Name:

Address:

City:

State:

Zip:

Email Address:

Home Phone:

Work Phone:

Mobile Phone:

Other name(s) by which you have been known (e.g., nickname, maiden name):

The Chester's Mill Police Department requires all patrol officers to attend the Maine Criminal Justice Academy. Pursuant to 25 M.R.S.A. 2804-G, an applicant to the Maine Criminal Justice Academy must be 21 years of age or older to qualify for a position as a law enforcement officer unless the applicant has an associate's degree or 60 credit hours of postsecondary education, in which case the applicant must be at least 20 years of age. Do you meet this requirement?

Have you submitted an application to the Chester's Mill Police Department in the past?

Have you ever worked for any law enforcement agency in any capacity?

List all law enforcement agencies to which you have applied in the past or are applying currently:

Beginning with your present (or most recent) employment, list all jobs that you have held in the past ten (10) years, including part-time, temporary, seasonal and self-employment.

Have you ever been terminated or asked to resign in lieu of termination?

If yes, explain:

Have you ever served in the United States military?

If yes, in what capacity:

Describe any military training received relevant to law enforcement:

Did you graduate from high school?

If not, have you passed an equivalency exam?

List any schools attended, starting with the most current, stating the number of years completed, and degree earned, if any:

Have you ever been subject to any disciplinary action, such as scholastic probation, suspension, or expulsion, during your scholastic career?

If yes, explain:

List any extracurricular activity that you think helped prepare you to become or gave you skills that will be useful to you as a police officer:

List any special license you hold (e.g., pilot, radio operator, SCUBA, etc.), including licensing authority, date of issue and date of expiration:

If you are fluent in a foreign language (or sign language), indicate the language and degree of fluency (excellent, good, fair):

List any other special skills or qualifications you possess that you think will be beneficial to you as a police officer:

Describe any other specific work experience or training received that you think will be beneficial to you as a police officer:

Have you ever been convicted or plead "guilty" or "no contest" to a crime?

If yes, explain:

Have you ever committed an illegal act or done anything that would have been considered unlawful if caught?

If yes, explain:

Have you ever failed a police background investigation in the past?

If yes, when?

To whom did you apply?

Has your driver's license ever been suspended or revoked (in any state)?

If yes, explain:

List any court action to which you have been a party, including divorce

List all states in which you have resided or held a driver's license:

Are you eligible to be lawfully employed in the United States?

List all individuals with whom you have resided during the past five (5) years, excluding family members:

List any family members presently employed by the Town of Chester's Mill in any capacity (including spouse, parents, children, siblings, uncles, aunts, nephews, nieces, and any of the same related as in-laws, step-relations, or half-relations):

In what activities do you participate to keep yourself in good physical condition?

List any activities in which you regularly volunteer:

Have you ever applied to carry a concealed weapon?

If so, when?

Where?

List any organization in which you have been a member, excluding memberships that would reveal your race or color, sex, sexual orientation, physical or mental disability, religion, age, ancestry or national origin or other protected status:

Do you have the full physical, mental, emotional, and medical ability to do this job, whether with or without a reasonable accommodation?

Is there any additional information you would like to submit?