone Number Description of Your Work
Reason for Leaving
Name of Previous Employer Address City State Zip Code Starting Date Leaving Date Job Title May We Contact Your Supervisor? Yes No Name of Supervisor Supervisor's Title Phone Number Description of Your Work
Reason for Leaving References - Please List Three Professional Reference That We May Contact Name Address Relationship Phone Number Name Address Relationship Phone Number Name Address Relationship Phone Number Special Purpose Questions I understand and agree that, in the event I am offered this position, I may be required to take a physical examination, background check and/or drug test, as a condition of the hiring process or continued employment. I agree to consent to take such test(s) at such time as designated by the Town of Pulaski and to release the Town of Pulaski, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s), other than claims related to privacy violations and/or discrimination under applicable federal and state laws. I understand that all potential employees are required to undergo a physical exmination, background check and/or drug test and that, in compliance with federal law, the records of such tests will be kept confidential and the information obtained will not be used to discriminate on the basis of disability, health problems, or medical conditions. Yes No Pulaski Police Department Police Officer Selection Requirements Polygraph Investigation A. Questions asked during the polygraph will address the following issues: 1) Current illegal drug use, 2) Buying and/or selling illegal drugs or steroids, 3) Falsifying employment application or other relevant documents, 4) Intentional physical or mental abuse of others, and 5) Crimes of moral turpitude (lying, cheating, stealing). B. Deception indicated from the polygraph examination will not be utilized as the sole reason for denying an applicant employment. Disqualifiers A. Criminal History: 1) Conviction of any felony. 2) Conviction of any crime involving moral turpitude (lying, cheating, stealing). 3) Conviction of a Class 1 or Class 2 misdemeanor of the Code of Virginia or equivalent within the last twelve months. Convictions beyond twelve months will be reviewed on a case by case basis. 4) Conviction, plea of guilty, or no contest plea to any sex offense or domestic assault under the laws of the Commonwealth of Virginia, another state, or the United States. 5) Conviction of a Class 3 or Class 4 misdemeanor of the Code of Virginia or equivalent within the last twelve months. Convictions beyond twelve months will be reviewed on a case by case basis. 6) Conviction, plea of guilty, or no contest to a felony or any offense that would be a felony if committed in the Commonwealth of Virginia. 7) Admission of felonious behavior. 8) All prior criminal behavior, whether arrested or not, will be reviewed on a case by case basis. 9) Any conviction taken under advisement will be reviewed on a case by case basis. B. Traffic Violations 1) Minus 6 or more points on a Virginia Operators License, or the equivalent for out of state license, at the time of application. 2) Conviction of Driving Under the Influence, Refusal to take Blood or Breath Test, Eluding Police, or Racing. 3) Reckless Driving or any suspension/revocation of driving privileges within the last 5 years for any reason will be reviewed on a case by case basis. 4) Any conviction taken under advisement will be reviewed on a case by case basis. C. Drug Use: 1) Recent possession of Marijuana. 2) Any possession of Schedule I drugs as defined by the Code of Virginia 54.1-3446 (e.g. LSD, PCP, mescaline, heroin and cocaine). 3) Any possession of Schedule II, Schedule III, Schedule IV or Schedule V drugs, as defined by the Code of Virginia 54.1-3448, 54.1-3450, 54.1-3452, 54.1-3454, unless prescribed by a licensed physician. 4) Any possession of designer drugs as defined by the Code of Virginia 54.1-3456 (e.g. ecstasy). 5) Any other drug possession will be reviewed on a case by case basis. 6) Selling any illegal drugs. 7) Buying any illegal drugs will be reviewed on a case by case basis. 8) Must not have produced a positive result on a pre-employment drug screening, where the positive result cannot be explained to the satisfaction of the agency. D. Other: 1) Dishonorable Discharge from any military service. 2) Less than Honorable Discharges will be reviewed on a case by case basis. 3) De-certification of law enforcement or jailor status by the Department of Criminal Justice Services, according to the Code of Virginia 15.2-1707, or similar status in other states. 4) Untruthfulness, falsification, or the intentional withholding of any information on any application, certificate, credential, interview, test, or documents associated with the position. 5) Cheating on any examination or testing associated with the position. 6) Criminal or ethical behavior unsuitable or inappropriate for a Police Officer as determined by the appointing authority. 7) Failure to submit a thoroughly complete application, composite history, and other required paperwork by the assigned deadline. 8) Failure to comply with deadlines to return requested information to the background investigator. 9) Failure to comply with applicant's appointment(s) without prior notification to the background investigator. 10) Credit history with a current unsatisfactory rating. 11) Not being a United States citizen. 12) Background investigation indicating less than acceptable job performance with past employers. 13) Incidents of past physical or mental abuse of anyone. 