village of allegany applications 2013.pdf · a. high school diploma or equivalency certificate...

1

Village of Allegany Police Department

Background Investigation Questionnaire

Applicant’s Name _________________________________________________

Position Applying For ______________________________________________

READ EACH QUESTION CAREFULLY BEFORE ANSWERING

1- This questionnaire must be fully completed.

EVERY QUESTION MUST BE ANSWERED! Missing or insufficient information may

result in a delay in the processing of your application. If a question does not apply to

you, indicate so by using the “N/A” (not applicable) symbol.

2- If you need additional space to answer any question(s), use the space allocated on

pages 20 and 21 of this package. If more space is needed, attach additional pages.

3- Print your name on the appropriate line at the top of each page.

4- This questionnaire must be completed legibly, in your handwriting, in black ink.

Print all information. Illegible responses may delay processing of this application.

5- ANSWER ALL QUESTIONS TRUTHFULLY AND FULLY! An applicant will

be disqualified if they have intentionally made a material misstatement or has practiced

or attempted to practice any deception, or in securing his/her eligibility for appointment.

A material misstatement of fact, fraud, or omission of material information will

disqualify an individual from employment consideration and appointment and may lead

to termination of employment.

6- You are responsible for returning this completed Background Investigation

Questionnaire and all necessary documents to the below address, by: _______________.

Failure to return questionnaire by this date will result in removal of your application from

consideration.

Allegany Police Department

ATTN: Chief Papasergi

106 East Main Street

Allegany, NY 14706

2

NAME: _________________________

You are responsible for providing copies of the following documents. (Not all

documents will be applicable to all applicants.) These documents are to be submitted

with completed Background Investigation Questionnaire. The copies cannot be returned

to you.

1- Armed Forces Discharge and Separation Documents. _____

2- Any license issued to you by a governmental agency. _____

3- Credit Profile 1-877-322-8228 _____

Any offer of employment is contingent upon providing the following:

4- Letter of Naturalization, if not a U.S. Citizen. _____

5- Any offer of employment may be contingent upon providing the following documents

if a high school degree or continued education is a prerequisite for the position:

A. High School Diploma or Equivalency Certificate _____

B. Degrees and transcripts from all educational institutions _____

including high school.

If it is necessary for you to request transcripts from an educational institution, you may

have them forwarded directly to:

Village of Allegany Police Department

Attn: Chief Dominic G. Papasergi

106 East Main Street

Allegany, NY 14706

3

NAME: _________________________

SECTION A – PERSONAL DATA

1- Full Name: ____________________________________________________________

Last First Middle

2- Current Address: _______________________________________________________

Street

________________________________________________________

City State Zip

________________________________________________________

Date Current Residence Commenced

3- Telephone Number _____________________ __________________________

Home Hours Available

_____________________ __________________________

Work Hours Available

May we contact you at work? ( ) YES ( ) NO

4- Social Security Number: ____________________/__________/_________

5- Is any additional information relative to change of name, use of an assumed name, or

nickname necessary to enable a check on your work record? ( ) YES ( ) NO

If yes, state names and dates.

6- Are you prevented from lawfully becoming employed in this country because of VISA

or immigration status? (Proof of citizenship or immigration status will be required upon

employment.) ( ) YES ( ) NO

7- Residence at time of birth: ________________________________________________

City

________________________________________________

County State

4

NAME: _________________________

8- Past Residences- starting previous to your present address, list all addresses where you

have lived, preceding backward to your birth. List time frames only for a period covering

the last ten years.

A. _____________________________________________________________________

Street City State Zip

________________________________________________________________________

Landlord’s Name Phone Number

Landlord’s Address Time Frame

B. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


C. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


5

NAME: _________________________

SECTION B – CONVICTIONS AND JUDICIAL PROCEEDINGS DATA

1- Excluding traffic infractions, have you ever been convicted of any violation of the law

in any jurisdiction? ( ) YES ( ) NO If yes, list.

