instructions to applicants - wordpress.com€¦ · web viewbirth place: phone: cell phone: email...

MANSFIELD POLICE DEPARTMENT

“COMMITTED TO OUR COMMUNITY”

CANDIDATE INFORMATION FORM AND APPLICATION FOR EMPLOYMENT

_________________________________________________APPLICANT’S NAME (Please Print: Last, First & Middle Initial)

POLICE PATROL OFFICER

YEAR-ROUND RESERVE OFFICER

COMPLETE AND RETURN TO:

MANSFIELD POLICE DEPARTMENT50 WEST ST.

MANSFIELD, MA 02048ATTN: INVESTIGATOR

INSTRUCTIONS TO APPLICANTS

1. READ ALL QUESTIONS CAREFULLY BEFORE ANSWERING.2. RETURN ONLY A COMPLETE APPLICATION THAT INCLUDES HAVING THE

APPLICATION NOTARIZED, AND COMPLETING AND RETURNING THIS PAGE.3. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND MAY BE CAUSE FOR

ELIMINATION FROM THE HIRING PROCESS.

All applications must include supporting documentation. Use the following checklist to indicate which forms you need to return to us. Check off the documents you are including. Copies and photostats are acceptable with the candidate information form, but you should be prepared to produce the original documents once background investigations are started.

BIRTH CERTIFICATE HIGH SHOOL DIPLOMA / GED CERTIFICATE HIGH SCHOOL TRANSCRIPT UNDERGRADUATE DEGREE(S) PREVIOUS YEARS TAX RETURN GRADUATE DEGREE(S) ALL COLLEGE TRANSCRIPTS AWARDS, HONORS, CITATIONS FROM ALL SCHOOLS ALL SPECIAL LICENSES (Law, Plumbing, Hairdressing, etc.) VEHICLE OPERATORS LICENSE HACKNEY OR CHAUFFEURS LICENSE FIREARMS LICENSE FIREARMS IDENTIFICATION CARD DD214 ARMED FORCES DISCHARGE ALL CERTIFICATES AWARDED FOR ANY SPECIAL SKILLS ALL CERTIFICATES AWARDED FOR COMPLETION OF PROFESSIONAL TRAINING

(includes but not limited to any certificates from any criminal justice training program, EMT certificates, etc.)

PERSONNEL FILES FROM PREVIOUS EMPLOYERS DATING BACK TEN (10) YEARS (must be sealed and mailed by employer.)

ALL REPORTS RELATED TO ANY EMPLOYMENT DISCIPLINARY ACTION OR INTERNAL AFFAIRS INVESTIGATION INCLUDING CONFIDENTIAL AGREEMENTS.

I AM APPLYING FOR THE POSITION OF (a separate application is required for each position) POLICE PATROL OFFICER YEAR-ROUND RESERVE OFFICER

I am aware that the completed candidate information form and all supporting documentation will become the property of the Mansfield Police Department, and will not be returned to me. I am also aware that members of the Mansfield Police Department will be assigned to conduct a thorough background investigation based upon this candidate information form and also based on information and

of 21MPD Employment Application Package – Rev. 9-15-2015

contacts that the investigators may develop on their own. Once I sign written waivers for the background investigators, I am aware that I must notify the Mansfield Police Department in writing in order to withdraw my name from further consideration and halt the background investigation. I am also aware that if I fail or refuse to sign the waivers, or cooperate with investigators, or to secure the cooperation of any person or organization named in this form, the Mansfield Police Department need not continue processing my application, and I will not be considered for employment. I understand that any misrepresentations or false statements can result in immediate disqualification.

____________________________________________ __________________________Candidate Signature Date

____________________________________________Candidate Printed Name

MANSFIELD POLICE CANDIDATE INFORMATION FORM

INSTRUCTIONS: Type, or print neatly in black ink. All spaces must be filled. Use NA where the information called for is not applicable. If more space is needed, attach 8 ½ x 11 inch additional pages.

PLEASE NOTE: We may reject any application that is incomplete, contains false or misleading information, or is not notarized on the page provided.

PERSONAL HISTORY

Full Name: DOB: Age:Social Security # - - Sex: Male Female Present Address:

(number, street name, apartment #,city, state, ZIP code)

Mail Address if different:Home Phone: Work Phone:Cell Phone: Email:

LIST ALL OTHER NAMES YOU HAVE USED, INCLUDING NICKNAMES AND MAIDEN NAME, AND THE CIRCUMSTANCES IN WHICH THE NAME WAS USED.

