Police Officer Applicant Background Questionnaire - Sierra Vista Police Department Page 10
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2430.
ILLEGAL/NON-MEDICAL USE OF OR CRIMINAL INVOLVEMENT WITH DRUGS/CONTROLLED SUBSTANCES:
In this section, disclose all illegal drug use (or criminal involvement) that was not for the purpose of treating or alleviating the symptoms of a medical
condition.
Drug use for medical purposes will be disclosed in a different portion of the application process.
HAVE YOU EVER SOLD, SMUGGLED
HOW MANY
HAVE YOU EVER USED, TRIED
IF YES HOW
DATE FIRST
DATE LAST
TYPE OF DRUG
OR TRANSPORTED FOR SALE OR
TIMES AFTER
OR EXPERIMENTED WITH?
MANY TIMES?
USED
USED
PERSONAL GAIN?
AGE 21?
MARIJUANA
YES NO
YES NO
COCAINE/CRACK
YES NO
YES NO
METHAMPHETAMINE/SPEED
YES NO
YES NO
HEROIN
YES NO
YES NO
OPIUM
YES NO
YES NO
MORPHINE
YES NO
YES NO
LSD/ACID
YES NO
YES NO
PEYOTE
YES NO
YES NO
MESCALINE
YES NO
YES NO
HASHISH
YES NO
YES NO
STEROIDS
YES NO
YES NO
ANY OTHER ILLEGAL DRUG
YES NO
YES NO
OR NARCOTIC
ILLEGAL USE OF
YES NO
YES NO
PRESCRIPTION DRUGS
31.
IF YOU ANSWERED YES ON ANY OF THE AREAS IN QUESTION #30, PROVIDE A FULL EXPLANATION ON THE CONTINUATION SHEET.
INCLUDE, IF APPLICABLE, THE FOLLOWING:
a. How the drug was ingested or consumed,
d.
How the drug was obtained,
b. The duration of usage,
e.
Why you stopped using the drug,
The motivation for use,
f.
Any other factors you believe are relevant.
C.
32.
CRIMINAL CONDUCT:
YES NO
a.
Have you ever committed a felony or an offense which would be a felony if committed in this state?
YES NO
b.
Have you ever committed a criminal offense involving dishonesty, theft, unlawful sexual conduct or physical violence?
If Yes to either 32a or 32b, provide a full explanation on the Continuation Sheet.
33.
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 shows a policy of advocating the commission of force or violence to deny
YES NO
other persons their rights under the Constitution of the United States of America or the state of Arizona, or which seeks to
alter the form of government of the United States of America by unconstitutional means?
If YES provide a full explanation on the Continuation Sheet.
34.
Do you have any knowledge or information, in addition to that specifically required in this questionnaire, which is or may
be relevant, directly or indirectly, to an investigation of your eligibility or fitness for the position you are seeking? This
YES NO
includes, but is not limited to: character traits, temperance habits, employment, education, subversive activities, family,
associations or traffic violations?
If YES provide a full explanation on the Continuation Sheet.
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
Applicant Meets Drug Standards/Does Not Meet Standards Yes No
ACIC/ACCH Checked
Criminal History Check Completed and Documentation in File
NCIC/III Checked
AZ POST Form PH (Sept. 2015) Page 7 of 10
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