Background Information Packet

Champaign Police Department

Background Information Packet

Service through Trust, Integrity & Respect Champaign Police | 82 E. University Ave | 217.351.4545 | www.champaignpolice.com | Facebook and Twitter @ChampaignPD

http://www.champaignpolice.com/

http://www.champaignpolice.com/

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Champaign Police Department Application Overview

Notice to Applicants

This application / background information packet is the first impression the City of Champaign / Champaign Police Department has of you as a potential employee. It provides us with the necessary information about your past employment and achievements. It also gives us information about your abilities to follow instructions and your diligence in completing an assigned task. The cover letter specifies a date that this background investigation packet must be returned to us. The failure to meet that requirement could be grounds for rejection of the application and opportunity for future testing.

Basic Requirements for Appointment

• Must be of legal status to work in the United States (U.S. citizen or holder of a Resident Alien Card or Employment Authorization Card).

• Must be 21 years of age for sworn positions or 18 years of age for non-sworn positions.

• Must possess a valid driver’s license if position requires operation of a motor vehicle.

• Must be a high school graduate or have a GED (General Equivalency Diploma). • If previously served in the military, received an honorable discharge. • Successful completion of all prescreening examinations. • Successful completion of a thorough background investigation. • For experienced officer applicants applying through the Experienced

Officer Hiring Program: o Post-probationary status with current or former civilian law enforcement

agency. o Must be in good standing with current department or left previous

position(s) in good standing.

Potential Applicant Disqualifiers

Driving History:

• More than one (1) minor traffic violation in the last three (3) years

• Any major violations in the last five (5) years o Attempting to elude a police officer o Careless driving or Reckless driving/speeding contest o Driving under influence of alcohol/drugs o Driving while impaired o Driving while license is suspended or revoked o Failure to stop/report an accident o Homicide, manslaughter or assault arising out of the use of a vehicle o Making a false accident report o Refusal to take a breathalyzer exam

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Champaign Police Department Application Overview

Drug Use History: It is the Board of Fire and Police Commission policy to hire the best-qualified candidate and to consider prior drug and alcohol use as a factor in making that determination.

Failure to disclose illegal drug use as requested in the initial application will result in disqualification for a minimum period of 5 years. Polygraphs may be used to confirm information provided.

Criminal Convictions / Arrests:

• Convicted of, pled guilty to, or pled nolo contendere to a crime that would be a felony offense as outlined in the Illinois Compiled Statutes.

• Within the last 10 years, has been convicted of, pled guilty to, or pled nolo contendere to any of the following misdemeanor offenses or similar offenses in another state (will be evaluated on a case by case basis):

o Sex Offenses o Bodily Harm

• Aggravated assault • Intimidation • Criminal sexual abuse • Domestic battery

o Weapons Offenses ▪ Unlawful possession of firearms and ammunition ▪ Defacing identification marks of firearms ▪ Illegal possession of weapons as described in 24-1(1) ▪ Illegal possession of a “silencer” ▪ Carrying, possessing a firearm, stun gun, taser or other

deadly weapon in a licensed place that sells intoxicating beverages

o Interference with Public Officers ▪ Resisting / obstructing a police officer ▪ Obstructing justice ▪ Escape – failure to report to penal institution ▪ Aiding escape

o Interference with Judicial Process ▪ Compounding a crime ▪ Perjury ▪ Subornation of perjury ▪ Communicating with jurors / witnesses ▪ Tampering with public records

• Pursuant to Public Act 100-0285, applicants are not obligated to disclose expunged juvenile records of adjudication or arrest.

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1. Review the entire packet before filling out the various forms. While reviewing the forms, determine if additional pages will be needed, and make photocopies of those pages prior to filling out the packet; or, if you run out of space for a specific topic (i.e. employment, residences), attach a separate sheet of 8 ½ x 11 paper for each topic. Each sheet should be labeled with the topic, and the format of the information should follow the format as requested in the packet.

2. Type or print legibly in black ink only.

3. When printing the background packet for completion, DO NOT print the document as two-sided.

4. All questions must be answered completely. Print “N/A” in the blank(s) for all questions not applicable to you.

5. Addresses – All addresses must be complete. A complete address must

contain the specific street address, apartment # if applicable, city, state, and zip code. Post office boxes alone will not be accepted. It is appropriate to provide both the street address and post office box.

