APPLICANT INTEGRITY QUESTIONNAIRRE

Date:

APPLICANT NAME:

APPLICANT DATE OF BIRTH:

APPLICANT SOCIAL SECURITY NUMBER:

As part of the background investigation being conducted by the State University of New York Police in connection with your possible selection for a Police Officer appointment, you are REQUIRED to answer the following nineteen (19) questions. If you answer “YES” to any of the questions numbered 1 through 17, write the number of the respective question on the response sheet attached and give a brief explanation for your answer. Instructions for the remaining questions (18 and 19) are listed just before those questions on the fourth page. You are to initial each of the five (5) pages, sign and date this form in the presence of a State University Police witness.

THE HONESTY AND INTEGRITY OF ALL APPLICANTS IS OF PRIMARY CONCERN DURING THE SELECTION PROCESS. THESE BASIC VALUES INCREASE IN IMPORTANCE OVER THE DURATION OF A CAREER WITH THE NEW YORK STATE UNIVERSITY POLICE. THE ANSWERS THAT YOU GIVE TO THE FOLLOWING QUESTIONS SHOULD REFLECT YOUR COMMITMENT TO, AND UNDERSTANDING OF, THESE CRUCIAL VALUES. FAILURE TO BE TRUTHFUL DURING THIS AND ALL OTHER PARTS OF THE SELECTION PROCESS WILL RESULT I YOUR APPLICATION BEING REJECTED AND WILL RESULT IN TERMINATION AFTER ANY APPOINTMENT HAS BEEN MADE.

Page 1 of 5 Initials: ______

1. Since you started driving, have you EVER had your driver’s license suspended or revoked in New York or ANY other state or country?

Yes No

2. Do you hold more than one driver’s license or have you ever possessed a driver’s license from

any other state, province or foreign country?

Yes No

3. Have you EVER been the subject of a criminal complaint or indictment, been convicted of or pled guilty to a crime or offense or been required to appear in ANY criminal proceeding or before ANY prosecuting officer or investigative agency?

Yes No

4. Have you EVER been ARRESTED, issued an appearance ticket, questioned, detained or taken into custody by ANY police agency or security service? This includes ANY juvenile offense(s) which may or may not have been sealed by a court, a prosecuting officer, or a juvenile authority and ANY youthful offender determination(s).

Yes No

5. Have you EVER tried, used or experimented with illegal drugs of ANY description? This includes, but is not limited to, amphetamines, barbiturates, cocaine, crack, ecstasy, hashish, heroin, inhalants, LSD, marihuana, mushrooms, PCP, and/or steroids.

Yes No

If yes: A. Type of drug(s): ______

B. Number of times you used each drug: ______

C. Date of last use of each drug: ______

6. Have you EVER provided or sold illegal drugs of any description to another person?

Yes No

If yes: A. Type of drug(s) sold/provided: ______

B. Number of times you sold/provided each drug: ______

C. Date of last transaction and type of drug(s) involved: ______

Page 2 of 5 Initials: ______

7. Have you EVER been involved in the illegal abuse, sale, purchase or diversion of legally

prescribed pharmaceutical drugs?

Yes No

If yes: A. Type of drug(s) sold/provided: ______

B. Number of times you sold/provided each drug: ______

C. Date of last transaction and type of drug(s) involved: ______

8. In ANY of your employment, business, educational experiences or volunteer work, have you EVER:

  • been disqualified or discharged from any position or asked to resign in lieu of being discharged;
  • resigned from a position with charges pending against you;
  • had a professional license suspended, revoked or modified; or
  • been disciplined, suspended or expelled for any reason?

Yes No

9. In ANY of your employments, businesses, educational experiences or volunteer work, have you EVER been the target or subject of a personnel or administrative complaint or been interviewed or required to respond in any way as either the subject or as a witness in any personnel or administrative complaint?

Yes No

10. Have you EVER been the subject of an allegation charging you with racial or ethnic bias or

sexual harassment?

Yes No

11. Have you EVER been either a plaintiff or defendant, or any other party, in ANY civil proceeding or lawsuit or received notification that a lawsuit or complaint against you was pending?

Yes No

12. Have you EVER failed to report receipt of wages, failed to file an income tax return on time

or been delinquent in the payment of any taxes?

Yes No

13. Have you EVER filed for bankruptcy?

Yes No

Page 3 of 5 Initials: ______

14. Have you applied to ANY other federal, state or local law enforcement agency for employment? (If your response to this question is “YES,” list all agencies and give the current status of your application.)

Yes No

15. Have you EVER been the subject of ANY background investigation by ANY federal, state or

local agency?

Yes No

16. Have you EVER been treated for a mental condition of ANY description? This would include:

  • treatment provided in a public or private hospital, clinic or resident facility;
  • treatment provided by a physician, psychiatrist, psychologist, social worker, counselor or any other type of health or mental health care provider;
  • treatment or counseling in a group session for any type of condition or disorder

Yes No

17. Have you EVER committed a terrorist act, made a terrorist threat, solicited or provided material support, for terrorist acts or hindered the prosecution of terrorists, OR, have you EVER associated with, conspired with or acted in concert, directly or indirectly, with terrorist organizations?

Yes No

QUESTIONS 18 & 19 REQUIRE AN EXPLANATION FOR A NO ANSWER ONLY.

18. Are the QUALIFICATIONS and CREDENTIALS that you listed on your StateUniversity

Police application TRUE and ACCURATE in all respects?

Yes No

19. Are all the other responses listed on your State University Police Applications TRUE and ACCURATE in all respects?

Yes No

______

Signature of ApplicantDateSignature of New YorkStateUniversity Police InvestigatorDate

Page 4 of 5Initials: ______

Use this page to respond to any of the listed questions. Number your response to match the appropriate question. Write only on the front of this page.

MAKE YOUR EXPLANATION(S) CLEAR, CONCISE AND LEGIBLE.

Page 5 of 5 Initials: ______

Rev. 12/2005