Name Circumstances

U.S. ITIZENSHIP YES NO SINGLE WIDOWED MARRIED DATE OF MARRIAGE _______________ PLACE ________________________ DIVORCED DATE OF DIVORCE __________________ PLACE ________________________ SEPARATED DATE OF SEPARATION ____________ PLACE _________________________

COURT GRANTING DIVORCE OR SEPARATION _______________________________________________


RESIDENCES

BEGINNING WITH YOUR CURRENT ADDRESS, LIST IN CHRONOLIGICAL ORDER, ALL OF THE PLACES THAT YOU HAVE RESIDED SINCE AGE 16. INCLUDE ALL RESIDENCES WHILE IN SCHOOL OR THE MILITARY.

FromMonth Year

FromMonth Year Apt.# & Street Address City State/Country

Name of Owner or Landlord: Telephone Number:

Name of Neighbor: FromMonth Year












Name of Neighbor:

Use additional sheets if necessary, follow the same format as above.

HAVE YOU EVER BEEN EVICTED? YES NO IF YES PROVIDE A DETAILED EXPLANATION ON A SEPARATE PAGE.


EDUCATIONAL BACKGROUND

ALL ENTRIES HERE MUST BE VERIFIED. YOU MUST INLCUDE WITH THIS FORM ALL DIPLOMAS, TRANSCRIPTS AND ATTENDANCE RECORDS CONCERNING ANY SCHOOL YOU HAVE ATTENDED.

Name of School Location Dates Courses Degree/Diploma GPAHigh School

College

Graduate

Miscellaneous

ARE YOU A MEMBER OF THE BAR? NO YES, STATE__________ ADMITTED __________________

AFTER AGE 16, WERE YOU EVER DISMISSED FROM A SCHOOL, OR WAS ANY DISCIPLINARY ACTION (INCLUDING SCHOLASTIC PROBATION) EVER TAKEN AGAINST YOU AT ANY TIME DURING YOUR SCHOLASTIC CAREER?

NO YES

IF YES, SCHOOL _________________________DATE ___________ ACTION _________________

EXPLAINATION:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU EVER BEEN INVOLVED IN ANY CAMPUS POLICE OR SCHOOL SECURITY ISSUE SUCH AS VIOLATION OF SCHOOL RULES & REGULATIONS OR DISTURBANCES?

NO YES Explain:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LIST AWARDS, HONORS, CITATIONS, POSITIONS HELD IN SCHOOL ORGANIZATIONS, ATHLETIC ENDEAVORS, AND ANY OTHER SPECIAL RECOGNITION YOU RECEIVED WHILE IN SCHOOL.


LIST ANY SPECIAL ABILITIES, INTERESTS, SPORTS, OR HOBBIES AND YOUR LEVEL OF PROFICIENCY.

Subject Level

MILITARY BACKGROUND

Have you ever served on active duty or inactive duty for training in the Armed Forces of the United States: NO YES Highest rank attained:____________________ Date of Commission:______________ Branch of military service:____________________ Service Number :_______________________________Dates of active duty: From ________________ To:________________________________________Type of Discharge: __________________________ Basis for discharge:________________________Are you now a member of the Reserve Component?NO YES Branch:_______________________Location of drills or meetings:___________________________________________________________Location of Annual Training: ___________________________________________________________Current Rank:_____________________Duty Assignment:____________________________________Address of unit or armory:______________________________________________________________Phone # of unit:_______________________ Unit Commander:_________________________________

While serving as a member of the Active or Reserve Component of the Armed Forces of the United States, were you the subject of any type of disciplinary action, including so-called “non-judicial” or Article 15, UCMJ, actions?

NO YES Describe if yes: ________________________________________________________________________________________________________________________________________________________________________

Have you ever served in the Armed Forces of another country? NO YESIf yes, what country? ________________________________________________

FOREIGN LANGUAGE

INDICATE YOUR PROFICIENCY IN EACH PHASE OF ANY FOREIGN LANGUAGE. RATE YOURSELF AS “SLIGHT”, “GOOD”, OR “FLUENT”.

Language Speak Understand Read Write


FOREIGN TRAVEL

Have you ever visited or resided in any foreign country, including any travel in the Armed Forces? NO YESPassport number: _____________________Date Issued: __________________________________Place passport issued:_______________________________________________________________

Country Visited From To Reason

CURRENT EMPLOYER

Name of Company: Phone #Address: Start Date: Immediate Supervisor: Phone #Your Title & Duties:In the past 12 months, how many days have you been absent from work? Why?