A. ____________________________________ _______________ _________________

Charge Date Police Agency

____________________________________ _________________________________

Court Disposition

B. ____________________________________ _______________ _________________


____________________________________ _________________________________

Court Disposition

C. ____________________________________ _______________ _________________


____________________________________ _________________________________

Court Disposition

2- List information on any traffic tickets (excluding parking offenses) that you have

received.

A. ____________________________________ _______________ _________________


____________________________________ _________________________________

Court Disposition

B. ____________________________________ _______________ _________________


____________________________________ _________________________________

Court Disposition

C. ____________________________________ _______________ _________________


____________________________________ _________________________________

Court Disposition

6

NAME: _________________________

3- Are there currently any penalties or fines outstanding against you which have not been

satisfied? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4- Other than charges or traffic infractions, list a brief accounting of any contact you have

had with a law enforcement agency. Include incidents when you were questioned and

incidents when you were a victim or witness to an incident or crime.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

7

NAME: _________________________

SECTION C – EMPLOYMENT AND EXPERIENCE DATA

1- List all employers for whom you have worked, starting with your present or most

recent employer, and continuing back in reverse chronological order. Account for all

periods of time, including periods of unemployment. Include a brief description of your

duties and responsibilities for each job listed.

A. _____________________________________________________________________

Name of Employer

_____________________________________________________________________

Employer Address City State Zip

_____________________________________________________________________

Phone Number Supervisor

_____________________________________________________________________

Job Title Salary Start Date End Date

_____________________________________________________________________

Job Description

_____________________________________________________________________

Reason for Leaving

B. _____________________________________________________________________

Name of Employer

_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________

Job Description

_____________________________________________________________________

Reason for Leaving

8

NAME: _________________________

C. _____________________________________________________________________

Name of Employer

_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________

Job Description

_____________________________________________________________________

Reason for Leaving

D. _____________________________________________________________________

Name of Employer

_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________

Job Description

_____________________________________________________________________

Reason for Leaving

E. _____________________________________________________________________

Name of Employer

_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________

Job Description

_____________________________________________________________________

Reason for Leaving

9

NAME: _________________________

2- Were you ever fired, terminated, discharged, or asked to resign from any position?

( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

3- Has any disciplinary action other than that referred to above ever been taken against

you in connection with any employment or position that you have held?


________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4- Have you ever applied for a Civil Service position?


________________________________________________________________________

Position Location Results Date

________________________________________________________________________

Position Location Results Date

5- Has any such Civil Service application been rejected?


________________________________________________________________________

________________________________________________________________________

6- Are you a notary public or commissioner of deeds?


________________________________________________________________________

Certification # County Expiration Date

10

NAME: _________________________

7- Do you hold, or have you ever had, any professional licenses, permits, or certificates

authorizing you to practice any occupation, profession, or calling? Include licenses

issued by a governmental agency. ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

Profession Issuing Authority Date

________________________________________________________________________


________________________________________________________________________


8- Do you have, or have you ever had, any interest as an officer, partner, or shareholder

in any business, partnership, or other business venture? ( ) YES ( ) NO If yes,

give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

9- Has any public service agency (ex: police agency, fire dept.) ever conducted a

background investigation on you? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

SECTION D – MILITARY SERVICE DATA

1- Do you have, or have you ever had, any selective service classifications?


________________________________________________________________________

Date Classification Issuing Authority

________________________________________________________________________


________________________________________________________________________


11

NAME: _________________________

2- Have you ever served in the Armed Forces of the United States, or any state, including

any Reserve or National Guard unit? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

Branch Service Number Discharge Type From/To Dates

A. What was your highest rank attained? ______________________________________

B. What was your rank at time of discharge? ___________________________________

C. Have you ever received a discharge or separation from military service which was

classified anything other than “honorable”? Include General Discharge.


________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

(A dishonorable discharge is only one of the factors considered in the employment

decision. It is not an absolute bar to employment.)

D. List the requested information on any assignments you had while on active duty.

________________________________________________________________________

Name of Unit Location From/To Dates

________________________________________________________________________


________________________________________________________________________


E. Did you receive any commendations, awards, or medals in connection with your

military service? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

12

NAME: _________________________

F. Were you ever subjected to any disciplinary proceedings while in the military service?

Include Court-martials, Summary Proceedings, or Article 15 actions.

( ) YES ( ) NO If yes, indicate below and also attach additional pages

containing full explanation.

________________________________________________________________________

Charge Location/Unit Date Disposition

________________________________________________________________________

Charge Location/Unit Date Disposition

G. What types of training or education did you complete while in military service? Do

not include basic training.

________________________________________________________________________

Training Location Date

________________________________________________________________________


________________________________________________________________________


H. Has any military or governmental agency ever conducted any type of character or

background investigation on you for a security clearance?


________________________________________________________________________

Type & Reason Agency Date

________________________________________________________________________


________________________________________________________________________


13

NAME: _________________________

SECTION E – EDUCATIONAL DATA

1- Circle the number indicating the highest level of education you have achieved.

1. Less than high school graduate 6. Baccalaureate Degree

2. High School Equivalency Diploma 7. Work toward Master’s

3. High School Graduate Diploma 8. Master’s Degree

4. Some College - no degree 9. Work toward Doctorate

5. Associate Degree 10. Doctorate Degree

2- Provide the requested information concerning all schools, colleges, and universities

which you have attended. List schools in reverse chronological order, starting with

current institution or the institution you last attended.

A. _____________________________________________________________________

Name Grades Attended

________________________________________________________________________


________________________________________________________________________

Type of Diploma/Degree Graduated?

B. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


C. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


D. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


14

NAME: _________________________

3- Do you possess a high school equivalency or G.E.D. diploma?


________________________________________________________________________

Issuing Agency Number Date

4- Were you ever the subject of any disciplinary action or proceeding at any educational

institution that you attended? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

5- Do you possess fluency in a second language? ( ) YES ( ) NO If yes, give details.

________________ ( ) Speak ( ) Read ( ) Write ( ) All

________________ ( ) Speak ( ) Read ( ) Write ( ) All

6- Do you possess fluency in sign language/manual communication?


________________________________________________________________________

7- List any other skills or training which are not previously listed. Include hobbies and/or

other interests. Do not include any organization which may indicate your political

affiliation, age, national origin, color, marital status, religion, a disability, veteran status,

or other status protected by law.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

15

NAME: _________________________

SECTION F – GENERAL DATA

1- List the details concerning all loans currently outstanding in which you are principal

debtor, mortgage holder, co-signer, guarantor, or surety. Include mortgage, car loans,

education loans, personal loans, etc.

A. _____________________________________________________________________

Creditor/Bank Account Number

________________________________________________________________________


________________________________________________________________________

Type of Loan Monthly Payment Current Balance

B. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


C. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


D. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


16

NAME: _________________________

2- Provide the requested information concerning any credit cards or revolving charge

accounts held by you. Include MasterCard, VISA, gas charge cards, store charge cards,

etc.

A. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


B. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


C. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


D. _____________________________________________________________________


________________________________________________________________________


________________________________________________________________________


3- Have you ever filed for bankruptcy, been refused credit, been evicted from a residence,

or had property repossessed? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

17

NAME: _________________________

4- Have you or has any partnership or corporation in which you have a principal interest

ever been adjudicated bankrupt? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

5- Do you hold, or have you ever had, a pistol permit or similar authorization to carry a

firearm in this state or any other? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

Issuing Authority Certificate Number Date

________________________________________________________________________


________________________________________________________________________


6- Has any application by you for such a permit or authorization ever been denied?


________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

7- Do you now own, or have you ever owned any firearms of any type?


________________________________________________________________________

Type Make/Model Serial Number From/To Date

________________________________________________________________________


________________________________________________________________________


18

NAME: _________________________

8- List any recreational activities, excluding hobbies, in which you engage, and any

affiliated clubs or organizations in which you are involved with (ex: YMCA, Scouting).

Do not include any organization which may indicate your political affiliation, age,

national origin, color, marital status, religion, a disability, veteran status, or other status

protected by law.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

9- Do you have any knowledge or information of any circumstances, conditions, or

qualifications, other than what has been requested in the foregoing questions, which may

effect or be relevant, directly or indirectly, to an assessment of your character, maturity,

integrity, temperament, ability, qualification, or eligibility for appointment to the position

for which you are applying for? ( ) YES ( ) NO If yes, give details.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

10- Briefly state your reasons for desiring the position for which you are applying.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

19

NAME: _________________________

SECTION G – REFERENCE DATA

List the required information concerning persons who may attest to your character,

integrity, and ability for the position you are applying for. List four (4) personal and

three (3) business references (supervisors or CO-workers). Do not include relatives as

personal references.

PERSONAL REFERENCES:

A. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


B. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


C. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


D. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


BUSINESS REFERENCES:

A. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


B. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


C. _____________________________________________________________________

Name Phone Number

________________________________________________________________________


20

NAME: _________________________

The following two pages are provided for detailed answers to preceding questions when

additional space is necessary. Indicate the section letter and question number to which

the answers below apply.

Section Question # Answer

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

21

NAME: _________________________

Section Question # Answer

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

______ _________ ____________________________________________________

22

NAME: _________________________

In your own handwriting, copy the following paragraph in the space provided. Then sign

the form in the appropriate place having your signature witnessed by a notary public.

Your signature affixed in the indicated location is an endorsement of your agreement

with the contents of the handwritten paragraph:

“I hereby acknowledge that I have read the instructions contained in the foregoing

application, and have completed the application in accordance with the instructions. I

affirm that I have completed the applications fully, truthfully, and to the best of my

knowledge. I am aware that any deception or any attempt to deceive by me in the

completion of this application, or in the subsequent background investigation to be

conducted by the Village of Allegany Police Department, may result in a rejection of my

application from consideration for the position I am applying for. I acknowledge that a

material misstatement or fraud may disqualify me from employment or lead to

termination of employment.”

I authorize the Village of Allegany Police Department to conduct a background

investigation in order to assess my eligibility for employment. I authorize all persons

who may have information relevant to this investigation to disclose it (including

photocopies where requested). I release all persons from liability on account of such

disclosure and investigation, including but not limited to, prior employees of the Village

of Allegany Police Department or their agents. I understand that the investigation may

include verification of past employment, education, residential history, criminal record

check, and references.

I authorize that a photocopy of my signature may be used to obtain information regarding

the investigation. This authorization is valid for a period of one (1) year.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

23

NAME: _________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I, ________________________________, being duly sworn, depose and say: that I am

the person whom the foregoing application concerns; that I completed the application in

my own handwriting; and that the answers I have given to each and every question

therein are full, complete, true, and correct to the best of my knowledge.

Applicant’s signature: ____________________________________ Date ____________

Sworn to before me this _____________ day of _____________________, 20________.

Notary Public: ___________________________________________

24

AUTHORIZATION AND RELEASE

OF MILITARY AND VETERANS RECORDS

To Whom It May Concern:

I, _______________________________________, hereby authorize and instruct any

person, agency, firm, organization, or institution to release and deliver to the Village of

Allegany or their designated representative, upon a production of this document or a copy

of service that I have had in any of the Armed Forces of the United States, of and other

country or territory, or in the Reserve Forces or National Guard, including but not limited

to:

1- Any applications or documents to my entry into such service;

2- Any performance evaluations or ratings relative to the quality of such service;

3- Any records or information concerning any disciplinary actions during such

term of service;

4- Any and all records and information concerning the termination of such

service, and the character and designation of such termination;

5- Any and all information concerning any awards, medals, decoration, or

commendations earned during such service;

6- Any and all records, documents, or information relevant to my character,

integrity, temperance, conduct, or capabilities.

This authorization shall include the right to inspect and copy any such documentation or

records by the Village of Allegany or their designated representative, and shall further

supersede and make ineffective any restriction, letter, document, instruction, or

authorization filed by me, or any person on my behalf, with any such person, officer,

agency, firm, institution, or organization, if such document would limit or restrict the

grant of power there under.

Applicant’s signature: _____________________________ Date ___________________

25


OF EDUCATIONAL RECORDS

TO WHOM IT MAY CONCERN:

I, ________________________________, hereby authorize and instruct any person,

agency, firm, or institution of which I am a present or former student, matriculated or

otherwise, or to which I made application to pursue any course of study, to release and

deliver to the Village of Allegany or their designated representative, upon production of

this document or a copy of it, any and all information or records relating to said education

or training, or application including, but not limited to:

1- Any evaluation or comments of any person relating to the quality of my work

to

2- Records relating to any disciplinary action taken against me, whether

concerning academic performance or my conduct;

3- Records relating to the reasons or details of my termination from said course of

study, or any class or part thereof;

4- Any other information concerning my character, integrity, maturity, or

capabilities contained in any file maintained by such person, agency, firm, or

institution, for any purpose whatsoever.

This authorization shall include the right of inspection and copying of any document

contained in said records or files, by the Village of Allegany or their designated

representative. This authorization shall further supersede and make ineffective any

restriction, letter, document, instruction, or authorization previously filed by me or with

any person on my behalf with any such person, agency, firm, or institution, if such

document would limit or restrict the grant of power there under.

I hereby further authorize the Village of Allegany to make copies of this authorization

and release, and to give such a copy to any person, agency, firm, or institution requesting

same from whom the above information has been requested.

Applicant’s signature: ___________________________________ Date _____________

26


OF EMPLOYMENT/UNEMPLOYMENT RECORDS

TO WHOM IT MAY CONCERN:

I, ______________________________, hereby authorize and instruct any person, firm,

company, agency, or organization of which I am a present or former employee or to

which I made application for employment or unemployment benefits, to release and

deliver to the Village of Allegany or their designated representative, upon production of

this document or a copy of it, any and all information or records relating to said

employment/unemployment or application, including, but not limited to:

1- My original application;

2- My punctuality record;

3- Any performance or quality of work evaluation;

4- Records relating to any disciplinary actions related to my employ;

5- Records relating to the reasons for termination from said employment or for

rejection of my application for employment;

6- Unemployment records or information concerning application, rejection,

benefits, entitled/received, dates/period of receipt, reason for termination or

judicial action taken or contemplated;

7- Any other information concerning my character, integrity, maturity, or

capabilities contained in any file maintained by such person, agency, firm,

company, or organization for any purpose whatsoever.

This authorization shall include the right of inspection and copying of any document

contained in said records or files by the Village of Allegany or its designated

representative. This authorization shall further supersede and make ineffective any

restriction, letter, document, instruction or authorization previously filed by me or with

any person on my behalf with any such person, firm, company, agency, or organization,

if such document would limit or restrict the grant of power there under.

Applicant’s signature: ______________________________ Date ___________________

27

WAIVER FOR USE OF DATE OF BIRTH

In order to complete its background check, the Village of Allegany must verify the

information you provide in the attached Background Investigation Questionnaire

regarding criminal and driving history. As such records are indexed by date of birth, the

Village of Allegany requests that you provide your date of birth and authorize the Village

of Allegany to use your date of birth to conduct criminal record and driving history

checks.

The criminal record and driving history checks are crucial to the Village of Allegany’s

hiring decisions, so if you choose not to authorize such checks, your application will not

be further processed.

( ) I do authorize the Village of Allegany to conduct a check of my criminal record and

driving history and for that purpose, my date of birth is:

_________________________________.

( ) I do not authorize the Village of Allegany to conduct a check of my criminal history

and driving record.

Applicant’s signature: _______________________________ Date __________________