14) Obtaining a score that is below the established standard on any test or evaluation administered during the selection process. 15) No applicant shall be, shall have been or shall become a member of any organization which advocates the forceful overthrow of the United States government or any other organization cited as being subversive or un-American by the United States Attorney General. 16) Tattoos or other similar body art on the ears, head, face, hands, eyebrows, eyelids, neck or tongue are prohibited. Tattoos, or other similar body art, may only be visible on the arms, above the wrists and on the legs. These images or wordings must not be offensive, racial, provocative, vulgar, insulting, or in poor taste. 17) The wearing of body piercing jewelry or gauge style ornamentation is prohibited. There will be no piercings of any kind in the tragus, concha, helix, lip, nose or face. Intentional body modification, body alterations and/or other body adornments shall not be visible. These shall include: •split or forked tongue •foreign objects inserted in the tongue or mouth •intentional bodily scarring or branding •dermal or subdermal implants, or •any intentional body modifications or body alterations that pose a health hazard or impact the employee’s ability to perform their official duties. Female officers may wear small, plain, post, clip-on, or stud type earrings. No earrings that suspend from the ear lobes or loop around any part of the ear may be worn. Earrings are not to exceed two per ear and are to be worn only in the ear lobe. 18) Must live within a one hour drive (legally) from the Pulaski Police Department. 19) No smoking tobacco use on or off duty. Conditions Of Employment A. You must live within a one hour drive of the Town Municipal Building while traveling at the legal speed limit. B. You are required to meet applicable Virginia state law for law enforcement certification. C. Employment as a Pulaski Police Officer requires that you will work on a variety of shifts that include holiday and weekend work. D. You agree that upon employment with the Department not to smoke any tobacco products on or off duty. E. You must possess a valid Virginia Operators License prior to entrance into the police academy. F. Upon appointment, you will serve as a probationary employee for one year. Officers serving in a probationary status may have that period extended for "less than satisfactory job performance" or be dismissed from employment at the discretion of the appointing authority. G. You must agree to meet and follow any applicable personal appearance and grooming standards. H. You must sign an employment contract. I. Police Officer applicants must possess a high school degree or equivalent from an accredited educational institution at the time of appointment. J. Applicants must be 21 years of age at the time of appointment. Physical Agility and Strength Test A. There are a variety of skill defined, job related elements that will comprise the physical agility and strength test. These elements are subject to update and revision. B. Examples of elements to be utilized include running, a weapon manipulation, wall climb, window obstacles, and dummy exercises (includes dragging and lifting). C. Applicants must successfully complete all elements of the physical agility and strength test to continue in the selection process. Medical/Psychological Standards A. Applicants offered a Conditional Offer of Employment must successfully complete a medical examination. The medical examination will evaluate the applicant's ability to successfully perform the essential job functions. 1. Vision: Must be correctable to 20/30 and pass a color vision examination. 2. Hearing: Hertz | 500 | 1,000 | 2,000 | 3,000 | 4,000 | Decibels | 25 db | 25 db | 25 db | 30 db | 45 db |
B. Applicants offered a Conditional Offer of Employment must successfully complete a psychological evaluation. The psychological evaluation will evaluate the applicant's ability to successfully perform the essential job functions. Re-application/Retesting/Process Duration A. An applicant who fails to achieve a passing score on two written examinations within a twelve month period must wait one year to reapply. An applicant who fails the physical agility andstrength test may reapply at the next application posting. Applicants who are disqualified due to an unacceptable background are not eligible to be reprocessed. B. Unsuccessful candidates who fail due to unacceptable background normally will not be eligible to be reprocessed. Exceptions can be authorized by the Chief of Police. C. The selection process normally lasts three to four months. Applications remain active for six months from the date of the written test. Applicants, unless disqualified, may be processed within this six month period. Applicants will be periodically updated on their status when being actively processed. Authorization “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.” This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. Date Electronic Signature We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, genetic information, national origin, citizenship status, physical or mental disability, or any other legally protected status. Completing this application does not obligate us in any way. If you require an accommodation in order to participate in any phase of the application process, please contact the Town of Pulaski Human Resources office at (540) 994-8642 or email [email protected]
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