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MinimumqualificationsforemploymentwiththeYoungsvillePoliceDepartment: 1.Mustbe21yearsofage 2.Mustbeahighschoolgraduate 3. Must conform to and abide by laws of the United States, the State of Louisiana and anysubdivisions thereof 4.Musthaveavaliddriver’slicenseandgooddrivinghistory 5.Musthave: A–NoFelonies B–Nomisdemeanorchargesthatwouldprohibityoufromcarryingafirearm. 6. Must be able to pass a physical which includes a drug and back screen through the City ofYoungsville’sappointedphysicians 7.Mustbeingoodphysicalshapeinordertocompletepolicetraining 8.MustbearegisteredvoterProcedurespriortobeginningdateofemployment: 1.Submitcompletedapplication,alongwithcopiesofanycertifications,driver’slicense,andvoter registrationcard. 2.Ifapplyingforreservestatus,youwillfollowthesameproceduresasafull-timeapplicant. 3.Applicantwillbescreenedthroughprioremploymenthistory,criminalhistory,andDLcheck. 4.ApplicantwillbecontactedbyeithertheChiefortheAssistantChief,tosetupandappointmentfortheinterview,onlyintheeventofanopeningandyouareselectedasacandidate
5. If accepted for employment, arrangements will be made for physical, drug screening andpsychologicaltestthroughHumanResourceDepartment.6.Submitprior“PriorServiceCertificate”ifapplicable.7. Prior tobeginningdate, applicantwill be suppliedwith the Youngsville PoliceDepartmentDrugPolicy,andmustseetheHumanResourceDepartmentforsigningofallappropriatepaperwork.8.ThenreceivePolicyManual,equipment,etc.,fromeithertheChieforAssistantChief.9.CompletePropertySheetwiththeCaptainofPatrol.10. Application will receive appropriate paperwork from the Human Resource Department to getsworntodutyandreceivecommissioncardbeforebeingturnedovertohisFTO(FieldTrainingOfficer).
YoungsvillePoliceDepartment P.O.Box310 304FourthStreet
Youngsville,LA70592337-856-5931
337-856-4904fax_______________________________________________________________________________________________
APPLICANTSAREGIVENCAREFUL,FAIRANDEQUALCONSIDERATION.IFITDETERMINETHECHIEFOFPOLICEWISHESANINTERVIEW,YOUWILLBENOTIFIED.
YPD12/16/151OF12APPLICATIONFOREMPLOYMENTYOUNGSVILLEPOLICEDEPARTMENTP.O.BOX310304FOURTHSTREETYOUNGSVILLE,LA70592337-856-5931FAX337-856-4904
POSITIONAPPLIEDFOR: DATEOFAPPLICATION
CHECKONE:FULLTIME()RESERVEOFFICER()CLERICAL() 1.LASTNAME FIRST MIDDLE MAIDEN/OTHER
PRESENTSTREETADDRESS APT.# CITY STATE ZIPCODE
AGE D.O.B. SOCIALSECURITY# RESIDENCEPHONE CELLPHONE
SEX HEIGHT WEIGHT HAIRCOLOR EYECOLOR PLACEOFBIRTH
DISTINGUISHINGMARKS:PHYSICALDEFECTS,BIRTHMARKS,SCARS,ETC.
DRIVERSLICENSE# STATE TYPE EXPIRATIONDATE
2.TheCivilRightsActof1964prohibitsdiscriminationinemploymentbecauseofrace,color,religion,sexornationalorigin.Pleaseindicatewhichgroupyou.(Checkone).AmericanIndian OrientalAmerican CaucasianBlackAmerican SpanishSurnameorSpanish Other
CHECKONEMARITALSTATUS:MARRIED()SINGLE()ENGAGED()SEPARATED()DIVORCED()WIDOW()3.NAMEOFPRESENTSPOUSE D.O.B. SOCIALSECURITY#
HEIGHT WEIGHT HAIRCOLOR EYECOLOR ADDRESS(IFDIFFERENT)
4.COMPLETETHEFOLLOWINGINFORMATIONREGARDINGEX-SPOUSE:NAME(MAIDEN/OTHER) DATEOFBIRTH
5.RELATIVES:LISTYOURCHILDRENINCLUDINGSTEP/ADOPTEDCHILDREN:NAME DATEOFBIRTH RESIDENCE
LEAVETHISAREABLANK:FINGERPRINTEDBY:___________________________PHOTOGRAPHEDBY:__________________________DATE:______________________________________PHYSICAL/DRUGSCREEN:_______________________STARTDATE:_______________ACCEPTED:YESNOIFNO:_______________________________________
YPD12/16/15Page2of12
Eventhougharelativeisdeceased,giveallinformationrequestedandindicatelastresidence.
A.FATHER’SNAME DATEOFBIRTH RESIDENCEADDRESS
MOTHER’SNAME DATEOFBIRTH RESIDENCEADDRESS
B.STEPFATHER’SNAME DATEOFBIRTH RESIDENCEADDRESS
STEPMOTHER’SNAME DATEOFBIRTH RESIDENCEADDRESS
C.BROTHER’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS
SISTER’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS
D.FATHER-IN-LAW’SNAME DATEOFBIRTH RESIDENCEADDRESS
MOTHER-IN-LAW’SNAME DATEOFBIRTH RESIDENCEADDRESS
E.BROTHER-IN-LAW’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS
YPD12/16/15Page3of12
SISTER-IN-LAW’SNAME(S) DATEOFBIRTH RESIDENCEADDRESS
ListallrelativesemployedbytheCityofYoungsvilleorPoliceDepartment:
FULLNAME RELATIONSHIP DEPARTMENT
6.Residences:(Listallresidencesforthepastten(10)yearsbeginningwithyourpresentaddress.Includeoff-baseresidenceswhenintheserviceand/ordormitorieswhenincollege.)
MONTH YEAR ADDRESS CITY STATE
7.CharacterReferences:(Listthree(3)personsnotemployeesorrelativeswhoknowyouwellenoughtogivecurrentorformerinformationaboutyou.)
NAME ADDRESS(INCLUDEZIPCODE) HOMEPHONE BUSINESSPHONE
OCCUPATION
YPD12/16/15Page4of12
8.EmploymentHistory:Listalljobsheldinthepastfive(5)yearsregardlessoflengthoftimeemployed.Startwithyourpresentplaceofemployment.
DESCRIPTIONOFDUTIES REASONFORLEAVING
DESCRIPTIONOFDUTIES REASONFORLEAVING
DESCRIPTIONOFDUTIES REASONFORLEAVING
DESCRIPTIONOFDUTIES REASONFORLEAVING
DESCRIPTIONOFDUTIES REASONFORLEAVING
YPD12/16/2015Page5of12
A.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVOR
TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER
B.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR
TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER
C.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR
TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER
D.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR
TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER
E.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR
TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER
DESCRIPTIONOFDUTIES REASONFORLEAVING
9.Education:Listyoureducation,includinghighschool,colleges,businessandtechnicalschool:
SCHOOLNAME ADDRESS FROM TO GRADUATE
YES()NO()
YES()NO()
YES()NO()
YES()NO()
YES()NO()
10.Doyouhaveanyknowledgeortrainingofbusinessmachines?Ifyes,pleaseexplainbelow:
11.HaveyoueverappliesforapositionwiththeYoungsvillePoliceDepartment?
YES NO IFYES,EXPLAINBELOW:
HaveyoueverappliedforapositionwithanotherLawEnforcementorotherGovernmentAgency?
YES NO IFYES,EXPLAINBELOW:
F.FROM NAMEOFEMPLOYER JOBTITLE NAMEOFSUPERVISOR
TO ADDRESSOFEMPLOYER SALARY TELEPHONENUMBER
YPD12/16/15Page6of12
12.Haveyoueverordoyounowhaveanyofthefollowingillness:
ILLNESSES YES NO ILLNESSES YES NOSYPHILIS TUBERCULOSIS DIABETES CRAMPSINLEGS CANCER KNEEPROBLEMS KIDNEYTROUBLE FREQUENTORSEVEREHEADACHES HEARTTROUBLE DIZZINESSORFAINTINGSPELLS STOMACHTROUBLE NERVOUSTROUBLEOFANYSORT RHEUMATISM/ARTHRITIS ANYDRUGORNARCOTIC EPILEPSY LOSSOFARM,LEG,FINGERORTOE EYETROUBLE CAR,TRAIN,SEA,ORAIRSICKNESS SWOLLENORPAINFULJOINTS WEARGLASSES EXCESSIVEDRINKING WEARANARTIFICIALEYE HIGHORLOWBLOODPRESSURE WEARHEARINGAIDS AIDS STUTTERORSTAMMER MULTIPLESCLEROSIS ATTEMPEDSUICIDE
a.Haveyoueverhadanyoperationswithinthepastfive(5)years?
YES NO IFYES,PLEASEEXPLAINBELOW,GIVINGDATE(S)ANDTYPEOFSURGERYORSURGERIES:
B.Doyouhaveanyotherphysicaloremotionalconditionthatwouldlimityourjobperformanceorendangerothers?
YES NO IFYES,PLEASEEXPLAINBELOW:
13.Doyouoryourspousehaveanyimmediatecivil/criminalactionpendingagainstyou?
YES NO IFYES,PLEASEEXPLAINBELOW:
a.Haveyoueverreceivedatrafficcitationorbeeninvolvedinatrafficaccident?
YES NO IFYES,PLEASEEXPLAINBELOW:
YPD12/16/15Page7of12
b.Haveyoueverbeenarrestedorconvictedofafelony?
YES NO IFYES,PLEASEEXPLAINBELOW:
c.Listallmisdemeanorarrestsand/orconvictionsbelow:
DATE CHARGE(S) DETAININGORARRESTINGAGENCY PENALTY
14.Haveyouoryourspouseeverhadyourwagesgarnished?
Yes No
a.Haveyouoryourspouseeverbeenpartytoasmallclaimsorothercourtaction?
Yes No
b.IfemployedbytheYoungsvillePoliceDepartment,doyouanticipateanyincomeotherthanyourincomingpoliceincome? YesNoc.Haveyoueverbeenrefusedalife,auto,healthorotherinsurancepolicy?YesNo 15.Whentheanswertoanyoftheabovequestionsisyes,pleaseexplainbelow:
YPD12/16/15Page8of12
16.Listallorganizations,clubsandsocialgroupsofwhichyouarenow,orhavebeenamember:
17.Ifitbecamenecessary,inthecourseofyourpolicyduties,totakeahumanlife,wouldyouhaveanyreluctancetodosobecauseofreligiousorotherbeliefs? YesNo 18.HaveyoueverservedintheArmy,Navy,MarineCorps,AirForce,R.O.T.C.,orothermilitaryorsemi-militaryorganizations?
YES NO ORGANIZATIONENLISTMENT
DATEDISCHARGE
DATE TYPE RANK
Presentdraftclassification:
19.Wearelookingforapermanentemployeeandwillmakeaninvestmentintraining.Isthereanyreasonwhyyouwouldnotexpecttofinishtrainingandstaywiththedepartment?YesNoYPD12/16/15Page9of12
20. Do you understand that the police academy training is a period of selection, that you must complete itsuccessfully,thatmaydischargedfromthisschoolatanytime,thatyoumustsubmityourselftostrictdisciplineandthatyoumaynothaveanyotheremploymentorattendanyotherschoolwhilearecruitinthepolicyacademy? YesNo 21.Specialskillsandabilities:
22.Haveyoueverreceivedcompensationforinjuries?YES NO IFYES,EXPLAINBELOW:
23.AreyouaUnitedStatecitizen?YesNo
YPD12/16/15Page10of12
Iamawarethatanymisrepresentationorfalsificationsmadeinconnectionwithmyobtainingemploymentwiththe
Youngsville Police Departmentwill be grounds for rejection or dismissal. The fact set forth inmy application for
employment are true and correct. I understand that if employed, false statements on this application shall be
consideredsufficientcausefordismissal. Youareherebyauthorizedtomakeany investigationofmypersonaland
financial record through any investigative agencies or bureaus of your choice. In making this application for
employment, Ialsounderstandthataninvestigativereportmaybemadewherebyinformationisobtainedthrough
personal interviewswithmy neighbors, friends or others withwhom I am acquainted. I understand that if I am
successful candidate for employment, I will be required to take a physical examination, psychological test, drug
screenandperhapsappearinfrontoftheMayorandCouncilMembers.
____________________________________________APPLICANTSSIGNATURE____________________________________________WITNESS(COMPANYINTERVIEWER)
I have applied for employment with the Youngsville Police Department for the position of
______________________________, with requires a personal background check. I hereby authorize their
investigationofmyprevious recordandcharacterand toascertainanyandall informationwhichmayconcernmy
recordandcharacter,whetherthesameisofrecordornot. Thisauthorizationincludes,but isnot limitedtobank,
credit, school, selective services, physical, hospital, or employer records, and releases all persons, organizations,
corporationsfromanychargesbecauseoffurnishingsaidinformation.Aphotostaticcopyofthisauthorizationshall
beconsideredaseffectiveandvalidastheoriginal.
YPD12/16/15Page11of12
Bysigningbelow,youagreetoenterintoacontractwiththedepartmentinreferenceto:Ifyouvoluntarilyleavethe
Youngsville Police Department within 362 days of your employment, you will be required to reimburse the
department for the cost of your employment, your pre-employmentphysical, your pre-employmentphysical, your
pre-employment drug test, uniforms, training andpolicy academy fees (if applicable) and anyother costs that are
spentonthetrainingperiod. Youalsoagreetopayall legalcost incurredbytheYoungsvillePoliceDepartmentto
enforce this contract, and agree that any amount due can be withheld from your final pay or any retirement
accumulated.
TOBECOMPLETEDBYAPPLICANT:
_________________________________________________________________________________________(PRINTNAME)(SIGNATURE)_________________________________________________________________________________________(ADDRESS) (DATE)WhydoyouwanttobecomeemployedwiththeYoungsvillePoliceDepartment?(Inyourownhandwriting)
YPD12/16/15Page12of12