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C E N T R A L F A L L S D E T E N T I O N F A C I L I T Y CO R P O R A T I O N
PR E -EM P L O Y M E N T BA C K G R O U N D Q U E S T I O N N A I R E
Page 1 of 26
Name Date
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY
I hereby consent to and authorize Central Falls Detention Facility Corporation (CFDFC) and all other state,
county, municipal and federal law enforcement agencies to search all available law enforcement records and
indices for criminal records, regarding me including, but not limited to, NCIC and to release CENTRAL FALLS
DETENTION FACILITY CORPORATION (CFDFC) and its agents from all liability for receiving and utilizing
this information.
Current Address:
Place of Birth:
Date of Birth:
Social Security Number:
Eye Color:
Hair Color:
Height:
Weight:
Name (print):
Other Names (Aliases, Maiden Name):
Signature of Applicant Date
Signature of Witness Date
Page 2 of 26
Name ___________________________________ _____ Date _______________________
AUTHORIZATION TO RELEASE INFORMATION AND WAIVER
As an applicant for a position with the Central Falls Detention Facility Corporation (CFDFC), I am requested
to provide information for use in determining my qualifications, moral character, honesty and suitability. I
hereby request and authorize the full disclosure of any and all records, files, reports, notes, opinions or any
other information you may have concerning me, in any format whatsoever, including information of a
confidential nature, to an authorized agent of the CFDFC. This includes, but is not limited to, the release of
all employment files or records, evaluations, disciplinary records, background investigation files, polygraph
results, psychological reports, medical records, and any and all internal affairs investigations, complaints or
grievances filed by or against me, training files, educational or school records and transcripts, civil service
test applications, test results, financial records, credit history, military records, arrest or criminal records,
including any investigative files or reports, court records, probation reports and photographs.
A photocopy or an electronic facsimile of this signed authorization form is to be considered as valid as the
original.
I understand that any information obtained by a personal history background investigation, which is
developed directly or indirectly, upon this release authorization will be considered in determining my
suitability for employment by the CFDFC.
I hereby release you, your organization, its representatives, agents and employees, and the CFDFC, its
representatives, agents and employees from any and all liability whatsoever, and/ or damages that may result
from furnishing the above information.
Applicant Signature
Staff Witness
Page 3 of 26
C E N T R A L F A L L S D E T E N T I O N F A C I L I T Y C O R P O R A T I O N
C O R R E C T I O N A L O F F I C E R P R E - E M P L O Y M E N T A P P L I C A T I O N
Applicant Name: Date of Birth:
Last First Middle
Address:
Street City State Zip Code
Phone Number: Email Address:
You are required to notify the Donald W. Wyatt Detention Facility Human Resource Department of any
change to the above information.
The Central Falls Detention Facility Corporation is an equal opportunity employer. Qualified applicants are
considered for employment without regard to race, color, gender, national origin, disability or veteran status
or any other legally protected status.
This application must be submitted in person at the Wyatt Training Center, 950 High Street Central Falls, RI.
You will be notified of the physical agility test date and time. Please review the physical fitness test
requirements and other recruitment information at: www.wyattdetention.com
This application is for the position of correctional officer at the Donald W. Wyatt Detention Facility
(CFDFC) in Central Falls, Rhode Island. All of the following information is required to be submitted with
your application in order for it to be considered “complete”:
Three (3) Current Letters of Recommendation (Must be signed, dated, include contact information)
Copy of Current Driver’s License
Copy of Driving Abstract
Copies of Vehicle Registration(s) and Proof of Insurance
Copy of Birth Certificate
Proof of Citizenship
Copy of Social Security Card
Copy of High School Diploma/G.E.D.
Official College Transcripts, if applicable
Copy of DD-214, if any military service
Current Credit History Report
Page 4 of 26
Print Name: Date:
I understand that appointment tendered to me will be contingent upon the results of a thorough background
investigation.
I further understand that during the application process and or background investigation, I am required to
report to the Donald W. Wyatt Detention Facility Training Department any changes in my personal history
covered in the pre-employment background questionnaire.
Prior to submitting my pre-employment background questionnaire, I have reviewed it carefully for
truthfulness, completeness and accuracy.
