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PASCO POLICE DEPARTMENT VOLUNTEER APPLICATION Today’s Last First Middle Maiden/Other Current Residence Business Residential Date of Birth Social Security U.S. Citizenship____Yes____No If No, Citizen of which Visa Classification________________ Driver’s License List all the addresses where you have lived in the past five years, beginning with your present address and list backward. Attach additional sheets if necessary. Address, City, State, Zip Code Date From Date To Month Year Month Year Address, City, State, Zip Code Date From Date To Month Year Month Year Address, City, State, Zip Code Date From Date To Month Year Month Year Education: (Circle highest grade completed) 10, 11, 12, 13, 14, 15, 16, 17, Name of High School attended: Location of High School attended: 1 ---PAGE BREAK--- High School Diploma or equivalent must be presented for verification Name and location of college(s) attended: Do you speak or read a foreign language? Yes ( ) No ( ) Which one(s)? CRIMINAL HISTORY CHECK Have you been convicted of a felony or misdemeanor crime? Yes ( ) No ( ) If yes, explain on page 10. EMPLOYMENT HISTORY List all employment you have had over the past ten (10) years, beginning with the most recent. Include military, full and part-time employment and all periods of employment. Attach additional sheets if necessary. Business Name Address, City, State, Zip Code Phone From: Month Year Position Held Supervisor To: Month Year Duties Co-Worker Reason For Leaving Employment (Circle One) Fired Quit Laid-Off Asked to leave [Explain] Business Name Address, City, State, Zip Code Phone From: Month Year Position Held Supervisor To: Month Year Duties Co-Worker Reason For Leaving Employment (Circle One) Fired Quit Laid-Off Asked to leave [Explain] 2 ---PAGE BREAK--- Business Name Address, City, State, Zip Code Phone From: Month Year Position Held Supervisor To: Month Year Duties Co-Worker Reason For Leaving Employment (Circle One) Fired Quit Laid-Off Asked to leave [Explain] PERSONAL REFERENCES List only persons you have known for at least one year. Do not list relatives, former employers, teachers or physicians. Name: Last/First/Middle Home Address, City, State, Zip Code Home Telephone Business Name Business Address, City, State, Zip Code Business Telephone Name: Last/First/Middle Home Address, City, State, Zip Code Home Telephone Business Name Business Address, City, State, Zip Code Business Telephone Name: Last/First/Middle Home Address, City, State, Zip Code Home Telephone Business Name Business Address, City, State, Zip Code Business Telephone DOMESTIC VIOLENCE Have you ever been convicted of any type of crime involving domestic violence? Yes ( ) No ( ) Have you ever committed an act of domestic violence? Yes ( ) No ( ) If yes explain on page 4. Have you ever been involved in a child abuse or child neglect investigation of any kind? Yes ( ) No ( ) If yes explain on page 4. 3 ---PAGE BREAK--- Have you ever been a victim of a Domestic Violence? Yes ( ) No ( ) If yes explain on page 4. Have you ever been a Respondent in a Protection Order? Yes ( ) No ( Explain on page 4. Have you ever been a Petitioner in a Protection Order? Yes ( ) No ( ) Explain on page 4. ADDITIONAL QUESTIONS Have you used marijuana, illegal drugs, or abused prescription drugs? Yes ( ) No ( ) If yes, name the substance, the frequency of use, and period of uses on page 4. Have you ever bought, sold, distributed, manufactured or abused illegal drugs? Yes ( ) No ( ) If yes, name the substance, the frequency of use, and period of uses on page 4. Since the age of sixteen, have you ever stolen money or property from an employer or stolen money or property from someone else? Yes ( ) No ( ) If yes, explain the circumstances, item or amount, and when on page 4. CERTIFICATION STATEMENT I certify that all of the above questions have been answered to the best of my knowledge, and I understand that any false answers, omissions, or deceptions may be the basis for my rejection or termination from volunteering. I understand before being accepted into this program a criminal history check, personal history reference check and personal interview will be conducted. Signature: Date: When using this additional space below note the specific section. 4 ---PAGE BREAK--- OFFICIAL OFFICE USE ONLY Date Started: Date Ended: 5 ---PAGE BREAK--- WAIVER AND AUTHORIZATION TO RELEASE INFORMATION TO WHOM IT MAY CONCERN: In exchange for the consideration by the Pasco Police Department of my application to volunteer, I authorize you to provide to the Pasco Police Department any and all information you might have concerning me, my work record, my reputation, my medical records, my military service record, and my financial status, including any information that may deemed confidential or privileged. This information is necessary for the Department to determine my qualifications and fitness for the volunteer position which 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 information furnished will be used by the Pasco Police Department in conjunction with the volunteer application and future employment with the Department. I further release the provider of this information from any and all liability or damages which may result from the furnishing of the information requested above. I further authorize the release of any information received by the Department in the evaluation of my volunteer application (including the release of all test results) to another law enforcement agency. I further agree that a photocopy reproduction of this Waiver and Authorization to Release Information shall for all intents and purposes be treated as an original. This Waiver and Authorization shall be valid for a period of 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. DATED this day of Applicant: Type or Print Name Social Security Number Signature SUBSCRIBED AND SWORN TO before me this of Notary Public in and for the State of Washington. Residing in My Commission Expires: 6 ---PAGE BREAK--- PASCO POLICE DEPARTMENT VOLUNTEER AGREEMENT As a Volunteer, I agree to: • Perform the tasks outlined in my task description to the best of my ability. • Attend any training offered that will enhance my performance within the Department. • Report to work on time when scheduled, and to call my supervisor if I am unable to report. • Comply with and follow the same rules and policies as required of all Pasco Police Department employees. • Refrain from using my Volunteer position to attempt to influence anyone in any manner. • Strive to help the Department obtain its goal and objectives. • Notify my supervisor and the Volunteer Coordinator upon terminating my involvement with the program, and participate in an exit interview/evaluation. I will relinquish to the Volunteer Coordinator any and all items or equipment issued to me including, but not limited to, an identification card, identification codes/keys at the time of voluntary or involuntary termination. • Notify the supervisor or Volunteer Coordinator of any arrest or citation for any traffic, misdemeanor or felony charge. • I am aware that my Volunteer status may be terminated at any time for failing to follow the rules, procedures, and terms of this agreement. I further understand that I am an “at will” volunteer and may be removed without cause. I have read and understand all the conditions of this agreement. Volunteer’s Volunteer Coordinator’s 7 ---PAGE BREAK--- PASCO POLICE DEPARTMENT VOLUNTEER STATEMENT OF CONFIDENTIALITY AND WAIVER FORM I understand that any material omissions and/or false information I record on the application will be sufficient reason for rejection of this application or termination of my Volunteer status. In addition, I authorize and request former employers, schools, individual agencies, organizations or law enforcement agencies to answer any and all questions that may be asked and do here withhold such persons harmless for giving any information within their knowledge or record. As a condition of acceptance as a Volunteer, I agree to submit documents relating to my identity and employment authorization within prescribed time limits in accordance with the Immigration Reform and Control Act of 1986. I understand that I do not have the right to continue my status or utilize appeal rights as a Volunteer if terminated. Also, I understand that I am not an employee of the City of Pasco or any department thereof, and am not eligible for any remuneration or benefits of any kind or nature. I understand and agree that in the performance of my duties as a Volunteer with the Pasco Police Department, I will hold all names and information regarding the Department in the strictest confidence. Further, I understand that intentional or involuntary disclosure of confidential information to unauthorized sources may result in my termination as a Volunteer. I further agree to release the City of Pasco, Washington, its departments, and employees from accountability for any accident, injury, or other liability incurred or suffered by me while carrying out the duties of a Volunteer. Volunteer Signature Date: Volunteer Date: 8 ---PAGE BREAK--- Pasco Police Department VOLUNTEER EMERGENCY DATA SHEET Date: Name: Last First Middle Job Classification: Volunteer Home Address: Home Phone: City: State: Zip Code: PERSON TO BE NOTIFIED IN CASE OF EMERGENCY PRIMARY CONTACT Name: Relationship: Home Address: Telephone Business Address: Telephone No. Cellular No. Pager No. SECONDARY CONTACT Name: Relationship: Home Address: Telephone Business Address: Telephone No. Cellular No. Pager No. YOUR PHYSICIAN INFORMATION Name: Address: City: State: Zip Code: 9 ---PAGE BREAK--- 10 Phone Numbers: Business Home Emergency Number Other Are you Allergic to any Drugs? No ( ) Yes ( ) Specify: ANY ADDITIONAL INFORMATION YOU WISH TO SUPPLY SO EMERGENCY CARE CAN BE OBTAINED FOR YOU QUICKLY, IF NEEDED, PLEASE MAKE NOTATION BELOW.