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CHEYENNE MOUNTAIN STATE PARK APPLICATION FOR COMMISSIONED RANGERINSTRUCTIONS: READ CAREFULLY

PRINT IN INK – DO NOT TYPE

Read every question carefully. Answer every question. If a question does not pertain to you, indicate so by marking “D.N.A.” within the appropriate space. Leave no blank spaces unless otherwise directed.

All information is subject to verification. Any misstatements, misrepresentations or omissions by you are cause for disqualification for employment consideration. Any falsifications discovered after you are employed are cause for dismissal.

1. Name (Last) (First) (Full Middle)

2. List any other names, nicknames or aliases you have used or been known by, including birth or married names

3. Home Address No. Street City State Zip Dates (From/To)

4 Previous Address No. Street City State Zip Dates (From/To)

Previous Address No. Street City State Zip Dates (From/To)

Previous Address No. Street City State Zip Dates (From/To)

5. 6. Home Phone Number Cell Phone Number/Pager Number

7. 8. Social Security Number P.O.S.T. Certificate Number/State of Issue

9. Place of Birth: City County State Country

10. Are you a U.S. Citizen by birth: Y N (If Yes, go to Question #16)

11. If not, are you a naturalized U.S. Citizen Y N

12 Date and Place of Naturalization

Office Use Only

Application #

Interview

Hire Y N

Start Date_

Supervisor Initial_

Section Hired

POSITION APPLIED FOR – CIRCLE ONE - (Specify Unarmed, Armed or Both, if qualified)

Return completed application to: Cheyenne Mountain State Park

410 JL Ranch HeightsColorado Springs, CO 80926

Phone: (719) 576-2016Fax: (719) 576-9099

E-mail: Cheyenne.Park@state.co.us

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Applicant’s Printed Name (last, first, middle)

13. If not a U. S. Citizen, what is your citizenship?

14. Alien Registration Number

15. Are you authorized to work in the U.S.? Y N

16. List any scars, tattoos, identifying marks, etc., which you have:

17. Have you ever been a member of the Armed Forces? Y N (If No, go to Question #26)

18. Branch_ 19. Dates From To

20. Type of Discharge 21. Present Status

22. Were you ever subject to any disciplinary action while in the service? Y N

23. Date(s) of Action 24. Reason for Action_

25. Nature of Action

(If you have had more than one period of service, or served in the armed forces of any other nation, give details on the back of this page.) ATTACH A COPY OF YOUR DD-214 TO THIS APPLICATION.

26. Provide the information requested below concerning high schools, colleges and universities you have

attended, using complete addresses. ATTACH COPIES OF DIPLOMAS AND CERTIFICATES.

School Address Dates Attended Hours Degree

27. List any correspondence, trade or military schools you have attended, using complete addresses. ATTACH COPIES OF DIPLOMAS AND CERTIFICATES.

School Address Dates Attended Hours Degree

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Applicant’s Printed Name (last, first, middle)

28. List all professional licenses or certificates you now hold or have held, including the issuing agency or department. ATTACH COPIES OF CURRENT LICENSES OR CERTIFICATES.

License/Certificate Date of Issue Date of Expiration Issued By

29. List all organizations, professional associations, or societies of which you are, or have been a member.

30. What languages are you fluent in, either oral and/or written?

31. Have you ever been expelled or suspended from any school? Y N (If No, go to Question #34)

32. Dates of Suspension/Expulsion

33. Reason for Suspension/Expulsion

QUESTIONS #34 THROUGH #45 REQUIRE A “YES” OR “NO” ANSWER. FOR ANY QUESTION THAT YOU ANSWER “YES”, PROVIDE ON A SEPARATE PAGE, A DETAILED EXPLANATION, INCLUDING ALL NAMES AND PERSONS OR AGENCIES INVOLVED, DATES, PLACES AND THE OUTCOME OF ANY INCIDENTS. BE VERY SPECIFIC.

34. Have you ever been the subject of a complaint or disciplinary action alleging any breach of ethics, improper or unprofessional conduct by any court, administrative agency, disciplinary committee, medical or bar association, or other professional organization?

Y N

35. Have you ever been denied a privileged or professional license, withdrawn a privileged or professional

license application or had any disciplinary action taken against any such license that you have held, either individually or as part of an ownership/management group.