I hereby certify that all statements made in the pre-employment background questionnaire are true and
complete and I understand that any discrepancies, misstatements, omissions and or falsifications will be
cause for disqualification and for my name to be removed from the eligibility list or will be cause for further
review and or dismissal if an appointment was made. I authorize the facility to use my Social Security
number and date of birth for the purpose of conducting a pre-employment background investigation
including, but not limited to a BCI/criminal record check.
Date: Time:
Candidate’s Full Signature:
It is recommended that you read the entire application before writing on it.
You MUST print all information clearly.
“Complete” applications will be utilized to conduct a pre-employment background investigation.
All documents will be reviewed and only those candidates meeting the criteria of the Central
Falls Detention Facility Corporation hiring practices will be considered further in the hiring
process.
Failure to provide all required information may result in disqualification from the hiring process.
Any discrepancies, misstatements, omissions and or falsifications will be cause for
disqualification and for your name to be removed from the eligibility list or will be cause for
further review and/or dismissal if an appointment was made.
HOW DID YOU HEAR ABOUT US? PLEASE LIST ALL THAT APPLY: MINIMUM QUALIFICATIONS:
CFDFC employee referral (provide name): Fluency in the English Language
Publication (provide name): Legal Resident of the United States
RI Dept. of Labor & Training High School Diploma or G.E.D.
Internet website: Driver’s License
College Recruitment:
RI Human Resources Outreach & Diversity Office
Job Fair (location):
Radio / Television (station):
Friend / Family Member
Other:
Page 5 of 26
P E R S O N A L IN F O R M A T I O N :
Candidate Name: Last Middle First Maiden D.O.B.
Candidate Nicknames or Aliases:
Candidate Current Address: Street City State Zip Code
Rent Own Parents Other
How long have you lived there? Years: Months:
List your current landlord’s name and telephone number:
Candidate Descriptors:
Height: Weight: Eye Color: Hair Color:
Candidate Place of Birth United States Citizen (Yes or No) Social Security Number
Candidate’s Driver’s License: State License Number
Home Phone Number: Cell Phone Number:
Are you currently registered with Employ Rhode Island or Network Rhode Island? Yes No
Are you currently unemployed? Yes No
Are you currently receiving food stamps or other public assistance? Yes No
Do you have any permanent tattoos on your body at this time?
If yes, please list and describe all of your tattoos:
Page 6 of 26
F A M I L Y IN F O R M A T I O N :
Marital Status: Single Married Separated Divorced Annulled
Spouses Name: Maiden Name:
Date of Birth: Address:
Telephone: Email:
Emergency Contact: Emergency Contact:
Address: Address:
Telephone: Telephone:
List the following information about your ex-spouse (if applicable), or any current or
former significant other with whom you are or previously have been in a dating
relationship:
Name: Date of Birth:
Address:
Telephone: Email:
Name: Date of Birth:
Address:
Telephone: Email:
List the following information about your children:
Name: Date of Birth:
Address:
Telephone: Email:
Name: Date of Birth:
Address:
Telephone: Email:
Page 7 of 26
F A M I L Y IN F O R M A T I O N ( C O N T I N U E D ) :
Mother’s Name: Maiden Name:
Date of Birth: Address:
Telephone: Email:
Father’s Name: Date of Birth:
Address: Telephone:
Email:
Siblings Name: Date of Birth:
Address: Telephone:
Email:
Siblings Name: Date of Birth:
Address: Telephone:
Email:
Siblings Name: Date of Birth:
Address: Telephone:
Email:
Siblings Name: Date of Birth:
Address: Telephone:
Email:
Siblings Name: Date of Birth:
Address: Telephone:
Email:
Page 8 of 26
RE S I D E N C E :
Have you ever lived in another state? Yes No
State: From: (mm/dd/yy) To: (mm/dd/yy)
Address:
State: From: (mm/dd/yy) To: (mm/dd/yy)
Address:
Have you ever lived in another country? Yes No
Country: From: (mm/dd/yy) To: (mm/dd/yy)
Address:
Country: From: (mm/dd/yy) To: (mm/dd/yy)
Address:
List all current and former roommates. Use an additional sheet if necessary:
Name: Date of Birth:
Address:
Telephone: Email:
Name: Date of Birth:
Address:
Telephone: Email:
