Police Officer Applicant Background Questionnaire - Sierra Vista Police Department Page 11

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YES  NO 

35.

Do you have prior peace officer certification/employment in Arizona or any other state(s)?

Dates of Employment

If YES provide the following information:

City

State

Name of Agency

From

If prior Arizona certified, attach verification of most current AZ POST continuing and proficiency training and firearms qualifications.

Has your peace officer certification been revoked, suspended, canceled or denied for any reason?



YES

If YES provide a full explanation on the Continuation Sheet.

Have you, while on duty as a peace officer and without authorization, used or been under the influence of spirituous liquor?



YES

If YES provide a full explanation on the Continuation Sheet.

Have you received discipline for any improper conduct as a peace

officer.

If YES provide a full explanation on the



YES

Continuation Sheet. Discipline: Letter of

reprimand/counseling,

suspension, termination or demotion.

36.

Have you applied with any other law enforcement agencies in the past three years?



YES

If YES provide the following information:

Date of Application

Was Polygraph taken?

Name of Agency



YES



YES



YES



YES



YES

37.

CERTIFICATION:

I hereby certify under penalty of law that the entries on this statement and the attached Continuation Sheet are true, complete and correct to the best

of my knowledge and belief. These entries are made in good faith. I understand that a false or misleading statement on this form constitutes a

violation of the law and is cause to deny, suspend or revoke peace officer certification.

SIGNATURE OF APPLICANT:

DATE:

AGENCY VERIFICATION:

INITIALS:

DATE:

INITIALS:

Previous Agencies Applied To Queried and Results Documented

Certification History Verified and Results Documented in File

Training and Firearms Requirements Documentation in File

Valid Certification Verified and Documentation in File