With the exception of Child Support, do you derive income from any other source?

EMPLOYMENT HISTORYList chronologically all employment that you have had for the last fifteen years, or since your sixteenth birthday, whichever is longest. Include all seasonal and part-time employment. Include and explain all periods of unemployment. All the time in questions must be accounted for.

Employer #1 Address Supervisor Name & Phone #

Job Title: Responsibilities:Start Date: Finish Date:Check Reason for leaving: New Job Terminated Seasonal Retired Other*Were you subject to an Internal Investigation? Yes( ) No( ) If yes, explain:












FINANCIAL RECORD

In the last 5 years, have you, or a company of which you own 10% or more, filed for bankruptcy, been declared bankrupt, been subject to a tax lien, or had legal judgment rendered against you for a debt? If you answer “Yes”, provide date of initial action and other information requested below. No Yes

Month/Year Type of Action Business Name Name/Address of Court handling case (State, Zip Code)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Are you now 180 days delinquent on any loan or financial obligation? Include loan or obligations funded or guaranteed by the Federal Government. If you answer “Yes”, provide information requested below? No Yes

Month/Year Type of Loan or Obligation(Account#) Name/Address of Creditor/Obligee (State, ZipCode)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has your credit record ever been considered unsatisfactory, or has your application for credit ever been refused?No ( ) Yes ( ) If yes , explain: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all loans and credit cards whose principal outstanding balance exceeds $1000, and on which you are individually or jointly liable either directly or as a guarantor.

Creditor Amount Borrowed Balance

SUPPORT ORDERS

1. Are there any orders/agreements entered into regarding child support/alimony? NO Yes

2. If “Yes” to question 1, are the orders/agreements being fulfilled to their fullest? No Yes

3. If “Yes” to question 1, have there been any previous problems in fulfilling these orders/agreements?

No Yes

If you answered “Yes” to 1, 2 or 3 above, explain below. (Include Court, Judgment, Penalties)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


INCOME TAXES

1. Have your Massachusetts Tax Returns been filed on time for the last 7years? No Yes

2. Have your Federal Tax Returns been filed on time for the last 7 years? No Yes

3. Are you delinquent on any State or Federal Tax liabilities? No Yes

If you answered no to 1, 2, or yes to 3 above, explain your answer(s) in the space below._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

BUSINESS INVOLVEMENT

Do you presently own, or within the last 7 years have you owned, more than 10% of the following:1. A Company No Yes2. A Partnership (include general or limited partnership) No Yes3. Joint Venture No Yes

If you answered “Yes” to 1, 2, or 3 above, provide the required information below:Name of Business Location (address, city, zip code) Percentage owned________________________________________________________________________________________________________________________________________________________________________________________________

Do you or any member of your immediate family (spouse or child) presently have a greater than 10% equity interest in any business entity (include general or limited partnership, joint venture or joint enterprise)? No Yes

If you answered “Yes”, provide the information required in the space provided below.

Name of Business Location (address, city, zip code) Percentage owned________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Who owns the business interest? Describe the Nature of the Business________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


If the company does business with the Commonwealth, list the agency(ies) and the nature of business conducted with the agency(ies).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PROPERTY OWNERSHIPList any real property in which you, your spouse, or your minor children have an equity or financial interest.

Property Address Owner Relationship (self, spouse, etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REFERENCES

List three (3) references. These references can not be former or present employers, fellow employees, police officers or government officials. They must be responsible members of good repute in the community whose combined association with you covers, as well as possible, the last ten years. Do not list spouse, former spouse or other relatives and try not to list anyone who is listed elsewhere on this form. If the reference is retired, list their former occupation. Address must include number, street, city, state, and ZIP code.

1Name: Home Address: Home/Cell Phone:

Occupation: Business Address:

Email Address:

Work Phone:



Email Address:

Work Phone:

3Name: Home Address: Home /Cell Phone:


Email Address:

Work Phone:

SOCIAL REFERENCES

List three (3) social references in your own age group. Include members of both sexes. Do not list relatives, past or current roommates. You should list people that have known you for the past two years or more.