Y N

36. Have you ever been convicted of a misdemeanor crime which has, as an element, the use or attempted

use of physical force, or the threatened use of a deadly weapon, committed against a current or former spouse or domestic partner, parent, guardian, sibling or child?

Y N

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Applicant’s Printed Name (last, first, middle)

37. Has a formal complaint ever been made against you, or against any business or organization in which you were either employed or a member, which alleged that your actions or activities had caused a violation of any person’s civil rights?

Y N

38. Have you ever been involved, for any reason, in any type of civil action as a defendant or respondent?

Y N

39. Has a lien, judgement or collection procedure ever been instituted against you?

Y N

40. To your knowledge have you ever been or are you now under investigation for any crime, civil wrong or violation of lawfully adopted regulatory rules or regulations by any federal, state or local government agency or by any grand jury?

Y N

QUESTIONS #41 THROUGH #45 REQUIRE A “YES” OR “NO” ANSWER. FOR ANY QUESTION THAT YOU

ANSWER “YES”, YOU MUST OBTAIN OFFICIAL DOCUMENTATION FROM THE COURT WHERE YOU APPEARED, SHOWING THE FINAL DISPOSITION (OUTCOME) OF YOUR CASE. IF YOU RECEIVED A DEFERRED JUDGEMENT, A DEFERRED SENTENCE, PAROLE OR PROBATION, YOUR DOCUMENTATION MUST INCLUDE THE DATE THAT YOU WERE DISCHARGED OR RELEASED FROM PROBATION OR OTHER SUPERVISION.

41. Have you ever been arrested, served with a criminal summons, charged with, or convicted of any crime or

offense in any manner in this or any other country? • You must include ALL arrests, charges and convictions regardless of the outcome, even if

the charges were dismissed or you were found not guilty. • You must include ALL arrests, charges and convictions regardless of the class of the crime

(felonies, misdemeanors, and/or petty offenses) • You must include ALL serious traffic offenses, including but not limited to DUI; DWAI;

reckless driving; careless driving; leaving the scene of an accident (hit and run); driving under denial, suspension or revocation; or any offense which resulted in your being taken into custody.

• DO NOT RELY upon your understanding that an arrest or charge is “not supposed to be on your record”.

Y N

42. Has a criminal indictment, information or complaint ever been returned against you, in this or any other

country, but for which you were not arrested or in which you were named as an un-indicted co-party?

Y N

43. Have you ever been questioned by a city, county, provincial, federal or any other domestic or foreign governmental or law enforcement or regulatory agency, commission or committee?

Y N

44. Have you ever been subpoenaed to appear to testify before a federal, state, county or other domestic or

foreign governmental grand jury, board, commission or regulatory body?

Y N

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Applicant’s Printed Name (last, first, middle)

45. Have you ever received a pardon or its equivalent for any criminal offense in this or any other country?

Y N

46. Have you ever been the victim of a crime? Y N If “Yes” explain

47.

Was this crime reported to the police? Y N

48. Have you ever been fingerprinted by a police agency other than for an arrest? Y N

49. Are there any reasons that you are unable to operate a motor vehicle?

Y N If “Yes” explain

50. Do you possess a valid Colorado Driver License? Y N

51. 52. Driver License Number/State Date of Expiration

53. List any and all states in which you have held a valid driver license and the year(s) it was valid:

54. Has your privilege to operate a motor vehicle in any state ever been subject to denial, suspension, revocation or probation?

Y N If “Yes” explain

55. List all traffic citations you have received during the past five years:

Date Agency/Location Violation Penalty/Disposition

If there are additional violations, list them on a separate sheet.

56. Are there any warrants or outstanding judgements pending against you at this time?

Y N

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Applicant’s Printed Name (last, first, middle)

57. Have you ever been a security officer, law enforcement officer, reserve officer, agent or employee of aprivate security firm, military law enforcement or public law enforcement agency?

Y N (If “No” go to Question #59)

58. What positions and agencies have you previously worked or volunteered?

Agency/Company Position Paid or Volunteer Dates (From-To)

59. Were you ever discharged or forced to resign because of unsatisfactory service or while underinvestigation; or did you ever resign while an investigation was pending against you?

Y N If “Yes” explain

60. Were you ever discharged, asked to resign, furloughed or put on administrative leave (with or withoutpay), or subjected to disciplinary action?

