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REDMOND POLICE DEPARTMENT LAW ENFORCEMENT EXPLORER POST #2913 APPLICATION FOR EXPLORER UNIT MEMBERSHIP INSTRUCTIONS: Fill out this application completely and accurately. All statements in your application are subject to verification. Incorrect, misleading or false statements will result in your rejection. If space is inadequate, add another page and identify additional information by item number. Type or print all answers in black ink and all capital letters. If you have any questions, please contact an Explorer Advisor. Do not leave questions blank; write N/A if needed. PERSONAL HISTORY: 1. Name: (Last) (First) (Middle) 2. Address: (Number) (Street) (City, State, Zip) 3. Phone: (Home) (Cell) 4. Email: 5. With whom do you reside: 6. Date of Birth: (MM/DD/YYYY) 7. Place of Birth: (City, State, Country) 8. Height: Hair Color: Eyes: 9. Social Security Number: - - ---PAGE BREAK--- 10. Are you a U.S. Citizen? Natural Born? Naturalized? 11. List all organizations, clubs and associations of which you are or have been a member, or which you are or have been associated: 12. What are your hobbies, special skills, and abilities? Include any athletics, foreign languages, etc. FAMILY HISTORY: 13. Give the names of every living member of your immediate family: parents [biological, foster, step or whatever is applicable] and siblings. Name Relationship Address Phone RESIDENCES: 14. List addresses where you have lived in the past five years, starting with the most recent and moving back. Address City, State Approximate Dates ---PAGE BREAK--- WORK HISTORY: 15. List your previous employers, starting with your current job and moving back. Company Name Address/Location Job Title & Duties Approx. Dates 16. Were you ever discharged, fired or forced to resign from a job because of misconduct or unsatisfactory performance? Yes No If yes, please explain: EDUCATION: 17. Indicate below the schools you’ve attended: Name Location / City, State Approx. Dates College: High School: Jr/Middle: Elementary: 18. Please list your current classes. If you include a printed schedule, please remember to include school phone numbers. Class Instructor Phone Number ---PAGE BREAK--- 19. Attach a copy of your most recent grade report or transcript to this application. If unable, please explain why below. 20. Have you ever been expelled or suspended from any school, or have you ever received any official discipline by a school [detention, etc]? Yes: No: If yes, please explain: CRIMINAL HISTORY: Answer all of the following questions completely and accurately. Any falsifications or misstatements of the fact will result in disqualification. 21. Have you ever been stopped and/or questioned by the police? Yes No If yes, please explain: 22. Have you ever been arrested, issued a criminal citation or had to go to court reference a police investigation? Yes No If yes, please explain: 23. Have you ever been required to pay a fine in excess of $25.00? Yes No If yes, please explain: 24. Have you ever been placed on probation? Yes No If yes, please explain: ---PAGE BREAK--- 25. Have you ever used illegal drugs, including prescription drugs not prescribed to you? Yes No If yes, please explain: 26. Have you ever consumed alcoholic beverages? Yes No If yes, please explain: 27. Have you ever committed a crime but were not caught? Yes No If yes, please explain: DRIVING HISTORY: 28. Do you possess a valid Washington Driver’s License? Yes No Include Instruction Permit License Number: 29. Have you ever had your license revoked or suspended? Yes No If yes, explain in detail: 30. Has your license ever been placed on probationary status? Yes No Note: this is not referring to the Intermediate License. If yes, explain in detail: 31. Have you ever been involved in a motor vehicle collision? Yes No If yes, give details for each collision: date, location, injuries, investigating police agency if police responded, and cause of collision. ---PAGE BREAK--- 32. Have you ever received a traffic citation or warning? Yes No If yes, give details: police agency, date, offense. Include all written or verbal warnings. MEDICAL HISTORY: 33. Who is your family physician? Name primary care physician usually contacted or consulted, or clinic to be contacted for records in case of emergency. Name of Physician / Clinic Address Phone 34. List your medical insurance information in case of emergency: Company Address City, State, Zip Phone Policy # Subscriber # 35. List any serious allergies and necessary treatment in case of exposure epi-pen] OTHER: 36. Do you object to wearing a uniform? Yes No 37. Do you object to volunteering your time during evenings? Yes No 38. Briefly, in your own handwriting, explain what your present occupational plans are and why you wish to join this organization. ---PAGE BREAK--- 39. List three personal references who are not relatives. Name Address City, State, Zip Phone Number and Email 1. 2. 3. 40. Statement of Honesty and Fingerprint / Background Waiver: I understand that my prospective position with the Redmond Police Department Explorers is dependent upon the truthfulness and accuracy of the statements contained herein, and that I am subject to termination if any statement in this application is false or misleading. If hired I agree to conform to all rules and regulations of the Redmond Police Department and Redmond Police Explorers. I certify that I have read and understand the paragraph above, and that the information provided in this application is truthful to the best of my knowledge. I consent to and authorize the Redmond Police Department to conduct a background check including but not limited to a juvenile and criminal history records check, fingerprinting and reference checks. Applicant Signature Date Parent/Legal Guardian [If Under 18] Date ---PAGE BREAK--- 41. Waiver of Liability, Release of Claims and Indemnification As consideration for being a member of the Redmond Police Explorers and therby being permitted to engage in Redmond Police Explorer activities which may further my or my child’s education and knowledge of police activities; I, the undersigned, hereby agree to indemnify and hold harmless the City of Redmond, its officials, officers, employees, agents and volunteers from any and all claims, injuries, or damages of any nature, sustained to my person or property which occur as a result of or during my or my child’s accompanying members of the Redmond Police Department during their official duties, or during Redmond Police Explorer activities. I further release and waive any and all claims and causes of action, including but not limited to actions based on negligence, which may arise against the City of Redmond, its officials, officers, employees, agents and volunteers, as a result of any injury to my or my child’s person or property which occur as a result of or during my or my child’s accompanying members of the Redmond Police Department during their official duties, or while engaging in any Redmond Police Explorer activity. I further agree for myself, my heirs, executors, adminstrators and assigns, to defend and indemnify the City of Redmond, its officials officers, employees agents and volunteers, their sureties against any and all actions, suits, debts, claims, demands, damages, liability, or expenses of any kind incurred or arising by reason of any actual or claimed negligence or wrongful act or omission of mine or my child’s while accompanying any City of Redmond official, officer, employee, agent and volunteer, or while engaging in any Redmond Police Explorer activity. All parties signing below endorse the preceding three paragraphs as their own and represent that the waiver of liability, release of claims and indemnification is entered into a knowing an intelligent manner and pursuant to his or her free will. Applicant’s Signature Date Parent’s Signature [If Under 18] Date Parent’s Signature [If Under 18] Date