6. Names – Whenever names are requested, provide the last name, first name,

middle name or initial. If the subject has a middle initial only, indicate by “IO”. If there is no middle name, indicate by “NMN”.

7. Significant Other – The City of Champaign defines “significant others” as

persons who are of the opposite sex or of the same sex who have or had a dating or engagement relationship, and who share or formally shared a common dwelling, and / or have or allegedly have a child in common.

8. Court Activity – In answering questions related to court-based activity,

include case numbers, county of jurisdiction and date of conclusion. If the case involved the payment of child support or other court ordered payments, identify the person receiving the payment and that person’s name and complete address. If paying through the Circuit Clerk’s Office, list the address of the office, county and state to which payments are being made.

9. Relatives – When filling in the section devoted to relatives, identify the

relationship (brother, sister, step brother, step sister, etc.). Boxes should be marked with the appropriate relationship and filled in as needed to fit your circumstances.

10. Residences – When providing residences, list all your addresses going back

to high school. If your address was on a military base within the United States, list the county and state of jurisdiction; otherwise, indicate “foreign country”. For addresses outside of the United States, list “foreign country”. For all rental properties, complete landlord information must be provided.

Background Information Packet General Instructions

(New Hire Program)


11. Employment – In the employment history section, be as specific as possible. The employment history must list all jobs held (both full time and part time) since high school. If your employment history is less than 10 years, jobs held while in high school must also be included.

12. References – The reference section contains two different groups. The

general references should list three individuals (not relatives or current or former employers), who are responsible adults of reputable standing in their communities. These individuals must have been your acquaintances for a minimum of three years, and preferably for five years or longer. “Social acquaintances” are defined as people within your own age group who have known you well for a minimum of 3 years.

13. Training Records – Evidence of training must be submitted. For officers

applying through the Experienced Officer Hiring Program, a complete list of law enforcement training must be included with this packet. This list should be provided by the law enforcement agency the applicant worked for or by the law enforcement training and standards board for the state. In addition to the list, the applicant must provide certification for the basic law enforcement academy they attended, issued by the academy, and evidence of certification by the state in which the training was received.

14. Fingerprints – A full set of inked fingerprints on a Criminal Justice Applicant

Card must be submitted. Prints may be obtained by a local law enforcement agency or a private vendor. Live Scan printing will not suffice; a full set of inked prints is required.

15. Completion Deadline – The background information packet must be returned

to the Champaign Police Department by the deadline date specified in the cover letter. If supporting documents will not be available within that time frame, the applicant must provide in the cover letter a description of the document and when it is anticipated that the Champaign Police Department will be receiving the document.

16. Status Changes – The applicant is responsible for notifying the Champaign

Police Department’s Background Investigations Unit of any status changes in writing. This includes changes in address, employment and marital status. Send written notification to:

Champaign Police Department

Attn: Background Investigations Unit 82 East University Avenue

Champaign, IL 61820

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(New Hire Program)


17. Be Thorough – It is critical for the applicant to be thorough in completing thebackground information packet. It is not the responsibility of the ChampaignPolice Department to correct missing or incorrect information. The completedpacket is evaluated as part of the selection process.

18. Submit the completed packet to:

Champaign Police Department Attn: Background Investigations Unit

82 East University Avenue Champaign, IL 61820

In all cases, if supporting documents are being submitted separately from the background packet, please provide a cover letter describing which documents will be submitted separately, as well as who will be providing the documents to the Champaign Police Department. In the cover letter, also indicate if the documents will be submitted via fax or mail.

Fax separate documents to: Fax: (217) 403-6904 Attn: Champaign Police Department

Background Investigations Unit

Mail separate documents to: Champaign Police Department Attn: Background Investigations Unit 82 East University Avenue Champaign, IL 61820

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(New Hire Program)

If you have any questions while preparing this document or if you have questions related to the required documents, please telephone the Background Investigations Unit

at (217) 403-6934. Office hours are 8:00 a.m. – 4:00 p.m., Monday through Friday.

Confidential Page 1

All Applicants:

Attach an un-mounted full-face photograph

of yourself here.

Photo should not be larger than 2 ½ x 3. Legibly print your name

on back of photo.

Photo must have been taken within the last 2 months.

Important Notice

Because your ability to complete this document as directed will be evaluated and used as a basis for employment decisions, it is essential that you read and clearly understand the instructions accompanying these forms. Any requested information that is unanswered, incomplete or omitted may result in rejection of your application. Additionally, any false statements and / or deliberately evasive answers will be grounds for rejection of your application or termination (if hired) at a later date.

Personal History Name (Last, First and Middle) List other names you have used,

including nicknames.

________________________

________________________

Address Apt. No.

City County State Zip

Home Telephone

( ) Cell Phone

( ) If you have ever legally changed your name, please provide the following:

Date ____________________________

Location ________________________

Court ___________________________

Case # __________________________

Work Telephone

( ) Email Address

Date of Birth Age Social Security #

– –

Sex

O Male O FemaleHeight Weight Hair Color Eye Color

Marital Status

O Single O Married O Separated O Divorced O WidowedList requested information for all Marriages, Divorces, Legal Separations, or Annulments

Date City County State Marr/Div/LegS/Annl

If married, list your maiden name or your spouse’s maiden name and / or former spouse’s maiden name.

Name (Last, First and Middle) Date of Birth (Month/Day/Year)

For Administrative Use Only:

Data Entry By: Date: Letters Mailed By: Date:

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Personal History (Cont.) With whom do you live? Last Name First Name Middle Name Date of Birth Relationship

FinancialHave you ever filed for Bankruptcy? O Yes O No If yes, give details:

Date Court of Jurisdiction City State Case No.

Reason for Bankruptcy

Are You Paying Child Support? O Yes O No If Yes, to Whom? Name (Last, First, Middle) Child’s Name

Address City State Zip Telephone

( )

Name (Last, First, Middle) Child’s Name

Address City State Zip Telephone

( )

Law Enforcement Applications Have you previously applied to the Champaign Police Department? O Yes O No

Date(s)

Have you previously applied for a position with another law enforcement agency? O Yes O No

If yes, provide complete information. Do not list any agencies you were hired by.

Agency Applied to Date(s) Applied Status

Address City State Zip







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Relatives Spouse or Significant Other Name (Last, First, Middle)

Home Telephone

( ) Address City State Zip

Employer

Work Telephone

( ) Business Address

City State Zip

Date of Birth

Social Security No Maiden Name Check if

Deceased O

Former Spouse or Significant Other Name (Last, First, Middle)

Home Telephone


Employer

Work Telephone

( ) Business Address

City State Zip

Date of Birth

Social Security No Maiden Name Check if

Deceased O

Father Name (Last, First, Middle)

Home Telephone


Date of Birth

Employed By Work Telephone

( ) Check if

Deceased O

Mother Name (Last, First, Middle)

Home Telephone


Date of Birth


( ) Check if

Deceased O

Brother Name (Last, First, Middle)

Home Telephone


Date of Birth


( ) Check if

Deceased O

Brother Name (Last, First, Middle)

Home Telephone


Date of Birth


( ) Check if

Deceased O

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Relatives (Cont.) Sister Name (Last, First, Middle)

Home Telephone


Date of Birth


( ) Check if

Deceased O

Sister Name (Last, First, Middle)

Home Telephone


Date of Birth


( ) Check if

Deceased O

Relationship - Name (Last, First, Middle)

Home Telephone


Date of Birth


( ) Check if

Deceased O


Home Telephone


Date of Birth


( ) Check if

Deceased O


Home Telephone


Date of Birth


( ) Check if

Deceased O


Home Telephone


Date of Birth


( ) Check if

Deceased O


Home Telephone


Date of Birth


( ) Check if

Deceased O

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Residences (Include all addresses going back to your last year in high school.)

Current Address Dates:

From To Address Apt. # City State Zip

County of Residence Landlord Information (If applicable)County Resided In Landlord’s Name

Sheriff’s Address Landlord’s Address

City State Zip City State Zip

Sheriff’s Telephone

( ) Landlord’s Telephone

( )Previous Address Dates:

From To Own О Rent О Address Apt. # City State Zip




















( )

Own О Rent О

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Employment History Current / Most Recent Employer Employer Dates Employed

From To Address Telephone

( ) Employment Status

O Full Time O Part Time City State Zip Reason for Leaving

Your Job Title Supervisor’s Name / Title

Duties

Current / Most Recent EmployerEmployer Dates Employed





Duties

Past Employer Employer Dates Employed





Duties

Past Employer Employer Dates Employed





Duties

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Employment History (Cont.) Past Employer Employer

Dates Employed

From To Address

Telephone


O Full Time O Part Time City

State Zip Reason for Leaving

Your Job Title

Supervisor’s Name / Title

Duties

Past Employer Employer

Dates Employed

From To Address

Telephone


O Full Time O Part Time City

State Zip Reason for Leaving

Your Job Title

Supervisor’s Name / Title

Duties

Military Record Have you ever served in the Armed Services of the United States? O Yes O No

If yes, what branch?

Last Duty Station

Address

City

State Zip

Active Duty Dates

From To Rank at Discharge Discharge Type

Have you ever served in the National Guard? O Yes O No

Have you served in the Military Reserve? O Yes O No

Status O Currently Serving O Formerly Served

Status Inactive O Currently Serving O Formerly Served O Reserve

Branch Last Duty Station

Branch Last Duty Station

Address

Address


Unit Commander Unit Commander

Was any disciplinary action taken against you? O Yes O No If yes, explain below; include non-judicial.

Have you registered with the selective service? O Yes O No Registration #


Education High School High School Name

Address

Dates Attended

From To Graduated

O Yes O No City State Zip

High School High School Name

Address

Dates Attended

From To Graduated


College or University Name

Address

Dates Attended

From To Graduated


Major Minor


Address

Dates Attended

From To Graduated


Major Minor


Address

Dates Attended

From To Graduated


Major Minor

Transcripts must be provided from each institution attended

Specialized / Advanced Training or Trade Schools attended For experienced law enforcement applicants – please provide a copy of your training records from your previous law enforcement employer(s). Course Title Location Date Attended

Course Title Location Date Attended






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Driving History Do you have a valid Driver’s License? O Yes O No License Number State Date Issued Date Expires

Have you ever held a Driver’s License from another State? O Yes O No License Number State From To

License Number State From To

Traffic CitationsPlease list, to the best of your recollection, all traffic citations received in your driving history.Nature of Violation Approximate date County Citation Received In Accident Related

O Yes O NoNature of Violation Approximate date County Citation Received In Accident Related





O Yes O No

Has your Driver’s License ever been suspended or revoked? O Yes O No If yes, continue below.

Date of Sus / Rev Length of Sus / Rev City / County where violations occurred Issuing State

Please Describe Circumstances of Suspension / Revocation -

Date of Sus / Rev Length of Sus / Rev City / County where violations occurred Issuing State

Please Describe Circumstances of Suspension / Revocation -


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Criminal History Have you ever been convicted for any crime? (“Crime” for this purpose is defined as any criminal act, including city ordinance violations.) Pursuant to Public Act 100-0285, applicants are not obligated to disclose expunged juvenile records of adjudication or arrest.

O Yes O No

Charge Dateof Disposition

Case Disposition

Jurisdiction City County State

Please Describe Circumstances

Charge Dateof Disposition

Case Disposition

Jurisdiction City County State

Please Describe Circumstances

Have you ever been a plaintiff or defendant in a Civil Court Action other than a divorce? If yes, complete information below. O Yes O No Nature of Action Date of Action

Court of Jurisdiction Case Number Disposition

Name of Other Party Involved Address City State Zip

Confidential Page 11

Alcohol / Drug History

Alcohol Do you consume alcohol?

Have you ever gotten in trouble because of a drinking activity?

If yes, please explain –

Drugs Do you use or have you ever used any of the following? (Please check those that you have used.)

Marijuana Hashish Cocaine Heroin LSD Ecstasy Other Illegal Drug N/AIf you have checked any of the items above, complete the following for each drug used. Drug Used First Time Used Last Time Used

How was drug used

Please describe the circumstances of the use –

Drug Used First Time Used Last Time Used

How was drug used

Please describe the circumstances of the use –

Are you, or have you ever been, involved in the sale of any illegal drug or the unauthorized sale of any drug? Yes No

Have you ever used prescription drugs which were not prescribed for you? Yes No Drug Used If yes, please describe the circumstances of the use –

Drug Used If yes, please describe the circumstances of the use –

Yes NoYes No


General References Last Name First Name M.I. Years Known Occupation

Home Address Business Name

City

State Zip Business Address

Home Telephone

( )

Work Telephone ( )

City

State Zip

Email Address Last Name First Name M.I. Years Known Occupation


City


Home Telephone

( )

Work Telephone ( )

City

State Zip



City


Home Telephone

( )

Work Telephone ( )

City

State Zip

Email Address

Social Acquaintances Last Name First Name M.I. Years Known Occupation


City


Home Telephone

( )

Work Telephone ( )

City

State Zip



City


Home Telephone

( )

Work Telephone ( )

City

State Zip



City


Home Telephone

( )

Work Telephone ( )

City

State Zip

Email Address

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I, , do hereby authorize a review and full

disclosure of all military records concerning myself to any duly authorized agent of the City of Champaign

Police Department.

I understand that any of the information obtained by a personal background investigation, which is

developed directly or indirectly, in whole or in part, upon this release authorization will be considered

in determining my suitability for employment by the City of Champaign. I also certify that any person(s)

who may furnish such information concerning me shall not be held accountable for providing this

information; and do hereby release said person(s) from any and all liability which may be incurred as

a result of furnishing such information. I further release the City of Champaign, Police Department

from any and all liability, which may be incurred as a result of collecting such information.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy

does not contain an original writing of my signature.

I have read and fully understand the contents of this AUTHORIZATION FOR RELEASE OF MILITARY

RECORDS.

(Applicant Signature; include maiden name, if applicable) (Date) (Social Security Number)

(Branch of Service) (Service Number) (Date Release from Active Duty)

(Date of Birth) (Driver’s License # and State) (Witness Signature) (Date)

Authorization for Release of Military Records

(Print Name Legibly)

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I, , do hereby certify that all statements

made in this background information packet are true and complete to the best of my knowledge. I further

understand that providing false or misleading information or omitting required information in completing

this background information packet or during the selection process is grounds for exclusion from the

selection process or discharge if discovered subsequent to employment or after an offer of employment

has been made.

Signature (Full Legal Name)

Printed Name (Full Legal Name)

Date Signed and Completed

Have you remembered…

☐ Completed Authorization for Release of Personal Information

☐ Completed Authorization for Release of Military Records (if applicable)

☐ Photograph

☐ High School Transcript

☐ College Transcript(s)

☐ Training History (if applicable)

☐ Professional Certifications

☐ Resume

☐ High School Diploma/GED Certificate

☐ College Diploma(s)

☐ Credit History

☐ US Military Records (DD214)

☐ Professional Awards

Background Information Packet Certification of Statements Made


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I, ______________________________________________________, am applying for a position with the City of

Champaign, Illinois. I understand that in order to gauge my fitness for the position, the City of Champaign,

Illinois, must conduct a thorough and complete background investigation. I understand that in order

to facilitate a thorough and complete background investigation and to ensure complete candor on the

part of those providing the necessary information, I must:

1. Consent to an investigation by the City of Champaign, Illinois, concerning my background;

2. Waive any and all claims I might otherwise have against those individuals who conduct the

investigation, or those who cooperate and provide information to the City of Champaign; and

3. Waive my right to review the completed background investigation.

Position Applied For

In an effort to assist the City of Champaign in conducting the background investigation, I am requesting

full and complete disclosure of any information, which could be deemed relevant to job performance,

including character information. I further request that this release take precedence over any previously

agreed upon disclosure agreements that I may have entered into.

I understand that any of the information obtained by a personal background investigation, which is

developed directly or indirectly, in whole or part, upon this release authorization will be considered

in determining my suitability for employment by the City of Champaign, Illinois.

I understand that I must have this authorization signed and notarized by a notary public.

Initials

Authorization for Release of Personal Information, Waiver of Right to Inspect

and Waiver and Release of All Claims


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Information Requested Through this Release

I, ________________________________________, do hereby authorize a review of and full disclosure of all records

and recollections concerning myself to any duly authorized agent of the City of Champaign, Illinois, whether the said records and recollections are of a public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of records or recollections of:

• Educational Institutions; • Landlords; • Financial or Credit Institutions (includes records of loans, records of commercial or retail credit agencies and

other financial statements and records wherever filed); • Employment and Pre-employment records (includes applications, background reports, efficiency

ratings, recollections of employer and co-employees, complaints or grievances filed by or against applicant and records of discipline);

• Attorneys at Law or other Counsel (includes attorneys or counsel, whether representing applicant or another person in any case, either criminal or civil, in which applicant presently has or previously had an interest);

• Police Department or other Law Enforcement Agency.

I hereby do release any person(s) who may furnish information from any and all liability, which may be incurred as a result of furnishing such information. I further release the City of Champaign, Illinois, from any and all liability, which may be incurred as a result of collecting such information.

This Release specifically includes, but is not limited to, claims in tort under Illinois common law, state or federal civil rights violation or any other claims under state or federal constitution, city ordinance, statutes, rules or regulations. I hereby covenant and agree never to institute directly, or in any other manner, or participate as a party in any action or proceeding (whether judicial, administrative, or otherwise) of any kind whatsoever against any of the parties identified above relating to release or disclosure of information.

I understand that information obtained during this investigation may be provided to others providing that the City of Champaign is furnished a release signed by me authorizing the disclosure of such information.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature.

I have read and fully understand the contents of this two-page document entitled Authorization for Release of Personal Information, Waiver of Right to Inspect and Waiver, and Release of All Claims.

(Applicant Signature; include maiden name, if applicable) (Date) (Social Security Number)

(Date of Birth) (Driver’s License # and State) (Witness Signature) (Date)

NOTARIZATION State of: ________________________ County of: _____________________________________ Signed (or subscribed or attested) before me on ___________________ by ______________________________________________.

(date) (name of person)

______________________________________________ (seal) (signature of notary public)

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The following documents must be provided to the Champaign Police Department. A background investigation will not be initiated until all documents have been received. If you are unable to provide any of the documents within the time required, you must provide a cover letter with your background investigation packet that identifies which documents are missing and an anticipated date by which those documents will be provided to the Champaign Police Department.

Photograph - This must be a full-face photograph of you. The photo must not be larger than 2 ½ x 3 inches. The photo must have been taken within the last 2 months. Attach the photo to page 1 of the Background Information Packet in the space provided. Digital photography is acceptable as long as the print is on photo quality paper and the photograph is clear.

High School Diploma or G.E.D certificate

High School Transcripts – If you attended more than one high school, the record obtained must include the complete record from the earlier high school or a separate transcript from each school must be provided.

College Diploma

College Transcripts – If you attended more than one college, a transcript must be provided for each institution you attended.

Credit History – A complete credit history must be provided from one of the three credit reporting agencies. The free credit report must be obtained from the website www.annualcreditreport.com; a Credit Karma™ report will not be accepted. The credit report must have been obtained with in the last 60 days. Applicants are not required to submit a credit score.

Training History – If you are applying to the Police Department through the Experienced Officer Hiring Program, please provide a list and certifications for all law enforcement training you have participated in since your employment in the law enforcement field.

Professional Certifications and Awards

U.S. Military Records – If you have been discharged from the United States Military, you must provide a full DD-214 that includes your service record (including discipline). It is recommended that if you have multiple DD-214’s, a copy of each DD-214 should be provided.

Resume

Completed Authorization for Release of Personal Information

Completed Authorization for Release of Military Records (if applicable)

Background Information Packet Required Documents

If you have any questions while preparing this document or if you have questions related to the required documents, please telephone the Professional Standards Unit at (217) 403-6934. Office hours are 8:00 a.m. – 4:00 p.m., Monday through Friday.

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Background Information Packet

Documents

Transcript of Background Information Packet