Y N If “Yes” explain

61. Indicate any employers you do not wish us to contact and state why.

Agency/Company Reason for No Contact

62. Do you use, or have you ever used, alcohol? Y N

63. To the best of your recollection, how many times have you been intoxicated during the past 12 months,solely through the consumption of alcoholic beverages:

64. Indicate the number and type of drinks per week:

65. Do you feel you have a drinking problem? Y N

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Applicant’s Printed Name (last, first, middle)

66. Have you ever operated a motor vehicle while under the influence of an alcoholic beverage?

Y N

69. To the best of your recollection, how many times have you used marijuana?

First Date Used Last Date Used

70. Have you ever used any controlled substances without a doctor’s prescription (including amphetamines,barbiturates, hallucinogens, hashish, cocaine, opiates, etc)?

Y N

71. For each controlled substance used without a legal doctor’s prescription complete the following:

Type of Substance # of Times Used Beginning Date Ending Date Reason for Use

If additional room is needed use an additional sheet of paper.

72. Have you ever operated a motor vehicle while under the influence of narcotics, drugs or marijuana?

Y N

73. Have you ever missed any time at work due to use of drugs? Y N

74. Are you able to perform the essential functions of this job with or without reasonable accommodation?

With Without

75. If you are selected for the position applied for, is there anything in your personal or professionalbackground, which might reflect badly in the eyes of the public or create any actual or apparent conflict ofinterest?

Y N If “yes” explain

67. Have you ever missed any time at work due to use of alcohol? Y N

68. Do you use, or have you ever used, marijuana? Y N

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Applicant’s Printed Name (last, first, middle)

PLEASE READ THESE INSTRUCTIONS PRIOR TO COMPLETING THE WORK HISTORY

This portion must be accurate and complete. Applications lacking sufficient information will be rejected. List jobs in reverse order, starting with your present, or last employer. To evaluate your qualifications, we must have accurate and complete information on previous job tasks and levels of responsibility. Be thorough and specific in the detailing of duties.

Present or Last Employer Area Code/Phone Number

Address City State Zip

Position Hours/Week Dates of Employment (From – To) Supervisor Last Pay/Hour Reason for LeavingJob Duties

Present or Last Employer Area Code/Phone Number

Address City State Zip

Position Hours/Week Dates of Employment (From – To) Supervisor Last Pay/Hour Reason for LeavingJob Duties

Present or Last Employer Area Code/Phone Number

Address City State Zip

Position Hours/Week Dates of Employment (From – To) Supervisor

Last Pay/Hour Reason for Leaving

Job Duties

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Applicant’s Printed Name (last, first, middle)

List the names of five (5) adults, NOT related to you and NOT former employers or references, which are friends, fellow students or fellow employees. Names listed should be those of persons who you have seen frequently during the past year. Applications lacking sufficient information will be rejected.

Name Home Area Code/Phone Number

Address City State Zip

Occupation Employer Business Area Code/Phone Number

Years Known Relationship

Name Home Area Code/Phone Number

Address City State Zip

Occupation Employer Business Area Code/Phone Number

Years Known Relationship

Name Home Area Code/Phone Number

Address City State Zip

Occupation Employer Business Area Code/Phone Number

Years Known Relationship

Name Home Area Code/Phone Number

Address City State Zip

Occupation Employer Business Area Code/Phone Number

Years Known Relationship

Name Home Area Code/Phone Number

Address City State Zip

Occupation Employer Business Area Code/Phone Number

Years Known Relationship

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Applicant’s Printed Name (last, first, middle)

In your own handwriting, please indicate why you have chosen a career in the Natural Resources, Law Enforcement or Criminal Justice field and then list your goals and objectives in your chosen career.

CERTIFICATION I hereby certify that all of the information provided by me in this document is true, correct, accurate, and complete to the best of my knowledge and belief; and I understand that any false information or intentional omission may be grounds for dismissal from employment or the denial of employment.

