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Student Officer Application

Student Officer Application
Instructions:
Providing false or misleading information or purposely withholding information will result in rejection of your application, dismissal from employment and potential removal from the Civil Service eligibility list. Accordingly, all questions must be answered. If space provided is not sufficient for complete answers or you wish to furnish additional information, use the form provided to you by the Recruit Investigation Unit. Be sure to specify which section and question you are providing information for. Return this form along with other required documentation to your background investigator. This additional information must also be true and accurate.
First Name*
Middle Name
Last Name*
Ethnicity
optional
Date of Birth*
dd/mm/yyyy
Social Security Number
Place of Birth*
City, State, Country
Sex*
Height*
Feet, Inches
Scars, Marks, Tattoos
Have you ever used a different Social Security Number?*
If Yes, Explain
Have you ever used a Name or DOB different than that on your birth certificate?*
If Yes, Explain
Have you ever intentionally altered your name, address, or date of birth on any official document, certificate, or license?*
If Yes, Briefly Explain
List all other names you have used including any surname, maiden name, or alias names.
Name Used
Date(s) Used
Location(s) Used
Circumstances
Explain when and under what circumstances this name was used
Name Used
Date(s) Used
Location(s) Used
Circumstances
Explain when and under what circumstances this name was used
Have you ever legally changed your name?*
If Yes, Indicate the date of the change, court record location, and reason for change
Are you a United States Citizen?*
Are you a Naturalized Citizen?*
List your Naturalization Number
Are you currently in the process to be Naturalized?*
If Yes, what is your expected Naturalization Date?
*Provide all related documentation to your background investigator.
Current Address
Street Address*
Apartment Number
City & State*
Zip Code*
Residential Phone
Cellular Phone
Business Phone
Pager Number
E-Mail Address(es)*
List All. Starting with your primary e-mail address that you wish communications related to your application to be sent. Separate with a comma.
Social Media Sites & Usernames
Complete mailing address where you want your mail to be sent (including zip code)*
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Relationships

Relationship Status
1. Never Married
2. Married
3. Separated
4. Legally Separated
5. Single
6. Divorced
Mark each one of the above that describes your current relationship status
Significant Other
Name
Children
Names & Ages
Current Spouse/Significant Other
Please complete the following about your current spouse/significant other. If married, include a maiden name if applicable.
Full Name
Date of Birth
Social Security Number
Address
Place of Birth
Country of Citizenship
Other Names Used
If separated, date of separation
Phone Number
E-Mail Address
Former Spouse/Significant Other
Please complete the following about your former spouse/significant other. If married, include a maiden name if applicable.
Full Name
Date of Birth
Social Security Number
Address
Place of Birth
Country of Citizenship
Other Names Used
If separated, date of separation
Phone Number
E-Mail Address
Full Name
Date of Birth
Social Security Number
Address
Place of Birth
Country of Citizenship
Other Names Used
If separated, date of separation
Phone Number
E-Mail Address
Relationships
List the information related to all current or former domestic partners, persons with whom you have had a child, regardless of whether you have ever been married or lived together, person you are or were in a dating or engagement relationship within the past 10 years not listed in the above section.
Name
Date of Birth
Phone
Address
E-Mail
Relationship
Name
Date of Birth
Phone
Address
E-Mail
Relationship
Name
Date of Birth
Phone
Address
E-Mail
Relationship
Name
Date of Birth
Phone
Address
E-Mail
Relationship
Name
Date of Birth
Phone
Address
E-Mail
Relationship
Name
Date of Birth
Phone
Address
E-Mail
Relationship
Children
List the names, dates of birth, and addresses of each child
Full Name
Date of Birth
Social Security Number
Current Address
Place of Birth
Full Name of Other Parent
Phone Number of Other Parent
Address of Other Parent
Are you the parent or guardian?
Full Name
Date of Birth
Social Security Number
Current Address
Place of Birth
Full Name of Other Parent
Phone Number of Other Parent
Address of Other Parent
Are you the parent or guardian?
Full Name
Date of Birth
Social Security Number
Current Address
Place of Birth
Full Name of Other Parent
Phone Number of Other Parent
Address of Other Parent
Are you the parent or guardian?
Full Name
Date of Birth
Social Security Number
Current Address
Place of Birth
Full Name of Other Parent
Phone Number of Other Parent
Address of Other Parent
Are you the parent or guardian?
Full Name
Date of Birth
Social Security Number
Current Address
Place of Birth
Full Name of Other Parent
Phone Number of Other Parent
Address of Other Parent
Are you the parent or guardian?
Full Name
Date of Birth
Social Security Number
Current Address
Place of Birth
Full Name of Other Parent
Phone Number of Other Parent
Address of Other Parent
Are you the parent or guardian?
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Court Orders