Name: Date of Birth:
Address:
Telephone: Email:
Page 9 of 26
R E S I D E N C E ( C O N T I N U E D ) :
List all residences at which you lived for the last five [5] years (Do not include any
addresses prior to your fifteenth [15th] birthday):
Address: Street City State Zip Code
From (mm/dd/yy): To (mm/dd/yy):
With whom did you live? Telephone:
With whom did you live? Telephone:
Landlord’s Name: Telephone:
Address: Street City State Zip Code
From (mm/dd/yy): To (mm/dd/yy):
With whom did you live? Telephone:
With whom did you live? Telephone:
Landlord’s Name: Telephone:
Address: Street City State Zip Code
From (mm/dd/yy): To (mm/dd/yy):
With whom did you live? Telephone:
With whom did you live? Telephone:
Landlord’s Name: Telephone:
Address: Street City State Zip Code
From (mm/dd/yy): To (mm/dd/yy):
With whom did you live? Telephone:
With whom did you live? Telephone:
Landlord’s Name: Telephone:
Page 10 of 26
RE F E R E N C E S :
List three (3) personal references (DO NOT include any relatives by blood or marriage, or
any current law enforcement personnel):
Name:
Address: Street City State Zip Code
Telephone: Email:
Name:
Address: Street City State Zip Code
Telephone: Email:
Name:
Address: Street City State Zip Code
Telephone: Email:
Do you know any former or current employees of the Donald W. Wyatt Detention Facility?
Yes No
List all former and current Wyatt employees that you are acquainted with, related to,
know as a friend or know through a friend. Use an additional sheet of paper if necessary:
Name: Contact Number:
Relationship:
Name: Contact Number:
Relationship:
Name: Contact Number:
Relationship:
Page 11 of 26
R E F E R E N C E S ( C O N T I N U E D ) :
List law enforcement references, if any:
Name: Agency:
Rank: Telephone #:
Email:
Name: Agency:
Rank: Telephone #:
Email:
Name: Agency:
Rank: Telephone #:
Email:
E M P L O Y M E N T :
List all information regarding your employment for the last five (5) years. Use a separate
sheet of paper if necessary:
Company: Telephone:
Address: Street City State Zip Code
Supervisor’s Name: Dates of Employment:
Position: Reason for Leaving:
Duties:
Weekly Schedule: Weekly Hours:
Co-worker’s Name: Telephone:
Page 12 of 26
Company: Telephone:
Address: Street City State Zip Code
Supervisor’s Name: Dates of Employment:
Position: Reason for Leaving:
Duties:
Weekly Schedule: Weekly Hours:
Co-worker’s Name: Telephone:
Company: Telephone:
Address: Street City State Zip Code
Supervisor’s Name: Dates of Employment:
Position: Reason for Leaving:
Duties:
Weekly Schedule: Weekly Hours:
Co-worker’s Name: Telephone:
Company: Telephone:
Address: Street City State Zip Code
Supervisor’s Name: Dates of Employment:
Position: Reason for Leaving:
Duties:
Weekly Schedule: Weekly Hours:
Co-worker’s Name: Telephone:
Page 13 of 26
E M P L O Y M E N T ( C O N T I N U E D ) :
Have you ever been investigated by your employer for improper conduct, illegal activities
or equal employment violations which resulted in your being found in violation of any
policies, regulations, rules or any state or federal laws? Yes No
If yes, explain the circumstance to include date and employer:
Have you ever received a formal written reprimand, been terminated, suspended, fired,
asked to resign or resigned in lieu of termination by an employer? Yes No
If yes, explain the circumstance to include date and employer:
Have you ever quit a job without giving sufficient (2-3 weeks) notice at any job? Yes No
If yes, explain the circumstance to include number of times, dates, employer, when and why:
Have you ever participated in any internship program with any law enforcement agency?
Yes No
If yes, list the agency, your supervisor’s name, telephone number, email address and length of
time you spent as an intern:
Have you ever taken a polygraph exam? Yes No
Date: Location:
Reason:
Date: Location:
Reason:
Page 14 of 26
L A W E N F O R C E M E N T AP P L I C A T I O N S :
Have you ever applied for any position at the Donald W. Wyatt Detention Facility?
Yes No
Position applied for: Date:
List all police departments, correctional facilities or any other law enforcement agencies (not
including this application) that you have applied to. If you are unable to list all the departments, use
a separate sheet of paper and attach it to this questionnaire. Attach any copies of applications.
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Page 15 of 26
LA W E N F O R C E M E N T AP P L I C A T I O N S ( C O N T I N U E D ) :
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Agency: Date Applied:
Address: Street City State Zip Code
Telephone: Fax Number:
Hiring Status:
How far did you make it in the process?
Page 16 of 26
M I L I T A R Y :
List all military service in which you have served.
Branch: Unit:
Entry Date: Discharge Date:
Service Number: Highest Rank:
Commanding Officer’s Name:
Telephone:
Have you ever been investigated for any criminal activity while in the military or military reserves?
Yes No
If yes, please explain:
Have you ever engaged in any activities in another country that would be considered illegal in the
United States? Yes No
If yes, please explain:
Have you ever applied to and been rejected for military service? Yes No
Date: Branch:
Why was your application refused?
Have you ever been reduced in pay grade or been the subject of any judicial or non-judicial
disciplinary action while in the military, National Guard or military reserves?
Yes No
If yes, explain the circumstance to include dates, violations and penalties:
Have you ever received an “other than” honorable discharge? (i.e.: OTH/Medical) Yes No
If no, explain:
Page 17 of 26
CO U R T S :
Have you ever been charged with or convicted of a criminal offense? This includes charges
that have been dismissed, dropped or reduced. Yes No
If yes, provide the following information, use additional sheets if necessary:
Date: Charges:
Agency:
Disposition:
Description of Events or Circumstances:
Date: Charges:
Agency:
Disposition:
Description of Events or Circumstances:
Date: Charges:
Agency:
Disposition:
Description of Events or Circumstances:
Page 18 of 26
CO U R T S ( C O N T I N U E D ) :
Pursuant to Rhode Island General Law 12-1.3-4, law enforcement applicants must disclose
expunged records. Provide the following information if you have had any charges
expunged:
Date: Charges:
Agency:
Description of Events or Circumstances:
Date: Charges:
Agency:
Description of Events or Circumstances:
Are you now or have you ever been involved as a plaintiff or defendant in any civil court
action? Yes No
If yes, please provide the following information:
Date of Claim: Court Location:
Plaintiff Defendant
Description or Circumstances:
Date of Claim: Court Location:
Plaintiff Defendant
Description or Circumstances:
Page 19 of 26
CO U R T S ( C O N T I N U E D ) :
Are you required to pay child support and/or alimony, either by mutual agreement or by a
court order? Yes No
If you answered yes to the above question, have you ever been held in contempt by any
court for failure to pay child support and/or alimony? Yes No
If yes, please explain:
Have you ever had a restraining order or a no contact order against you for any reason?
Yes No
If yes, please explain:
Have you ever filed for bankruptcy? Yes No
If yes, please provide the following information:
Date: Court Location:
Results:
DR U G S :
Have you ever remained at a private gathering or party where illegal drugs,
pills/prescription medication or narcotics were being used? Yes No
Have you ever allowed someone to use illegal drugs, pills/prescription medication or
narcotics including marijuana at your residence? Yes No
Have you ever purchased any illegal drug, pills/prescription medication, narcotics or
substance including steroids? Yes No
Drug Name Date Purchased Amount Purchased Personal Use or Other
Page 20 of 26
DR U G S ( C O N T I N U E D ) :
Have you ever purchased, sold, supplied, manufactured, cultivated, ingested, inhaled or
injected any form of illegal drug, pills/prescription medication, narcotic or substance
including steroids? Yes No
Please provide the following information. Do not leave any blank spaces.
Substance Yes/No Number of
Times
Approximate
Date
Marijuana
Salvia
Hashish
Speed
Methamphetamine
Heroin
Mushrooms
Peyote
LDS
Cocaine
Crack
PCP
Ice
Ecstasy/Molly
Mandrax/Quaaludes
Steroids
Amphetamines
Barbiturates
Adderall
Inhalants
Any substance you thought may be illegal
Prescription medication not prescribed to
you
Any other natural, manufactured and/or
synthetic drugs where its use could be
questionable
Other
If you answered yes to any substance listed above, provide an explanation of what, where, when
with whom and why:
Page 21 of 26
E D U C A T I O N :
List the following information regarding your education beginning with High School then
College (if applicable):
School Name:
Date Attended: Degree Major:
Graduation Date: Degree Earned:
School Name:
Date Attended: Degree Major:
Graduation Date: Degree Earned:
School Name:
Date Attended: Degree Major:
Graduation Date: Degree Earned:
T R A F F I C :
Starting with your most recent violation, list in chronological order all moving and non-
moving violations (i.e.: parking, speeding, red light violations, etc.) that you have received
and the disposition of the violation (i.e.: plead guilty, paid fine, ticket dismissed, etc.).