Email Address:

Work Phone:



Email Address:

Work Phone:



Email Address:

Work Phone:

CRIMINAL RECORD

Have you ever been placed in protective custody? No YesIf yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted as an adult of a misdemeanor within the last five (5) years? No Yes If Yes, please explain:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted as an adult of a felony offense? No YesIf yes, please explain:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has any member of your family (including in-laws) or a close relative ever been convicted of any offense other than traffic violations? No YesIf yes, please explain: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________


CURRENT/FORMER SIGNIFICANT OTHERGo back ten years and include all marriages regardless of time:

Name: Occupation:Relationship: Former Spouse( ) Current Girl/Boyfriend ( ) Former Girl/Boyfriend ( )

Maiden Name: Dates of Relationship: From: To:

Address: DOB: SS#Birth Place:

Phone: Cell Phone: Email:













Other relatives or persons with whom you have resided for more than thirty days.

Name: Occupation:Relationship: Dates Lived Together: Maiden Name: From: To: Address: DOB: SS#

Birth Place:Phone: Cell Phone: Email:


Birth Place:Phone: Cell Phone: Email:


Birth Place:



**Add pages for additional persons in all categories.

LICENSES

Have you ever been issued any of the following types of licenses?

License to Carry State: ________ Number: ___________________ Firearms Identification Card State: _________ Number: ___________________ Drivers License State: ________ Number: ___________________ Private Investigator State: ________ Number: ___________________ Hackney State: ________ Type: ___________________

Have any of these licenses ever been suspended or revoked in this or any other State? No Yes ( ) If yes, please explain. ___________________________________________________________________________________

CIVIL INVOLVEMENTSHave you ever been sued or had your wages garnished? No Yes If yes, please explain.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you now, or have you ever been, a party in a civil or equity lawsuit? No Yes

If yes, please explain, including the name of the suit, the court in which it is/was heard, and the outcome. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever witnessed a crime, been a suspect in a crime or testified in court? No Yes If yes, please explain:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PREVIOUS INTERACTION WITH STATE AGENCIES

Have you ever filed a financial disclosure form with the State Ethics Commission or a similar body in another state? No YES

If yes, please provide with this form a copy of your most recent submission.

Have any proceedings been instituted against you by the State Ethics Commission or a similar body in another state? NO YES


To your knowledge, have any complaints or disciplinary actions been filed against you with regard to any licenses or registrations you possess? NO YES

To your knowledge, have any complaints or disciplinary actions been filed against you with regard to your membership in any professional or trade association(s)? NO YES

Do you presently have any business, hearings, complaints, or claims or any other matters pending before any regulatory agency or board? NO YES

Within the past 7 years, have you had any business, hearing, complaint, or claim with any regulatory agency or board? NO YES

If you answered “YES” to any of the above questions, explain your answer(s) in the space provided. Include nature of allegations, date and outcome of proceedings.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

POLICE EMPLOYMENT & TESTING

Are you now or ever been an applicant for any other government, state or local police/investigative position? NO YESIf yes, where have you applied and what is the status of that application?

Organization Date StatusPassed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___

Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___ Passed Test:___ Failed Test:___ Interviewed:___ On Current List :___ Expired List:___ Did not make list:___ Application completed:___

POLICE OFFICER DISCIPLINE

Have you ever been subject to an internal investigation or received any type of discipline from your current department or any department in the past? NO YES NOT APPLICABLE


If yes, please provide a brief description of the event or events and attach any related documents, whether or not there has been any confidential settlement:1.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please produce any documentation related to the investigation or discipline.

TATTOOS AND BODY ART

IN ADDITION - all Mansfield Police Department employees, regardless of the date of the tattoo, are PROHIBITED from displaying body art of any kind which, based on societal norms, is likely to offend. In general, displaying body art depicting the following is prohibited at any time:

* racism;* sexism;* obscenity; or* profanity.

The Chief or his designee shall render final judgment in these matters.

Further, upon the effective date of this policy(September 28, 2011), all Mansfield Police Department employees are prohibited from placing tattoos on their bodies which are likely to be seen by the general public during the normal performance of the employee's duties. Specifically:

i. Employees are prohibited from displaying tattoos, or any other form of body art, on their arms from three and one-half (3.5) inches above the elbow to the fingertips, on their lower extremities where they may be visible in uniform, (including the bicycle uniform when applicable), or on the neck, throat, face or head.

ii. ii. During the background check process or upon implementation of this order for current employees, disclosure of existing “visible in summer uniform” tattoos or other bodily modification shall be required.

Please list the location and describe all body art and tattoos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


______________________________________________________________________________________________________________________________________________________________________________________________________________________________

After completing this application and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification.

IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A

CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW

SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITIES.

CERTIFICATION THAT MY ANSWERS ARE TRUE

I have read each question asked of me and understand each question. My statements on this form, and any attachments to this form, including but not limited to a résumé, are true, and correct to the best of my knowledge and belief and are made in good faith.

Signature (sign in ink) Date

________________________________________________________________________________________________


MANSFIELD POLICE DEPARTMENT50 West St. Mansfield, Massachusetts 02048

Telephone (508)261-7300 Fax (508)339-1031

Ronald A. SellonChief of Police

I, ___________________, understand that all appointments are probationary for a period of twelve months following my successful completion of an approved police academy. I understand that during that twelve month period, I must demonstrate my fitness for continued employment by the Mansfield Police Department. I understand that I will be required to complete an employment contract with the Mansfield Police Department that will require me to reimburse the Police Department for the expenses of my hiring and training if my employment is terminated for any reason, prior to the end of my probation, within one year of my initial appointment. I also understand that it has been necessary to establish regular night and midnight shifts and that I must be available for these shifts as the department’s needs might require. I understand that I may be compelled to work beyond my regular work schedule if the departments needs require. I further understand that any appointment tendered me will be contingent upon the complete evaluation of my character and fitness, and an investigation of my background.

I understand that willfully withholding information, or making false statements on this application will be the basis for my dismissal from the Mansfield Police Department hiring process and future employment. I agree to these conditions and I hereby certify that all statements made by me on this application are true and complete, to the best of my knowledge. I am further aware that I will not be considered permanent employment in my position until I have successfully completed one year, from the completion of an approved academy, as a probationary officer. I understand that I must reside within 15 miles of the town of Mansfield or I can be terminated at any time.

_______________________________________ ________________Signature Date



Telephone (508)261-7300 Fax (508)339-1031


Notary Public’s Seal

Commonwealth of Massachusetts ) ss: County of _________________

I, ______________________________________, being duly sworn, depose and say I am the above named person. I signed the foregoing statement. Personally read and typed or printed by hand the answers to each and every question therein and I do solemnly swear that each and every answer is full, true, and correct in every respect.

I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision.

I understand that this application is but one element of the selection process for employment within the Town of Mansfield and that an acceptable background investigation does not guarantee me selection for the position.

I understand that false or misleading information given herein or during interview(s) will result in my being disqualified from further consideration and/or termination from employment with the Town of Mansfield.

___________________________________________Candidate Signature

Sworn to before me, this _____ day of _________________, 20__

________________________________________Notary Public or Commissioner of Deeds

Seal

Do not sign below until directed by Notary

_______________________________________________ Candidate Sign Here



Telephone (508)261-7300 Fax (508)339-1031


AUTHORITY FOR RELEASE OF INFORMATION

I, __________________________________, born on ________________________, and having filed an application for employment with the Mansfield Police Department, consent to having an investigation made as to my moral character, reputation, and fitness for the position for which I have applied, and such information as may be received by or reported to the Mansfield Police Department, the Mansfield Town Administrator, or the Mansfield Board of Selectmen. I agree to give any further information that may be required in reference to my past record.

I also authorize and request every person, firm, company, corporation, governmental agency, court, association or institution having control of any documents, records, and any other information pertaining to me to furnish to the Mansfield Police Department any such information, including but not limited to, consumer credit investigative reports, documents, records, files regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, and to permit the Mansfield Police Department or any of it’s agents or representatives to inspect and make copies of such documents, records, and other information. I also authorize the release of any internal investigations and results said investigations regardless of any confidential agreements I have entered into with any employer, past or present.

I hereby release, discharge, and exonerate the Mansfield Police Department, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information during the investigations made by or on the behalf of the Mansfield Police Department.

A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature.

This authority shall continue for three years from the date indicated under my signature unless sooner revoked in writing by me.

__________________________________ ________________________________Applicant Signature Witness

__________________________________Date

__________________________________Social Security Number



Telephone (508)261-7300 Fax (508)339-1031


Authorization for Release of Credit Report

I, _____________________________ hereby give the Mansfield Police Department permission to obtain my personal credit bureau file for the purpose of pre-employment evaluation.

Information from the peer report will not be used in violation of any applicable federal or state equal opportunity law or regulation.

Signed: _________________________ Date: ___________


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