Residential History

List of residences
List chronologically all of your residences since your 16th birthday starting with your current address and working backward. If you attended school away from your permanent residence then list the address you lived at while attending school. During military service be sure to list each place of residence including your base/ship/home port. Be sure to indicate physical residence. Do not use a post office box as an address.
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
Dates
Dates Start Date
—
Dates End Date
Street Address including apartment number
City
State & Country
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Residential History Continued

Persons you have resided with
List all persons with whom you have resided since your 16th birthday and their relationship to you. Exclude children.
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
Name
Phone Number
Current Address
Relation
Dates you resided with this individual
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Employment History

Employment History
List all employment since age 17. Begin with the most recent going backward. Include summer, part-time, and work study employment. You may include any verified work performed on a voluntary basis. If you were serving in the military indicate where you were located and the dates associated. If unemployed for a period of time, indicate dates of unemployment.
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Employment History continued
Has any of the following happened to you regarding your employment history? If you answered "YES" to any of the below questions, list each occurrence beginning with the most recent and working backward. Please provide the date fired, quit, or left under any conditions other than favorable.
Terminated from Job?*
Quit a job after being told you would be terminated?*
Left a job by mutual agreement under unfavorable circumstances?*
Circumstances
Explain the circumstances to which you answered "YES" in the order below
Date
Specify Reason
Employer Name
Supervisor's Name
Employer's Full Address
Employer's Telephone Number
Explain the Circumstances
Date
Specify Reason
Employer Name
Supervisor's Name
Employer's Full Address
Employer's Telephone Number
Explain the circumstances
Have you ever been self-employed or been a part-time or full-time owner of a business?*
Name of Business
Full Address
Telephone Number
License Number (if applicable)
Type of License Issued
Expiration Date
State Tax Number
Federal Tax Number
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Employment History Continued

Employee Discipline
Have you ever:
Stolen from an employer?*
Been accused of stealing by an employer?*
Lied to an employer about the number of hours you worked?*
Been accused of lying about the number of hours you worked?*
Been paid for hours that you did not work?*
Reported to work under the influence of alcohol or any drug?*
Fought verbally or physically with other workers or supervisors?*
Been disciplined for any reason including the use of sick time?*
Resigned from any job to avoid being terminated?*
"YES" Answers
For each "YES" answer in the above section, explain the incident on the provided form. Return the form to your background investigator.
Employee Discipline continued
During the past three (3) years, provide the total number of sick or unexcused days you have missed from work. Use the date your application is signed as the beginning of the three (3) year period. For example: if your application is signed 11/29/2021, the first year for use of sick time purposes would be 11/29/2020 through 11/29/2021, the second year would be 11/29/2019 through 11/29/2020, and the final year would be 11/29/2018 through 11/29/2019. Explain the circumstances on the provided form. Return the form to your background investigator.
Number of Days
12 months going backward
12 months going backward
Number of Days
12 months going backward
12 months going backward
Number of Days
12 months going backward
12 months going backward
How many of the above absences were excused by a doctor's note?
Please provide doctor's notes or other documentation for all excused absences. Provide these to your background investigator.
How many hours constitute a day of work at your place of employment?
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Law Enforcement Experience