Applicant’s Printed Name (last, first, middle)

Signature Date

INVESTIGATION AUTHORIZATION AUTHORIZATION TO RELEASE INFORMATION

I, , hereby authorize the Colorado Division of Parks (“the Division”), a law enforcement agency of the State of Colorado, to conduct an investigation into my personal background. I expressly authorize the Division to:

(1) Obtain any record of police contacts, arrests, summonses, intelligence information, and any other criminalhistory information and criminal justice information concerning me;

(2) Obtain any other information concerning me which is held pursuant to law or regulation by any court orgovernmental agency;

(3) Obtain consumer credit reports about me, and to obtain other financial information about me which willinclude: paying government insured student loans, paying child support, paying government obligationsof any type, and paying obligations in which there is a government or public interest;

(4) Obtain information concerning my receipt of government or government-authorized payments including,but not limited to, unemployment compensation, workman’s compensation, and other benefits of anytype;

(5) Obtain academic information and/or transcripts from any high school, trade, technical, or vocationalschool, college, or university necessary to determine that I meet the educational or technicalrequirements and/or hold certifications required for my position;

(6) Obtain employment history and employment reference information about me from my present employerand from any past employer I have had, and to obtain personal reference information;

(7) Obtain medical information about me sufficient to learn about the general status of my health.

I authorize any person to whom this form, or a reproduction hereof, is presented to release to the Division any information they have concerning me which meets the criteria set forth above in paragraphs numbered (1) through (7). I authorize this information to be released to the Division, even though such information may be designated as “confidential” or “non-public” pursuant to agreement or policy. Any information which has been sealed or expunged by court order, or which is not releasable pursuant to state or federal law, is not included by this release and may properly be withheld from the Division.

I understand that the Division reserves the right to investigate all relevant information, facts, and records to its satisfaction, and to determine the accuracy and worth of such records. I authorize the continued use of this release for as long as I remain employed by the Division.

Signature Printed Full Legal Name

Date of Birth Social Security Number

State of Colorado, County of_

Subscribed and sworn to before me this day of , 20 _.

Notary Public Signature

Commission Expires

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Voluntary Information The information in this box is voluntary. Information is requested for federal record keeping purposes only. This sheet will be permanently separated from the rest of your application. It is the policy of the state that its work force reflect the diversity of the state.

Ethnicity/Race-Check only one:

1- Black or African American, not Hispanic or Latino2- American Indian or Alaska Native3- Asian

4- Hispanic or Latino5- White, Not Hispanic or Latino6- Native Hawaiian or Pacific Islander

Gender: Male Female

Birth Date: Some positions have a legally required minimum age. Provide your entire birth date to be considered for these type(s) of jobs.

Month: Day: Year:

Address:

Telephone:

E-mail Address:

City State Zip

Street

Applicant name:

APPLICATION FOR COMMISSIONED RANGERRead every question carefully. Answer every question. If a question does not pertain to you, indicate so by marking “D.N.A.” within the appropriate space. Leave no blank spaces unless otherwise directed.All information is subject to verification. Any misstatements, misrepresentations or omissions by you are cause for disqualification for employment consideration. Any falsifications discovered after you are employed are cause for dismissal.ATTACH COPIES OF DIPLOMAS AND CERTIFICATES.PLEASE READ THESE INSTRUCTIONS PRIOR TO COMPLETING THE WORK HISTORY

CERTIFICATION

INVESTIGATION AUTHORIZATION AUTHORIZATION TO RELEASE INFORMATIONI authorize any person to whom this form, or a reproduction hereof, is presented to release to the Division any information they have concerning me which meets the criteria set forth above in paragraphs numbered (1) through (7). I authorize this infor...

2: 4: Previous Address No: Street: City: State: Zip: Dates FromTo: Previous Address No_2: Street_2: City_2: State_2: Zip_2: Dates FromTo_2: 5: 6: 7: 8: 12: Applicants Initials: Applicants Printed Name last first middle: If not a U S Citizen what is your citizenship 1: If not a U S Citizen what is your citizenship 2: List any scars tattoos identifying marks etc which you have 2: Branch: Type of Discharge: Present Status: Dates of Action: Nature of Action 1: Applicants Initials_2: Applicants Printed Name last first middle_2: List all organizations professional associations or societies of which you are or have been a member 1: List all organizations professional associations or societies of which you are or have been a member 2: List all organizations professional associations or societies of which you are or have been a member 3: 1_2: 2_2: 3_2: What languages are you fluent in either oral andor written 1: What languages are you fluent in either oral andor written 2: 1_3: 2_3: Have you ever been expelled or suspended from any school: Reason for SuspensionExpulsion 1: Applicants Initials_3: Applicants Printed Name last first middle_3: Applicants Initials_4: Applicants Printed Name last first middle_4: Have you ever been the victim of a crime: Do you possess a valid Colorado Driver License: List any and all states in which you have held a valid driver license and the years it was valid: 1_4: 2_4: Has your privilege to operate a motor vehicle in any state ever been subject to denial suspension: Date 1: Date 2: Date 3: Date 4: AgencyLocation 1: AgencyLocation 2: AgencyLocation 3: AgencyLocation 4: AgencyLocation 5: If there are additional violations list them on a separate sheet: Violation 1: Violation 2: Violation 3: Violation 4: Violation 5: Applicants Initials_5: PenaltyDisposition 1: PenaltyDisposition 2: PenaltyDisposition 3: PenaltyDisposition 4: PenaltyDisposition 5: Applicants Printed Name last first middle_5: 1_5: 2_5: 3_3: 1_6: 2_6: 3_4: 1_7: 2_7: 3_5: 1_8: 2_8: 3_6: 1_9: 2_9: 1_10: 2_10: Applicants Initials_6: Applicants Printed Name last first middle_6: First Date Used: Last Date Used: 1_11: 2_11: 1_12: 2_12: 3_7: 1_13: 2_13: 3_8: If additional room is needed use an additional sheet of paper: 1_14: 2_14: 3_9: 1_15: 2_15: 3_10: Applicants Initials_7: Applicants Printed Name last first middle_7: Applicants Initials_8: Applicants Printed Name last first middle_8: Home Area CodePhone Number: Address_4: City_6: State_3: Zip_6: Occupation: Employer: Business Area CodePhone Number: Years Known: Relationship: Name_2: Home Area CodePhone Number_2: Address_5: City_7: State_4: Zip_7: Occupation_2: Employer_2: Business Area CodePhone Number_2: Years Known_2: Relationship_2: Name_3: Home Area CodePhone Number_3: Address_6: City_8: State_5: Zip_8: Occupation_3: Employer_3: Business Area CodePhone Number_3: Years Known_3: Relationship_3: Name_4: Home Area CodePhone Number_4: Address_7: City_9: State_6: Zip_9: Occupation_4: Employer_4: Business Area CodePhone Number_4: Years Known_4: Relationship_4: Name_5: Home Area CodePhone Number_5: Address_8: City_10: State_7: Zip_10: Occupation_5: Employer_5: Business Area CodePhone Number_5: Years Known_5: Relationship_5: Applicants Initials_9: Applicants Printed Name last first middle_9: Enforcement or Criminal Justice field and then list your goals and objectives in your chosen career 1: Applicants Initials_10: INVESTIGATION AUTHORIZATION: Printed Full Legal Name: Date of Birth: Social Security Number: State of Colorado County of: Subscribed and sworn to before me this: day of: 20: Commission Expires: Signature1_es_:signer:signature: Signature2_es_:signer:signature: Applicant Name Voluntary Info: B11: OffAL11: OffAS11: OffMale11: OffFemale11: OffHS11: OffWh11: OffHI11: OffBirthday Month11: Birthday11: Birth Year11: Address Voluntary Info: Telephone Voluntary Info: Email Address Voluntary Info: City Voluntary Info: State City Voluntary Info: Zip City Voluntary Info: Citizen Yes: OffNat: Citizen Yes: Off Citizen No: Off

