APPLICATION FOR COMPETITIVE EXAMINATION FIRE AND POLICE CIVIL SERVICE BOARD PLEASE PRINT OR TYPE. FAILURE TO ANSWER ALL THE QUESTIONS IN THIS APPLICATION AND FAILURE TO ATTACH ALL REQUIRED DOCUMENTATION TO THIS APPLICATION MAY CAUSE YOUR APPLICATION TO BE REJECTED. Jrwre Pre WDD usr Rickey Lane Miller STREET ADORESSP.O, BOK NO. emronnN ‘ATER — Lake Charles LA, 70611 TOME TELEPHONE NUMBER (HTH AREA CODE} ‘FACE TELEPHONE NUMBER (TH AREA CODE) (ne) () 387-491-1311 [SELL TELEPHONE WONBER (TH AREA CODE) HAL RODRESS a SOciL SecunTY KOMEN um ONT OF RTH: _ONTHOATEVEAT, [AR YOU A CITIZEN OF THE UNITED STATES? DANVERS LCENSE No; AE <2 o_o _|_— 4 EXAMINATION FOR WHICH YOU ARE APPLYING (FILE A SEPARATE APPLICATION FOR EACH EXAMINATION) Police Chief ‘the Federal government requires thet we request the following race and sex information for statistical reporting purposes. Completion ofthis section is voluntary, and your application will not be rejected if you choose not to provide this information. DS aie write ace Ldetepente Jam indian Jasin 7 remaie other See EUG TIONS FOF BOUIN NATION VOU MUSTACHE, ae Ir crore wth cient low you mutt bo a ellzon ofthe Unted Stats, ond of gala. In aston o these requirements, the ioral runic fr and pole eh senvce board nach juricon has adopted it own austin requirement foreach fits competv classe. therefore, you must attach the necessary documentation to verify thst you meet al the requirements ofthe vil service board to which you are applying. You must attach a copy of the following documents: Proof that you are a elizen ofthe Urited States (Binh Certificate, US Passport, or Cerificate of Naturalization) Proot that you meet the age requtement of the civil service bosrd (Bith Certiiate) Proof that you ma‘ the education requirement as posted by the civil service board to be admitted to the exam Proof that you have 8 valid diver’ icense (if this Is © requement cf the civil service board to be admitted to the exam) Proof that you meet al other requirements a8 posted by the cil service board to be admited tothe exam ace Lot 7—<—$—$—$———— “AUTHORITY. FOR RELEASE OF INFORMATIC Lie! Sr GONIPLETED Ti APPLICATION WITH THE KNOWLEDGE AND UNDERSTANDING THAT ANY OR ALL EMS CONTAINED HEREIN MAY BE SUBJECT TO} aESTIORTION PRESCRIBED BY LAW, AND | CONSENT TO THE RELEASE OF INFORMATION CONCERNING MY CAPACITY AND FITNESS BY EMPLOYERS, EDUCATIONAL INSTITUTIONS, LAW ENFORCEMENT AGENCIES, AND OTHER INDIVIDUALS AND AGENCIES, TO DULY ACCREDITED INVESTIGATORS, CV [SERVICE BOARD MEMBERS ANO OTHER AUTHORIZED EMPLOYEES OF THE GOVERNMENT FOR THAT PURPOSE. NCERTIEY THAT THE ANSYIERS | HAVE CIVEN TO ALL QUESTIONS IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE. | KNOW THAT ANY MISREPRESENTATION HEREIN MAY CAUSE MY APPLICATION TO BE REJECTED, MY NAME RENOVED FROM THE ELIGIBLE LIST AND/OR MAY SUBJECT ME TO} eowissa. FROM EMPLOYMENT. “THAN A REDUCTION IN FORCE? vesL_] [yaw YoU Eve act CONVETED OFA ELON vesL] nol] 2. ou aE NED oF A eDEMEhOR DUR HE LAS 3 YEARS? ves] NOTE: iF YOU ANSWERED "YES" TO EITHER OF THE RBOVE QUESTIONS, PLEASE PROVIDE AN EXPLANATION IN THE EXPLANATION BLOCK BELOW. © ‘CONVICTION WiLL NOT NECESSARILY DISQUALIFY YOU FROM THE JOB FOR WHICH YOU ARE APPLYING. A CONVICTION WILL BE JUDGED ON ITS OWN MERITS WITH RESPECT TO TIME, CIRCUMSTANCES, AND SERIOUSNESS. page 2 of 7Gaga scroot ro ae a ie NEA ONT ‘Sam Houston High Schoo! Sam Houston High Schoo! ~ 7 /880 Sam Houston Phy orion on sunaency cemmesre fake Charles, LA. 7084 Son ToT Lake Charles, LA. 70811 | co nteae — a ‘one oF AR Universi of Vega School of Continuing and Professional Cai ‘Studies 17 Justice L = |/c. OTHER FORMAL TRAINING Cal jen |e nee (soanse, 743, MLITARY ETE, GASSES OR SEINARS - “TITLE OF INSTRUCTION OR CLASS (ATTACH ADDITIONAL PAGES IF NECESSARY) _” | FBI National Academy Quantico, VA 2014 FBI Executive Leadership Institute Alexandria, VA | 2015 L. | FBILEEDA- Supervisory Lablty Training Lake Charles, LA | 2012 U. S. State Depariment- Basic Feld Firearms Oficer Course Gonzales, tA | 2014 Execute Leadership Course | Maser ntuctor L ea Te aA Ps Couey Cu io. ‘foots 20%8 204 io ms i |e a fa ne ve ve ale page 3 of 7