Law Enforcement Experience
List all prior Law Enforcement experience. Begin with the most recent going backward. Include summer, part-time, and work-study employment. You may include any verified work performed for a law enforcement agency on a voluntary basis.
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Name of Employer
Address
City, State, Zip Code
Telephone Number
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Position
Salary
Reason for Leaving
Name of Supervisor & Telephone Number
Name of Co-Worker & Telephone Number
Have you ever been disqualified by any other law enforcement, criminal justice, or governmental agency?*
If "YES" explain
Have you ever attended a Massachusetts Municipal Police Training Committee approved police academy?*
If "YES", provide copies of all documentation and certificates to your background investigator.
Name of Academy
Address
City, State, Zip Code
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Have you ever attended a State approved police academy from another jurisdiction?*
If "YES", provide copies of all documentation & certificates to your background investigator.
Name of Academy
Address
City, State, Zip Code
Start Date - End Date
Start Date - End Date Start Date
—
Start Date - End Date End Date
Have you ever applied for a public safety position for any town, city, county, state, or agency?*
This includes if you were considered for employment with the Malden Police Department in the past.
Agency
Address
Date of Application
Assigned Investigator
Investigator's Contact Info
Outcome
Agency
Address
Date of Application
Assigned Investigator
Investigator's Contact Info
Outcome
Agency
Address
Date of Application
Assigned Investigator
Investigator's Contact Info
Outcome
Agency
Address
Date of Application
Assigned Investigator
Investigator's Contact Info
Outcome
Agency
Address
Date of Application
Assigned Investigator
Investigator's Contact Info
Outcome
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Educational History

Educational History
Schools Attended
Fill in information about all schools you have attended beyond 8th grade beginning with the most recent and working backwards. For schools you have attended within the past three (3) years, list a person who knows (or knew) you at the school such as a teacher, professor, or fellow student. For correspondence schools and extension classes, list records, locations, and addresses.
Dates Attended
Dates Attended Start Date
—
Dates Attended End Date
Type
Name of School
Address of School
Degree/Diploma/Certificate
Date
Date
Name, address, telephone of person who knew you there
Dates Attended
Dates Attended Start Date
—
Dates Attended End Date
Type
Name of School
Address of School
Degree/Diploma/Certificate
Date
Date
Name, address, telephone of person who knew you there
Dates Attended
Dates Attended Start Date
—
Dates Attended End Date
Type
Name of School
Address of School
Degree/Diploma/Certificate
Date
Date
Name, address, telephone of person who knew you there
Dates Attended
Dates Attended Start Date
—
Dates Attended End Date
Type
Name of School
Address of School
Degree/Diploma/Certificate
Date
Date
Name, address, telephone of person who knew you there
Were you ever suspended or had disciplinary action taken against you at any of these institutions?
If "Yes" explain the circumstances on the provided form. Return the form to your background investigator.
Did you have any interaction with a law enforcement agency or public safety department while attending any of the educational institutions above?
If "Yes" explain the circumstances on the provided form. Return the form to your background investigator.
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Military Record

Have you ever served in the Armed Forces of the United States?*
If "Yes", what is the highest rank attained?
What is your selective service number?
*If unknown, call 1-847-688-3177 or visit https://www.sss.gov/regver/wfverification.aspx
Are you currently assigned to active duty?
If "YES" when will your military commitment be fulfilled?
Branch of Military Service
Serial Number
Dates of Active Duty
Dates of Active Duty Start Date
—
Dates of Active Duty End Date
Dates of Reserve
Dates of Reserve Start Date
—
Dates of Reserve End Date
Type of Discharge
Basis of Discharge
Rank at Discharge
Was any type of disciplinary action or non-judicial punishment (Captain's Mast, etc) taken against you in the service?
If "Yes", explain the circumstances on the provided form. Return the form to your background investigator.
National Guard/Reserves
Do you claim Veterans Preference?
Did you claim D.A.V. status on your civil service application?
Location of Active Duty Tours
If you attend drills, meetings, or camps give the name of the unit, location, contact person, and telephone number
Persons who knew you
List the names of three (3) persons (fellow servicemen/women, commanding officers, etc) who knew you in the service to offer information about your background.
Rank
Name
Last Known Address/Telephone
Years Known
Rank
Name
Last Known Address/Telephone
Years Known
Rank
Name
Last Known Address/Telephone
Years Known
Required Documentation
*You must provide your Certificate of Release or Discharge from Active Duty DD-214 for each period of non-continuous service. The Malden Police Department requires the long, un-edited form. Provide it to your background investigator.
Have you ever served in the armed forces of another nation?*
If "Yes" explain briefly
Have you ever been denied entrance or re-entrance to any of the U.S. Armed Forces for any reason?*
If "Yes" explain briefly
Have you ever been charged, detained, or arrested on a military installation for any reason?*
If "Yes" explain briefly. Include dates, places, law enforcement authority, type of court/court martial, charges & actions taken against you.
Provide all reports and documentation related to the event(s) to your background investigator.
While in military service, were you ever arrested and/or convicted for any offense? A defendant in a trial? Or have you been subjected to any disciplinary or corrective action or military justice?
If "Yes" briefly explain. Include dates, places, law enforcement authority, type of court/court martial, charges and actions taken against you.
Provide all reports and documentation related to the event(s) to your background investigator.
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Driver's License Information