Citizen No: OffAuthorize to Work in US Yes: OffAuth to work in US No: OffMember of Armed Forces Yes: OffMember of Armed Forces No: OffDiciplinary action Yes: OffDiciplinary action No: OffExpelled Suspended Yes: OffExpelled Suspended No: OffBreach of Ethics Yes: OffBreach of Ethics No: OffDenied or Withdrawn yes: OffDenied or Withdrawn No: OffMisdemeanor Yes: OffMisdemeanor No: OffCivil Rights complaint yes: OffCivil Rights Complaint No: OffCivil Action Defendant Yes: OffCivil Action Defendant No: OffLien Yes: OffLien No: OffUnder Investigation Yes: OffUnder Investigation No: OffConvicted of Yes: OffConvicted of No: OffComplaint Return Yes: OffComplaint Return No: OffQuestioned by No: OffQuestioned by Yes: OffSubpoenaed Yes: OffSubpoenaed No: OffPardon Yes: OffPardon No: OffVictim Yes: OffVictim No: OffCrime Reported Yes: OffCrime Reported No: OffFingerprinted Yes: OffFingerprinted No: OffUnable to Operate Vehicle Yes: OffUnable to Operate Vehicle No: OffValid License Yes: OffValid License No: OffDate of Expiriation: License Revoked Yes: OffLicense Revoked No: OffWarrant pending yes: OffWarrant Pending No: OffSecurity Before Yes: OffSecurity Before No: OffUnsatisfactory service Yes: OffUnsatisfactory No: OffResigned Leave Yes: OffResigned Leave No: OffAlcohol Yes: OffAlcohol No: OffDrinking Problem yes: OffDrinking Problem No: OffUnder the Influence Yes: OffUnder the influence Yes: OffMissed Time Yes: OffMissed Time No: OffMarijuana Yes: OffMarijuana No: OffControlled Substance Yes: OffControlled Substance No: OffOperated Motor Influence Yes: OffOperated Motor Influence No: OffMissed Time Drugs Yes: OffMissed Time Drugs No: OffFunctions With Yes: OffFunctions Without No: OffBackground Other Yes: OffBackground Other No: OffPresent or Last Employer2: Emp Area Code Phone Number 2: Emp Address 2: Emp City 2: Emp State 2: Emp Zipcode 2: Emp Position 2: Emp Hours/Week 2: Emp Dates of Employment 2: Emp Supervisor Name 2: Emp Last Pay/Hour 2: Emp Reason for Leaving 2: Emp Job Duties 2: Present or Last Employer1: Emp Position 1: Emp Hours/Week 1: Emp Dates of Employment 1: Emp Job Duties 1: Emp Supervisor Name 1: Emp Address 1: Emp City 1: Emp State 1: Emp Zipcode 1: Emp Last Pay/Hour 1: Emp Reason for Leaving 1: Emp Area Code Phone Number 1: Present or Last Employer3: Emp Area Code Phone Number 3: Emp Address 3: Emp City 3: Emp State 3: Emp Zipcode 3: Emp Position 3: Emp Hours/Week 3: Emp Dates of Employment 3: Emp Supervisor Name 3: Emp Last Pay/Hour 3: Emp Reason for Leaving 3: Emp Job Duties 3: Name - Investigation Authorization: Application Number: Interview: Hire Yes/No: Start Date_es_:date: Supervisor Initial: Section Hired: Unarmed: Off1: Home Address No: Home Address Street: Home Address City: Home Address State: Home Address Zip: Home Address Dates To/From: Place of Birth City: Place of Birth County: Place of Birth State: Place of Birth Country: Military Service From: Military Service To: Reason For Action 1: School 2: School 3: School 4: School 1 Dates Attended: School 1 Hours: School 1 Degree: School 2 Address: School 2 Dates Attended: School 2 Hours: School 2 Degree: School 3 Address: School 3 Dates Attended: School 3 Hours: School 3 Degree: School 4 Address: School 4 Dates Attended: School 4 Hours: School 4 Degree: School 1 Address: School 1: Trade School 1 Dates Attended: Trade School 1 Address: Trade School 1: Trade School 1 Hours: Trade School 1 Degree: Trade School 2: Trade School 2 Address: Trade School 2 Dates Attended: Trade School 2 Hours: Trade School 2 Degree: Trade School 3: Trade School 3 Address: Trade School 3 Dates Attended: Trade School 3 Hours: Trade School 3 Degree: Trade School 4: Trade School 4 Address: Trade School 4 Dates Attended: Trade School 4 Hours: Trade School 4 Degree: LicenseCertificate 1: License/Certificate Date of issue_es_:date: License/Certificate Date of Expiration_es_:date: License Certificate Issued By: LicenseCertificate 2: License/Certificate Date of issue2_es_:date: License/Certificate Date of Expiration2_es_:date: License Certificate Issued By2: LicenseCertificate 3: License/Certificate Date of issue 3_es_:date: License/Certificate Date of Expiration 3_es_:date: License Certificate Issued By 3: LicenseCertificate 4: License/Certificate Date of issue 4_es_:date: License/Certificate Date of Expiration 4_es_:date: License Certificate Issued By 4: Reason Unable to Operate a Motor Vehicle: Explain Privilege to Operate Motor Vehicle Suspension: Discharged Resign Explain: With Disciplinary Action Explain: How many times have you been intoxicated during the past 12 months: How many times have you used Marijuana: Name1: Background additional explaination: Number of Drinks Per Week: Applicants Printed Name last first middle_10_es_:signature: Date Final_es_:date: Applicants Initials_11: