Police Department Personal History Statement Form (Page 6 of 22) in pdf

Employer’s name/address ___________________________________________________________________________

Telephone number: _______________ Supervisor’s name __________________________________________________

Start Date __________ End Date ___________ Starting salary __________________ Ending salary _________________

Your job title ___________________________________________________

Full time

Part time

Volunteer



Co-workers’ names - list three

1. ____________________________________________ Cell# ____________________

2. ____________________________________________ Cell# ___________________

3. ____________________________________________ Cell# ___________________

Why did you leave? _________________________________________________________________________________

May we contact this employer?

Yes

No If no, please explain ________________________________________



_________________________________________________________________________________________________

SIGNATURE OF APPLICANT

I certify that all information given on this application is true, correct, and complete to the best of my knowledge. I also certify that

I haveaccounted for all of my work, experience, and training on this application, and that I have not knowingly withheld any fact

or circumstancewhich would, if disclosed, affect my application unfavorably.

The City of Boise is hereby authorized to make any investigation of my employment, educational or background history

throughinvestigative agencies or bureaus of its choice. I release all relevant parties from all liability of any damages resulting from

furnishing such information.

If employed by the City of Boise, I agree to abide by its rules and regulations. I understand that discovery of misrepresentation

oromission of facts herein will make me ineligible for employment or be cause for immediate dismissal. I agree to furnish

additional information as may be required to complete my employment file. I understand that operating conditions may require

me to temporarilyand/or regularly work shifts other than the one for which I am applying and I agree to such scheduling change

as directed by my supervisor.

I have read and reviewed the description of the job for which I am applying. I understand that I must be capable of performing

theessential functions of the job effectively and safely, with or without reasonable accommodation.

I also understand that my employment may be subject to the successful completion of an employment physical examination,

and thatmy continued employment may be conditioned upon satisfactorily continuing to meet job-related physical and mental

requirements. If requested, I agree to submit to a job-related physical examination performed by a qualified medical person of the

City of Boise’s choice.Such exam shall be paid for by the City of Boise. I also agree that all information concerning said physical

examination can be supplied tothe City of Boise, or an authorized agent of this municipality, upon their request.

I further understand that the City of Boise is committed to providing a safe, productive, and efficient work environment and

toemploying a work force free from the use of illegal drugs, either on or off the job. The City of Boise has established a pre-

employment drug and alcohol testing policy. Pre-employment testing of applicants: As a condition of hiring, applicants will be

required to submit to a pre-employment drug and alcohol test conducted by the City of Boise’s authorized representative. Applicants

will provide a urine sample for drug testing. Breath alcohol testing will be performed by an evidential breath testing device. The test

results will be maintained in a confidential file, and only released to the City of Boise, its representatives, or as otherwise authorized

or required by law. The applicantreleases the City of Boise and its representatives from all liabilities relating to the drug testing

carried out under this policy, including,without limitation, the release of the test results. Any applicant who fails to report for a test,

refuses to take a test, fails to provide aspecimen, tampers with a test specimen or who is identified with verified positive test results

will be denied employment at that time.Applicants identified with verified positive test results may reapply after one (1) year from

the date of the initial test with proof of successfulcompletion of a rehabilitation program through a state-licensed facility.

I understand that this is an application for employment and that no employment contract, either express or implied, is being offered.I

also understand that if employed, such employment is for an indefinite period and can be terminated at will by either party, with

orwithout notice, at any time, for any or no reason, and is subject to change in wages, conditions, benefits, and operating policies.

Date: ___________________________________ Signature of Applicant: ____________________________________

Police Department Personal History Statement Form Page 6

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