Massachusetts Driver's License Number
Expiration Date
Expiration Date
Class
Restrictions
Have you ever possessed an operator's license from another state or country?*
If "Yes" explain briefly
List all registered motor vehicles you owned or leased within the past 5 years below
If necessary, provide additional info on the form provided. Return it to your background investigator.
License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
City Where Garaged
Insurance Company
License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
City Where Garaged
Insurance Company
License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
City Where Garaged
Insurance Company
License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
City Where Garaged
Insurance Company
License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
City Where Garaged
Insurance Company
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Driver History

As an operator/owner, have you ever received a written warning from a police officer in Massachusetts?*
As an operator/owner, have you ever received a citation from a police officer in Massachusetts?*
Has your license to operate a motor vehicle ever been suspended or revoked in Massachusetts or in any other state?*
As an operator, have you ever been involved in an automobile crash in any state?*
If "Yes" how many automobile crashes have you been involved in?
As an operator, have you ever received a written citation in any state other than Massachusetts?*
Have you ever operated a vehicle while under the influence of alcohol and/or drugs?*
Have you ever been cited or arrested for operating a vehicle while under the influence of alcohol and/or drugs?*
If you answered "YES" to any driver history question, explain the incident(s) below.
For automobile crashes, number and explain each incident separately.
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Fines, Tickets, Excise Taxes

Do you owe money for traffic fines in any jurisdiction?*
Do you owe money for parking tickets in any jurisdiction?*
Do you owe money for excise taxes in any jurisdiction?*
If "Yes" to any of the above, list the town/city or court jurisdiction and amount owed
City/Town/Court
State
Type of fine, tax
Amount Owed
City/Town/Court
State
Type of fine, tax
Amount Owed
City/Town/Court
State
Type of fine, tax
Amount Owed
NOTE: You will not receive further consideration for appointment until you provide proof of payment of all outside traffic fines, parking fines, and excise tax. You should consult the appropriate city or town hall to determine whether you have outstanding parking fines or excise tax bills.
If you have current appeals and/or litigation against these tickets, please explain below.
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Other Licenses

Have you ever been issued a firearms license or Firearms Identification Card (FID)?*
Date Issued
Date Issued
License/FID Number
Expiration Date
Expiration Date
Who Issued?
Address at time of issuance
City/Town
State
Zip Code
Have you ever applied for and been denied a firearm license?*
Have you ever applied for and been denied a Hackney License?*
Have you ever been issued a Hackney License?*
If "Yes", Date Issued and City/Town who issued
Have you ever been issued a special police officer's license?*
Were you ever denied a special police officer's license?*
If the answer to any of the questions above was "YES", have any of these licenses ever been revoked or suspended?
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Languages Spoken

Financial Background

Financial Background
Please ensure that you get an updated/recent CREDIT BUREAU check done at one of the following websites:
www.experian.com
www.transunion.com
www.equifax.com
Submit the CREDIT BUREAU CHECK to your background investigator.
Have you personally or a company in which you had more than ten percent (10%) ownership, filed for bankruptcy protection, been subjected to a tax lien or had a judgment rendered against you/company for debt?*
If you answered "YES", use the form provided and supply the date, the type of action (lien, bankruptcy judgment, etc), the name of the business (if applicable), the court involved and the docket number. Return this form to your background investigator.
Real Estate Ownership/Interest
List all real estate (land, houses, buildings, condominiums, etc) where you have an ownership interest as a principal, or as either the trustee or beneficiary of a real estate trust. If necessary, use the provided form for additional information. Return this form to your background investigator.
Property Address
Type of Property
Interest (owner, beneficiary,)
Property Address
Type of Property
Interest (owner, beneficiary,)
Property Address
Type of Property
Interest (owner, beneficiary,)
Civil Litigation
To the best of your knowledge, are there any civil action(s) pending against you?*
Have there been any civil actions commenced against you?*
Have you ever filed an insurance claim (for example theft, damaged or destroyed property, personal injury, accidents, etc)?*
If you answered "YES" to any Civil Litigation question, provide the following for each "YES" answer
Court Jurisdiction
Name of Case
Insurance Claim
Docket Number
Outcome
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Financial Background Continued

Gaming / Gambling

Use of Alcohol

Have you ever been involved in a fight while drinking?*
Have you ever been involved in a motor vehicle accident while drinking?*
Have you ever been taken into protective custody?*
If you answered "YES" to any of the above questions, explain the incident(s) below.
Continue |Go Back

History of Drug Use or Experimentation

Other Personal Declarations

Have you ever had sex with another person without their consent?*
Have you ever had unlawful sexual contact with a minor?*
Have you ever used drugs or alcohol to seduce a sex partner?*
Have you ever paid for or sought payment for sexual favors?*
Is there anything about your life that could subject you to blackmail?*
Have you ever sued someone or have you ever been sued?*
Is there anything not previously addressed that may cause a problem concerning your possible appointment as a police officer?*
Have you ever given misinformation or omitted information regarding an application for employer benefits, reimbursement, or compensation?*
Have you ever been a victim of a violent crime?*
Explain the circumstances to which you answered "YES" to any of the above questions.
Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group or combination of persons which has adopted, or has a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States by unconstitutional means?*
If the answer to the above question is "YES", explain fully here
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Other Personal Declarations Continued

An applicant for employment with a sealed record on file with the Commissioner of Probation may answer "no record" with respect to an inquiry herein relative to prior arrests and criminal court appearances. In addition, any applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances and adjudication in all cases of delinquency or as a child in need of services, which did not result in a complaint transferred to the Superior Court for criminal prosecution (See M.G.L. C276, s100a, s110c). However, one should know that the Malden Police Department/Recruit Investigations Unit will have access to said incidents.
Have you ever been convicted of a felony?*
If "Yes", Explain the circumstances
To the best of your knowledge and belief has any local, state, or federal law enforcement agency ever investigated your background for any purpose?*
If "Yes" Provide the information below
If necessary, use the provided form for additional information.
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
MM/YYYY
Investigating Agency
Purpose
Name of Investigator
Have the police ever been called to or summoned to an incident where you were present or had participated?*
If "Yes" explain briefly and include who called the police
Are there any incidents in which you have been contacted or interviewed by a police officer?*
If "Yes", list all such matters, even if not formally charged, no court appearance was required, found not guilty, or matter settled by payment or fine. Do not include traffic tickets.
Have you ever been in a physical confrontation or altercation with anyone, including your spouse, ex-spouse, children, relatives, girl/boyfriends, or parents? (To include pushing, shoving, etc.)*
If "Yes" explain briefly
Has your spouse, ex-spouse, children, relatives, girl/boyfriends or parents ever called the police on you for any reason?*
If "Yes" explain briefly
Has your spouse, ex-spouse, children, relatives, girl/boyfriends, or parents ever accused you of battery in a report or discussion with anyone else?*
If "Yes" explain briefly
Has anyone ever claimed that you have beaten, abused, mistreated, or sexually assaulted a child, no matter the relationship or non-relationship of the child to you?*
If "Yes" explain briefly
Have you ever been the victim of a crime?*
If "Yes" explain briefly
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References

List at least five (5) persons not related by blood or marriage who have known you for at least three (3) or more years. Do not list employees or supervisors (current or former).
Name
Complete Address/E-mail Address
Include City, State, and Zip Code
Phone Number
Name
Complete Address/E-mail Address
Include City, State, and Zip Code
Phone Number
Name
Complete Address/E-mail Address
Include City, State, and Zip Code
Phone Number
Name
Complete Address/E-mail Address
Include City, State, and Zip Code
Phone Number
Name
Complete Address/E-mail Address
Include City, State, and Zip Code
Phone Number
List at least 3 neighbors of your current address. If you have lived there less than 6 months, list the neighbors from your previous address. If you do not know your neighbor's name, indicate so, and provide the address.
Name
Complete Address/E-Mail Address
Include City, State, and Zip Code
Name
Complete Address/E-Mail Address
Include City, State, and Zip Code
Name
Complete Address/E-Mail Address
Include City, State, and Zip Code
Name
Complete Address/E-Mail Address
Include City, State, and Zip Code
Name
Complete Address/E-Mail Address
Include City, State, and Zip Code
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Training, Skills, Abilities, Interests

Summarize your experience, training, knowledge, skills and abilities, which, in your opinion, establishes your fitness for service with the Malden Police Department. Include experience in criminal justice agencies. Include special awards. If you need additional space, use the form provided.
Activity
Years
Awards/Certifications
Activity
Years
Awards/Certifications
Activity
Years
Awards/Certifications
Activity
Years
Awards/Certifications
Activity
Years
Awards/Certifications
Activity
Years
Awards/Certifications
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Applicant's Certification

Applicants Certification
I understand that any appointment tendered to me will be contingent upon the results of a complete character and fitness investigation, and I am aware that willfully withholding information or making false statements on this application will be the basis for rejection of my application or dismissal from the Malden Police Department and removal from the list of eligibility (Civil Service list). I agree to these conditions and hereby certify that all statements made by me on this application are true and complete, to the best of my knowledge.
I further understand that all appointments are probationary for a period of one (1) year commencing upon academy graduation. During this probationary time period my employment may be terminated at any time. I understand that I must successfully pass the Basic Student Officer Course at the police academy as well as a physical pre-screening administered by academy personnel. I also understand that the Malden Police Department has established regular night and midnight shifts. I understand that I may be called upon to work a variety of shifts including nights, holidays, and weekends. I agree to be available for any and all such assignments as the Malden Police Department may require.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date*
Date
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Supplemental Insert to Police Application

Do you hold any professional licenses, or have you held any other professional licenses in the past?*
If "Yes", what is the status of the license(s) and was it ever suspended or revoked?
Have you or your spouse performed any work or received any payments from any foreign government?*
Have you made any monetary or voluntary contributions to any foreign government?*
If "Yes", provide all details including the source and amount
Identify any instance where you testified before any district, municipal, state, or federal court and the nature of the testimony
Provide the names of any organizations, associations, or groups that you or any member of your immediate family has belonged to. Provide the status or type of position held within that group (to include any sports activities)
Have you or your spouse ever been the subject of a tax audit?*
Have you or your spouse ever been subject to a tax audit?*
Has there ever been a tax lien instituted against you or your spouse?*
If "Yes", describe the details of that lien
Describe any administrative proceedings in which you or your spouse has been involved in as a party or material witness.
Employment Record
Have you ever left a job under unfavorable circumstances?*
Have you ever been laid off from a job by an employer?*
Have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace?*
Have you received a written warning, been officially reprimanded, suspended, or disciplined for violating a security rule or policy?*
Do you have or have you ever had a U.S. Passport?*
Name in which it was issued
Passport Number
Date Issued
Date Issued
Expiration Date
Expiration Date
Status
Do you have dual citizenship?*
If "Yes", which country?
Foreign Contacts: Do you have or have you had close and/or continuing contact with foreign nationals within the last 7 years with whom you, your spouse, or your cohabitant are bound by affection, influence, and/or obligation? *
NOTE: A foreign national is defined as any person who is not a citizen or national of the U.S.
If "Yes", for each person include: Full Name, Dates known, Country or Countries of citizenship, Country of residence, Nature of relationship (business, personal, other), Type of contact (telephone, in-person, electronic correspondence, written correspondence, other), Number of contacts per year
Foreign Activities
Respond for the time frame of the last 7 years. Foreign financial interests (include stocks, personal property, company shares, investments, or ownership of corporate entities. Exclude U.S.-based fund managers and accounts managed through your employer).
Do you have or have you EVER had any foreign financial businesses, foreign bank accounts, or other foreign financial interests of which you have direct control or direct ownership?*
Type of financial interest
Amount in US dollars
Do you have or have you had any foreign financial interests that someone controls on your behalf?*
Type of financial interest and name of party who controls it
Amount in US dollars
Do you own or have you owned real estate in a foreign country?*
Type of property and dates owned
Location of property
Estimated value of property in US dollars
Do you receive or have you received any educational, medical, retirement, social welfare, or other such benefits from a foreign country?*
Type of benefit
Value in US dollars
Foreign Business, Professional Activities, and Foreign Government Contacts
Respond for the time frame of the last 7 years unless otherwise noted. Indicate if activity was on official US Government business.
Have you provided advice or support to anyone associated with a foreign organization that you have not previously listed as a former employer regarding any of the following: management, strategy, financing, or technology?*
Have you or any of your immediate family members been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency?*
Have you or any of your immediate family members had any contact with a foreign government, its establishment (embassies, consulates, agencies, or military services) or its representatives, whether inside or outside of the U.S.?*
Have you EVER held or do you now hold a passport that was issued by a foreign government?*
If "Yes", provide the name(s) in which your foreign passport(s) was issued, the issuing country(s), the passport number(s), the date(s) issued, the expiration date(s), and the status of each foreign country you have visited.
Travel Outside of the U.S. in the Last 7 Years
Respond for foreign countries you have visited in the last 7 years, beginning with the most current and working back. If you have lived near a border and have made short (one day or less) trips to the neighboring country (e.g. Canada or Mexico) you do not need to list each trip. Instead, provide the time period, the code, the country, and a note ("many short trips"). DO NOT list travel under official US Government business, but you must include any personal trips made in conjunction with the official US Government travel.
Code
MM/YYYY to MM/YYYY
Number of Days
Country
Code
MM/YYYY to MM/YYYY
Number of Days
Country
Code
MM/YYYY to MM/YYYY
Number of Days
Country
Code
MM/YYYY to MM/YYYY
Number of Days
Country
Code
MM/YYYY to MM/YYYY
Number of Days
Country
Association Record
The following questions pertain to your associations. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are dangerous to human life and appear to be intended to intimidate or coerce civilian population to influence policy of a government by intimidation or coercion or to affect the conduct of the government by mass destruction, assassination, or kidnapping.
Have you EVER been an officer or member of, or made a contribution to, an organization dedicated to terrorism, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities?*
Have you EVER been an officer or member of, or made contribution to, an organization dedicated to the use of violence or force to overthrow the US Government, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities?*
Have you EVER been an officer or a member of, or made contribution to, an organization that unlawfully advocates or practices the commission of acts of force or violence to discourage others from exercising their rights under the US Constitution or any state of the US with the specific intent to further such unlawful acts?*
Have you EVER advocated any acts of terrorism or activities designed to overthrow the US Government by force with the specific intent to incite others to unlawful action in furtherance of such aims?*
Have you EVER knowingly engaged in any activities designed to overthrow the US Government by force?*
Have you EVER knowingly engaged in any acts of terrorism? Your truthful response and information derived from your response to this question are for academy application purposes.*
Have you EVER participated in militias (not including official state government militias) or paramilitary groups?*
Have you EVER been investigated for security clearance?*
If you answered "YES" to any of the above questions, you must also explain in detail. Use the form provided and return this form to your background investigator.*
1. Yes, answered in detail on sheet of paper
2. No, answer to all above questions
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Driver History

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Financial Background

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Use of Alcohol

History of Drug Use or Experimentation

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References

Training, Skills, Abilities, Interests

Applicant's Certification

Supplemental Insert to Police Application

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