Please disclose any traffic stops during which warnings and/or no citations were issued. Use
additional pages if necessary.
Date: Violation:
City/State: Agency:
Disposition:
Describe Circumstance:
Date: Violation:
City/State: Agency:
Disposition:
Describe Circumstance:
Page 22 of 26
Date: Violation:
City/State: Agency:
Disposition:
Describe Circumstance:
Date: Violation:
City/State: Agency:
Disposition:
Describe Circumstance:
Have you ever been involved in any motor vehicle accidents? Yes No
Date: City/State:
Agency: At Fault: Yes No
Explain Circumstances:
Date: City/State:
Agency: At Fault: Yes No
Explain Circumstances:
Date: City/State:
Agency: At Fault: Yes No
Explain Circumstances:
Have you ever left the scene of a motor vehicle collision without reporting the incident to a
law enforcement entity within the jurisdiction which it happened? Yes No
Date: City/State:
Explain Circumstances:
Page 23 of 26
P O L I C E CO N T A C T S :
Please list all police contact (i.e.: reporting a crime, victim of crime, witness, etc.):
Date: Agency:
Location/Address:
Explain Circumstances:
Date: Agency:
Location/Address:
Explain Circumstances:
Date: Agency:
Location/Address:
Explain Circumstances:
Date: Agency:
Location/Address:
Explain Circumstances:
L I C E N S E /RE G I S T R A T I O N :
Has your license to operate a motor vehicle ever been suspended? Yes No
Date: State of Suspension:
Reason for Suspension:
List any vehicle(s) registered to you, along with any motor vehicle insurance policy
information:
State Registration Plate Insurance Provider / Policy Number
State Registration Plate Insurance Provider / Policy Number
Page 24 of 26
P E R S O N A L DE C L A R A T I O N S :
Have you ever had any contact with any inmate(s)/detainee(s), including visitations, letters
or phone calls to any correctional institutions? Yes No
Inmate’s Name: Date:
Correctional Institution:
Inmate’s Name: Date:
Correctional Institution:
Inmate’s Name: Date:
Correctional Institution:
Are you currently or have you ever been a member or associate of any gang (i.e., Street,
Motorcycle, etc.) Yes No
If yes, please explain:
Have you ever had any negative contact with a Social Service Agency? (i.e.: DCYF) Yes No
If yes, please explain:
Have you ever used any other name or alias at any time during your life? Yes No
Name/Alias: Date(s):
Name/Alias: Date(s):
Page 25 of 26
P E R S O N A L DE C L A R A T I O N S ( C O N T I N U E D ) :
Have you ever applied for a permit to carry a concealed weapon? Yes No
Date Applied: Permit Granted: Yes No
Weapon: Agency Applied To:
Reason for Permit:
List any foreign languages that you speak, read or write and your level of proficiency:
List your hobbies and interests:
Do you belong to any memberships, organizations or do volunteer work (past/present)?
Yes No
If yes, please explain:
Explain your use of alcohol including the type used:
When is the last time you were intoxicated?
When was the last time you attended a party? What was the reason for the party?
Does anyone in your household currently use illegal drugs or prescriptions? Yes No
If yes, please explain:
Page 26 of 26
P E R S O N A L DE C L A R A T I O N S ( C O N T I N U E D ) :
Have you ever been involved in any activity outside of the United States that would have
been considered illegal in the United States? Yes No
If yes, please explain:
Have you ever intentionally or unintentionally viewed, possessed, downloaded or
distributed child pornography? Yes No
Have you ever filed a police complaint or called a law enforcement agency to complain
about the actions of an officer? Yes No
Is there anything in your background that you think would prevent you from being a
qualified correctional officer that has not been asked on this application? Yes No
If yes, please explain:
Special Qualifications and Skills:
List any and all special qualifications and skills which pertain to the position you are applying for: