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WAIVER AND AUTHORIZATION TO RELEASE INFORMATION To Whom It May Concern: In exchange for the consideration by the Pasco Police Department of my application for the Explorer program, I authorize you to provide the Pasco Police Department with any information that you may have concerning me, my work record, my reputation, my medical records, my military service record, my fingerprints, and my financial status. Information of a confidential or privileged nature may be included. The information is necessary for the Department to determine my qualifications and fitness for the position I am seeking with the Pasco Police Department. I understand my rights under Title 5, United States Code, Section 552(a), the "Privacy Act of 1974," and waive those rights with the understanding that the Pasco Police Department will use the information furnished in conjunction with the Explorer Volunteer application. I further release the provider of this Information from all liability or damages resulting from furnishing the information requested above. I further agree that a photocopy reproduction of this Waiver and Authorization to Release Information shall be treated as an original for all intents and purposes. This Waiver and Authorization shall be valid for one hundred and eighty (180) days from the date written below. I hereby waive my right, now and in the future, to examine, review, or otherwise discover the contents of this investigation and all related documents thereto. This waiver and authorization to release Information also applies to the signed Parent/Guardian below. Dated Applicant Name: Social Security Number: Signature: Parent/Guardian Name: Signature: SUBSCRIBED AND SWORN before me Notary Public in and for the State of Washington. Residing in My Commission Expires: ---PAGE BREAK--- Pasco Police Department Explorer Application Revised 11/2023 INSTRUCTIONS (READ CAREFULLY) COMPLETE IN INK OR TYPE Before you submit your application, see that ALL information called for has been supplied. If your application is incomplete, it may affect the outcome of your application. Your application must be signed. Unsigned or incomplete applications cannot be accepted. All statements are subject to investigation and verification. Any false statement will be cause for rejection of your application and removal of your name from the register or dismissal from the Explorer Unit. The investigation of your application will include, but not be limited to, the following: Police Records Check, and School Records Check. I hereby certify that this application contains no willful misrepresentation and that the information being given by me is true and complete to the best of my knowledge and belief. I am aware that should an investigation at any time disclose any such misrepresentation or falsification, my application will be rejected, and my name may be removed from the Police Explorer eligibility list and/or membership of the Pasco Police Explorer Unit. PARENT/GUARDIAN: Last First Middle Maiden Name: Any other names you have gone by: S/S No.: WA. Driver’s License Current Address: Phone No.: City: State: Zip: Date of Birth: Height: Weight: Color of Hair: Color of Eyes: Place of Birth: ---PAGE BREAK--- Pasco Police Department Explorer Application Revised 11/2023 APPLICANT INFORMATION Name: Last First Middle Maiden Name: Any other names you have gone by: S/S No.: WA. Driver’s License: Current Address: Phone No.: City: State: Zip: Date of Birth: Height: Weight: Color of Hair: Color of Eyes: Place of Birth: EDUCATION Name of High School Attending: Location of High School Attending: High School Diploma or equivalent must be presented for verification Name and location of college(s): 1. 2. 3. Major subject Years completed Semester/Quarter Hours credited Degree Year if graduated Received 1. 2. 3. ---PAGE BREAK--- Pasco Police Department Explorer Application Revised 11/2023 COLLEGE DEGREE & TRANSCRIPTS MAY BE REQUESTED FOR VERIFICATION 1. Name and location of other schools attended (list below): Dates attended Major Graduated (Yes or No) 2. Have you ever been arrested for or convicted of a felony? Yes No Charge Date Convicted (Yes or No) Disposition 3. In the past seven years have you been arrested for, or convicted of a misdemeanor or a gross misdemeanor? (Answer on the following page.) Charge Date Convicted (Yes or No) Disposition 4. Have you in the past 3 years been found guilty of a traffic infraction? Infraction Date Disposition 5. RESIDENCE: (List all places you have lived during the past five years) Dates: To: From: Address: City: State: Zip: ---PAGE BREAK--- Pasco Police Department Explorer Application Revised 11/2023 Dates: To: From: Address: City: State: Zip: Dates: To: From: Address: City: State: Zip: Dates: To: From: Address: City: State: Zip: Dates: To: From: Address: City: State: Zip: Dates: To: From: Address: City: State: Zip: CHARACTER REFERENCES: List four persons who are not related to you, and are not former employers, who have definite knowledge of your character and fitness, for the position for which you are applying. 1. Name: Address: City: State: Zip: Phone: Occupation: Years Known: 2. Name: Address: City: State: Zip: Phone: Occupation: Years Known: ---PAGE BREAK--- Pasco Police Department Explorer Application Revised 11/2023 3. Name: Address: City: State: Zip: Phone: Occupation: Years Known: 4. Name: Address: City: State: Zip: Phone: Occupation: Years Known: 6. In the past three years have you used: Intoxicants [ ] Narcotics [ ] Stimulants [ ] Any form of Marijuana [ ] Hallucinogenic [ ] Tranquilizers [ ] If so, state to what extent: 7. Have you ever been fired or forced to resign in lieu of discharge from any job? If the answer is “yes,” explain in detail in the space provided below, keeping in mind that you are responsible for withholding information that might disqualify you for service in this department. 8. Social Media Accounts: Email(s): Facebook: X (Twitter): Snapchat: Tik Tok: Instagram: ---PAGE BREAK--- Pasco Police Department Explorer Application Revised 11/2023 9. Are there any unfavorable incidents in your life, not previously mentioned, which may be discovered by investigation? Yes No If yes, explain: I understand that it is my responsibility to keep the Pasco Police Department informed of any change of address and/or telephone number, and that failure to do so may result in my name being removed from the eligibility file. I have read and understand all questions and statements contained in this application. I certify that all questions and statements are true, correct, and complete to the best of my knowledge and belief, and I understand that any falsification or omission of facts shall be sufficient cause for termination. Date: Signature of Applicant Date: Signature of Consenting Parent/Guardian NOTE: The attached waiver must be signed by a notary and returned with your application. This application is for the sole use of the Pasco Police Department’s Explorer Program.