APPLICATION FOR COMPETITIVE EXAMINATION MUNICIPAL FIRE AND POLICE CIVIL SERVICE BOARD LEASE PRINT OR TYPE. FATLURE TO ANSWER ALL QUESTIONS IN THIS APPLICATION MAY CAUSE YOUR APPLICATION TO ~E DELAYED OR REJECTED, fave: erst MIDDLE TAs shew Lee catdwen ‘STREET ADDRESG/?.0._DOX NO cay /Foms Sana? [MON Toe, a. 70607 HOME CELEHONE MOMEER (WITH AREA CODE) OFFIGE TELEPHONE NONGER (WITH AREA CODE) (337) 491-2311 [me a BREE OF BIRTH MONTH/OATE/ ER: ARE YOU A CITIZEN OF THE UNITED STATES? ARE YOU A REGISTERED VOTER OF THE STATE OF yous ONO ‘LOUISIANA? 1m YES DN TITLE OF POSITION FOR WHICH YOU ARE APPLYING (FILE A SEPARATE APPLICATION FOR EACH TYPZ OF Lsosrerom) CHIEF OF POLICE ‘The Federal governnent requires that we request the following race and sex information for statistical reporting purposes. Completion of this section is voluntary, and your application will not be rejected Ip 3oe ease rsa hel fateceai m Male = White D Black 0 Hispanic 0 Am. Indian O Asian OFemale | 0 Other [ SPECIAL INSTRUCTIONS FOR DOCUMENTATION WHICH SHOULD BE ATTACHED TO YOUR COMPLETED APPLICATION FOR EXAMINATION So that our civil service board say evaluate your qualifications for admission to the examination, [plesse attach « copy of the documents checked () below to your completed application: 'VOUER REGISTRATION CARD HIGH SCHOOL DIPLOHA OR GED EQUIVALENCY CERTIFICATE VALID DAIVERS LICENSE COLLEGE TRANSCRIP, TF APPLICABLE BIRTH CERTEPICATE CERTIFICATE VERIFYING THE ABILITY TO TYPE 45 WOM WITH MINIMAL ERROR i SPECIAL CERTIFICATIONS OR LICENSE REQUIRED FOR ADMISSION 10 SPECIFIC CLASSES I ososeq AUTHORITY FOR RELEASE OF INFORMATION T HAVE COMPLETED THIS APPLICATION WITH THE KNOWLEDGE AND UNDERSTANDING THAT ANY OR ALL ITEMS CONTAINED HEREIN MAY BE SUBJECT TO INVESTIGATION PRESCRIBED BY LAW, AND I CONSENT TO THE RELEASE OF INFORMATION CONCERNING MY CAPACITY AND FITNESS BY EMPLOYER, EDUCATIONAL INSTITUTIONS, LAW ENFORCEMENT AGENCIES, AND OTHER INDIVIDUALS AND AGENCIES, TO DULY ACCREDITED INVESTIGATORS, CIVIL SERVICE BOARD MEMBERS AND OTHER 1 AUTHORIZED EMPLOYEES OF THE GOVERNMENT FOR THAT PURPOSE. I CERTIFY THAT THE ANSWERS I HAVE GIVEN TO ALL QUESTIONS IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE. I KNOW THAT ANY MISREPRESENIATION HEREIN MAY CAUSE MY APPLICATION 70 BE REJECTED, MY NAME ‘pene foe gE EunGIBE [AND/OR MAY SUBJECT ME 10 DISMISSAL FROM EMPLOYMENT. CIVIL SERVICE BOARD ONLY (I ror use oF " Voter a Citizen o Age 0 Education |o vet. Pref. 1. CHM 2. V. CHM 3 4. 5BACKGROUND INFORMATION IF YOU ARE APPLYING FOR A JOB WHICH REQUIRES THE ABILITY 70 DRIVE A VEHICLE, PLEASE PROVIDE YOUR DRIVER'S LICENSE NUMBER: LA 005322422 WITHIN THR PAST 5 YEARS, HAVE YOU BEEN TERMINATED, OR RESIGNED IN LIEU OF TERMINATION, FROM ANY POSITION FOR REASONS OTHER THAN A REDUCTION IN FORCE? Oo YES = NO NOTE: IF YOU ANSWER "YES" TO THIS QUESTION, PLEASE PROVIDE AN EXPLANATION IN THE EXPLANATION BLOCK PROVIDED BELOW. [[4- tae ‘vou ever BaEN convicTED OF A FELONY? oO YES = NO B, HAVE YOU BEEN CONVICTED OF A MISDEMEANOR DURING THE LAST 3 YEARS? Oo YES = NO NOTE: IF YOU ANSWERED "YES" TO EYTHER OF THE ABOVE QUESTIONS, PLEASE PROVIDE AN EXPLANATION IN THE EXPLANATION BLOCK BELOW. A 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 | Serxoussss. EXPLANATION. PLEASE USE THE SPACE PROVIDED BELOW TO EXPLAIN ANY "YES" ANSWERS TO THE ABOVE THREE QUESTIONS. ATTACH ADDITIONAL PAGES IF NECESSARY. TRAINING/ EDUCATION AL BIGH scHOOL To ae [eg cro on smorcanazom ane sEcurven 05/24/3909 LaGrange Senior High School 3420 Louisiana Ave Lake Charles, LA 70607 Dr orp nor aearuame, mor cxvoiers osane: [B- counuce = | a | Se] as) save oF cates on mevERSrEY/ocamzon Resoc McNeese State University 7 89 Generar | 12/2011 | studies Sustice—— C. OTHER FORMAL TRAINING qvenuss, 02 seearaas ammo | cus | adie Pex [[caicasieu Regional Training Academy Lake ‘9/oa- | as © ia Charles, 1a |i1/% | © ; T7is= | wee FBI National Academy Quantico, val Jip | = ™ 40 SPECIAL QUALIFYING EXPERIENCE, CERTIFICATIONS, OR LICENSES Attach additional pages if NO. 1 NO. 2 NO, 3 necessary ‘me oF iiamas op RE oF ——— Police daternal Affaire | Cortificate oF Siateriearioe Peewee Kehlevenent in criminal Ssstice Education ‘mig_pe, Caoiaes joo | Federcl _Gureas of | University of worth | University of Virginie sitter ce Srerszoncar seem | Investigation Floride tam urones cn comvaniar | Sune 27, 200 Taly 22, 20H September 18, 2015 LIST ANY SPECIAL COURSE WORK, TRAINING, OR EXPERIENCE WHICH MAY DE BENEFICIAL IN THE JOB FOR WHICH YOU ARE APPLYING, OR WHICH MAY SATISFY ANY SPECIAL QUALIFICATION REQUIREMENTS, Traffic Accident Reconstruction through Northwestern State University 1. 2. Interview and Interrogation through U.S. Attorney's Office 3. _liring and Background Investigations through Public Agency Training Council [IF YOU HAVE COMPUTER EXPERIENCE, PLEASE LIST ANY SOFTWARE PACKAGES OR COMPUTER LANGUAGES WITH WHICH YOU HAVE A WORKING KNOWLEDGE: N/A. [ TYPING ABILITY: __45 wee VETERAN'S PREFERENCE Five-point veteran's preference is granted to veterans who receive passing scores for an entrance class end were discharged honorably or under honorable conditions from the U.S. Armed Forces aster having sexved during any of the following wartime periods: Septesber 16, 1940 through July 25, 19477 June 27, 1950 through January 31, 1955; and between duly 1, 1958 through May 7, 1975- After May 7, 1975, you must have served in a peacetime campaign or expedition for which campaign badges wore authorized to receive the veteran's preference points. (Exclude active duty for training in Revecves or National Guard.) Should you wish to receive the veteran's points, check the space provided cna attach a copy of your DD-214 which varifies the above information. OX QUALIFY FOR THE FIVE-POINT VETERAN'S PREFERENCE AS IDENTIFIED ABOVE, AND HAVE ATTACHED A COPY OF MY DD-214 10 THIS APPLICATION FOR VERIFICATION PURPOSES fF — af REQUEST FOR TESTING ACCOMMODATIONS UNDER THE AMERICANS WITH DISABILITIES ACT I£ you requize any special testing accommodations because of « disability which limits a major life activity, you must complete this section in order for your request to be considered. I em requesting testing accommodations under the Americans With Disabilities Act for the following disability (check box and specify disability) ; Required documentation to attach to your application: IN ORDER POR THIS CHVIE SERVICE BORED TO FROGESS YOUR ADA REQUEST, you must attach recent written documentation of your disability, including an assessment of accommodations which might be appropriate to compensate for your disability in » testing environnent, prepared by a DOCTOR, PSYCHOLOGIST REHABILITATION COUNSELOR, OCCUPATIONAL or PHYSICAL THERAPIST, or OTHER PROFESSIONAL with knowledge of your functional limitations a ‘The sequized documentation is attached to this application.