O’Fallon Police Department

Lateral Entry

Application

PersonalHistoryStatement

Forquestionsregardingthecompletionofthisdocumentcalloremail

Captain Kirk Brueggeman

(618) 624-9538

285 North Seven Hills Road O’Fallon, IL 62269

Call between thehours of9AM to 4PM Mondaythru Friday

***Donot call toscheduleyour InitialInterview***

Printclearlyanduseblackinkonly

______/ ______/ ______

LastName FirstName MiddleInitial

This application should be mailed or hand delivered to the O’Fallon Board of Fire and Police Commissioners at 285 North Seven Hills Road O’Fallon, IL 62269 no later than May 31, 2017 at 5:00 PM. Any application received after that time will not be accepted.

This section to be completed by the background investigator only.

InitialInterviewscheduledfor:Date:

______/______/

______Time:

______AM / PM

BackgroundInvestigator’sName:______

Investigator’stelephonenumber(s):(618)______-______

__ (618) ______-______

Investigator’sFAXnumber:(618)

AdditionaldocumentsrequestedbytheInvestigator:

PersonalHistoryStatementInstructions

The applicant, usingblackinkonly,mustneatlyprint allinformation.

Readeachquestioncarefullybeforeanswering.

Personal HistoryStatements thatare incomplete orillegible will notbeaccepted.You may be eliminated from the hiring process due to incomplete or illegible Personal History Statements.

It is mandatorythat everyquestioninthe Personal HistoryStatement be answered.If aquestion does notapplyenter“N/A”inthe spaceprovided. Useadditionalpaperifnecessary.

Whenprovidingcontacttelephonenumbersandemails,keepinmindyourbackgroundinvestigationwill be delayed ifyour Investigator is unable tocontact people you have listed.Contact informationlistedmustbewherethepersoncanmosteasilybereached(cell,work, emailor home).

Notifyeach person whois to be contactedand inform themanInvestigatormay be callingregardingyourbackgroundinvestigation.TellthemtobecandidwiththeInvestigator.

Ifyoufeelthatcontactingyourcurrentemployerwouldcreate aproblem, noteit in the “CurrentEmployer” sectionand discuss this withyourInvestigator duringtheInitialInterview.Inyour

discussionwith theInvestigator,anappropriate date can beestablished to contactyourcurrentemployer.

Anyfalse statements orintentional omissions of pertinentinformation on anydocument orduring anyoralinterviewmaybecause for disqualification or immediate termination ofyour eligibility.

Make sure you signthe“Applicant Certification”onpage thirty(30).

All questions about this document should be forwarded to Captain Kirk Brueggeman at

618-624-9538 or

InformationandInstructionsforthe Initial Background Interview

Do not call theCityofO’Fallon regardingthedateofyourInitialBackground Interview.

Youwill be contactedbyanInvestigator to scheduleyourInitialInterview.

Appropriate businessattire is requiredfor theInitialInterview.

After yourInitialInterview,factsmayarise orevents occur thatmaynot have beenknownor were notanticipatedbyyouat thetimeyousubmittedyourPersonal HistoryStatement. These facts or eventsmayrequireyou to submit revisions or amendments.Allsuchrevisions or amendmentsmust bereportedtoyourInvestigator assoonaspractical.

The following documents will be collected in the event we conduct a background investigation on you.

Youmustbringtheoriginalsofallrequireddocuments.Youmaymakeandbringcopiesofdocuments,however;youmustalsobringtheoriginalsofalldocumentsfor yourInitialInterview.

Donotwriteonthispage, YourInvestigatorwillcompletethisformduringyourInitialInterview.

Date ReceivedbyBIUInvestigatorsInitials

*Certifiedcopyofbirthcertificate.

Passport is required inthe absence ofa traditionalbirthcertificate.

Copy of your Illinoisand/oranyotherdriver’slicense(s).

*Certifiedcopyofanynamechangerecords.

LETSB or Out of State Certification

ResidentAlienCardorotherproofofimmigrationoralienstatus.

*Certifiedcopyofmarriagecertificate(s).

*CertifiedCopyofdivorcedecree(s).

*High school diploma or G.E.D. Certificate

DD214orentryleveldischargedocuments

Courtdocuments,chargingdocumentsoranydocumentsregardinganycriminalmatterpertainingtotheapplicantinhisorherpossession(i.e.expungements,charging

documents,dispositions,dismissals).

Otherdocumentsprovidedbyapplicant:

2

Print clearly and useblackinkonlyInvestigator’sinitials

Lastname / Firstname / Middlename
Othernamesyouhaveused(example:maidenname,name(s)byaformermarriage,ornamechange)
Listthecurrentaddresswhereyouphysicallyreside(Notapostofficeboxnumber).
Number,street,andapt.number / City / State / Zipcode
Lista mailingaddressifunabletoobtainmailatyourresidence.
Number,street,andapt.numberorPOBox / City / State / Zipcode
Residencetelephonenumber / Worktelephonenumber
()
Areacode / ( )
Areacode
E-mailaddress / Celltelephonenumber
( )
Dateofbir / th / Age / SocialSecurityNumber
Month / / / Day / /
Year (XXXX)
Sex / Height / Weight / Haircolor / Eyecolor / Race
Male / Female / Feet / Inches
Driver’sLicenseNumber / Classification / Restrictions / StateofIssue / ExpirationDate
Norestrictions / Month / / / Day / /
Year

Ifyouhaveadditionaldriver’slicensesorhaveheldalicenseissuedbyanyotherstate,useadditionalpaperandcheckbox

CheckboxifbornintheUnitedStatesor;

Countryofbirthifnotthe UnitedStates

CityofbirthCounty, ParishState ofbirth

USCitizen?YesNoIfnotaU.S.citizendate youfirstentertheUnitedStates:

/

MonthYear

Immigrationstatus:
ifnationalized:

NaturalizationCertificatenumber:

Date ofCertificate://

MonthDayYear

Investigator’sinitials

YesNoAreyoucurrentlyacertifiedpoliceofficerinIllinois?YesNoHaveyoueverbeenacertifiedpoliceofficerinIllinois?Yes No EMSCertified?

YesNoHaveyoueverbeencertifiedasapoliceofficer,deputysherifforcorrectionsofficerinanyStateorjurisdiction?

Ifyouanswered“YES”answerthefollowinginformation:

1.From whatacademydidyougraduate:

2.DateGraduated:

AcademyClassnumber:

3.AcademyDirector

YesNo1.Have youeverhadanarrest,chargeorconviction(felonyor misdemeanor)ofdomesticassault,domesticviolenceorassaultandbatteryexpungedorpardoned?Applicantmustprovidecourtdocumentsverifyingpardonorexpungment.

Whatwasthetypeofarrest,chargeorconvictionthatwasexpunged?

Dateexpunged:

/

MonthYear

YesNo2.Haveyoueverbeenchargedorconvictedofacrimeconstitutingafelonythathasbeenorisintheprocessofbeingexpungedorpardoned?

YesNo3.Haveyoueverusedacontrolleddangeroussubstance,narcoticdrugormarijuanawhileemployedtoenforceFederal,State,Militaryorlocallawbyanygovernmententityor whileinapositiondirectlyandimmediatelyaffectingpublicsafety?

YesNo4.Do youbelongto anyorganizationorinstitutionordo youadheretoanybelief(s)thatinanywaywouldrestrictorprohibityourworkingonparticulardaysorduringparticularhours?

YesNo5.Do youbelongto anyorganizationorinstitutionordo youadheretoanybelief(s)thatinanywaywouldrestrictyoufromconformingtoagencygroomingstandards?

YesNo6.Asalawenforcementorcorrections officerdoyoufeel youcouldtakeahumanlifeifyourlifeorthelifeofaninnocentpersonwasthreatened withgreatbodilyharmordeadlyforce?

YesNo7.Asalawenforcementorcorrectionsofficerwould youphysicallyassistanotherofficeriftheywerebeingphysicallyassaultedbyasuspect,prisoneroranyotherperson?

If“Yes”toquestionone(1)thrufive(5)or

If“No”toquestionsix(6)orseven(7)explainonpagetwenty-nine(29).

Investigator’sinitials

Areyounowusingorhaveyoueverused,tried,orexperimentedwith:

Yes / No / Marijuanainanyform? / YesNoHeroinoropiatesinanyform?
Yes / No / LSD(acid)? / YesNoPCP(green,flake,angeldust)?
Yes / No / Anydesignerdrugorhallucinogenic?
Yes / No / Anycontrolleddangeroussubstanceornarcoticdruginanyform?
Yes / No / Illegalsteroidsorillegallyobtainedsteroids?
Yes / No / Anydrugprescribedforsomeoneelseandusedbyyouwiththeintentionofgettinghigh?
Yes / No / Anysubstancethatwasinhaled,injected,oringestedwiththeintentionofgettinghigh?
Yes / No / Haveyoueverpurchased,sold,produced,cultivated,distributedortransportedacontrolleddangeroussubstance,narcoticdrug,ormarijuana?

Listdrug(s) used,dateoflastuse,ageatlastuseand numberoftimes used.

Drugorsubstanceused / Dateoflastuse / Ageatlastuse / Timesused
/
Month Year
/
Month Year
/
Month Year
YesNo AretheresponsestotheabovedrugusequestionsthesameresponsesyougaveduringthePreliminaryScreening?Ifnot,explainbelow.

YesNoDoyouconsumealcoholicbeverages?

If“Yes”to whatextentdoyouconsumealcoholicbeverages?

Investigator’sinitials

Print clearlyand use blackink only

YesNoGraduatedHighSchoolorG.E.D.Certified? Name of highschool: ______

Date of Graduation: ______/ ______

Location ofSchool: ______

MonthYearCityState

School telephone numberif withinfive(5)years of graduation:() ______- ______

AreaCode

YesNo Iattended oramattendinganaccredited college(s) oruniversity.

YesNo Currently enrolled?Total credit hours earned: ______

YesNo Ipossess a degreefroman accredited college or university:

Type of Degree:AABABSMAMSOther:______

Leave blank ifdegree not yetreceived.

College(s) or university name andlocation:Name: ______

Location: ______/ ______

Telephonenumber,ifwithin five(5) yearsofattendanceor graduation. (

Areacode
) ______- ______

YesNo Have you ever been placed on academic probation fromany college or university?

Explain onpage twenty-nine (29)if necessary

List anyforeignlanguagesyouarefluent inand/orspecialskillsyoupossess. List anytradeschoolsor specialized coursesyouhave completed. Includeanymilitary or othertraining you feel isrelevant.

Investigator’sinitials

Print clearlyand use blackink only

List all scars, tattoos, identifyingmarks, etc. Fully describe andstateexactlywherelocatedandsizesininches. Provide detaileddescription, photoand/or drawing ofany tattoos,scars, brands ormarkingsdesignating membershipin anyorganization, group,club, or gang.Continue onpagetwenty-nine(29)ifnecessary.

YesNo Doyouhave,or haveyoueverhad, a tattoo,cut (scarring),brand (burn)orany bodymarkings signifyingmembershipin, or affiliation with, a criminal enterprise, street gang, motorcycle cluboranyothergroupor club?

YesNo Haveyouever been photographed or had photographs taken of tattoos oranybodymarkings by anylawenforcementagency?

YesNo Doyounow have or everhad a nickname, alias or used anothername while affiliatedwith a street gang,motorcycle club, or any other group orclub?

Names used: ______

Current Military Status

Nomilitaryservice

Active dutyDischargedReservesNationalGuardInactiveInactiveReadyReserve

Military Service

Branch ofService:

TermofService: From: ______/

To:/

MonthYearMonthYear

Typedischarge:HonorableOther than honorableDid not completebasictrainingand released fromcommitment

YesNo Areyou eligiblefor re-enlistment?

Typeofdischargeifother thanhonorable:

YesNo Have youeverbeen denied orrejected entry into any typeof military service?

YesNoHaveyouever servedin the military of anyother country?

Military Discipline

YesNoHaveyou received any type of punishment or non-judicialpunishment(NJP)underTheUniformCodeof Military of Justice (UCMJ)?

If“Yes”explainon pagetwenty-nine(29).

Investigator’sinitials

Spouse, fiancéeor significant other(firstname, last name) / Spouse’smaiden name / Dateof marriage
Month / /
Year
Current address of spouse,fiancée or significant other if not living with you. Write “SAME” ifaddressisthe same as yours.
( / Areacode / ) / Best time tocall:DaytimeEvening

Complete the first sectionbelow to provide informationif youwere raised by someoneotherthan your parents orstep parents.If youwereraised by yourparents or step parents, place“N/A” in thefirst block below and proceed to “Father’s Name.”

Print clearly anduse blackink only
Person’s name (first name, middle initial, last name) / Relationshipto you (aunt, uncle,etc.)
Deceased
Current Residence Address / Contactnumber
()
Areacode / Besttimetocall: / Daytime / Evening
Father’s name (first name, middle initial, last name) / Dateofbirth
Deceased / Month / / / Day / /
Year
Current Residence Address / Contactnumber
( / Areacode / )
Besttimetocall: / Daytime / Evening
Mother’sname(first name, middle initial, last name) / Dateofbirth
Deceased / Month / /
Day / /
Year
Current Residence Address / Contactnumber
( / Areacode / )
Besttimetocall: / Daytime / Evening
Step-Father’s name (first name, middle initial, last name) / Dateofbirth
Deceased / Month / /
Day / /
Year
Current Residence Address / Contactnumber
(
Areacode / )
Besttimetocall: / Daytime / Evening
Step-Mother’s name (first name,middle initial, last name) / Dateof birth
Deceased / Month / / / Day / /
Year
Current Residence Address / Contact number
(
Areacode / )
Besttimetocall: / Daytime / Evening

Investigator’sinitials

Print clearlyand use blackink only

Childrenand Dependents

Number ofdefendantchildrenliving withyou:

Number ofdefendantchildren not living withyou:

Number of other dependent’slivingor notliving withyou:

Relationship(s)toyou:

Contact Information forotherparentof childif not currently living withyou

Name ofotherparent:

______/______

Firstname Lastname

Contactnumber: (

)

AreacodeBest time tocall:DaytimeEvening

Contact Information forotherparentof childif not currently living withyou

Name ofotherparent:

______/______

Firstname Lastname

Contactnumber: ()

AreacodeBest time tocall:DaytimeEvening

If divorced, widowed, or hadanannulment,provide all thefollowinginformation.

Formerspouse’s name (first name, last name) / Date of marriage / Dateoffinal divorce
/
MonthYear / /
MonthYear
ContactInformation
DeceasedName: ______/______
FirstnameLastname
Contactnumber: ()
AreacodeBest timetocall:DaytimeEvening
Formerspouse’s name (first name, last name) / Date of marriage / Dateoffinal divorce
/
MonthYear / /
MonthYear
ContactInformation
DeceasedName: ______/______
FirstnameLastname
Contactnumber: ()
Area codeBesttimeto call:DaytimeEvening

Investigator’sinitials

List as referencesthree(3) individuals youhaveknownfor atleastfive(5)yearsandwhohave knowledgeof youandyourqualifications. Examples are friends, friends ofthefamily,teachers,classmates,ormilitaryacquaintances. Do notincluderelatives, familymembers,or individuals who belong tothe lawenforcement profession.

Name (first name, last name) / Current Address
Contactnumber:( )Best time tocall:DaytimeEvening(Homeor cell)Areacode
How long haveyouknown? / Occupation / Relationship
Years:
Name (first name, last name) / Current Address
Contactnumber: ( )Besttime tocall:DaytimeEvening(Home orcell)Areacode
How long haveyouknown? / Occupation / Relationship
Years:
Name (first name, last name) / Current Address
Contactnumber: ( )Best time tocall:DaytimeEvening(Homeor cell)Areacode
How long haveyouknown? / Occupation / Relationship
Years:
List below any individuals who are members of law enforcement agencies whom you are acquaintedwith or relatedtoand who haveknowledge of you and yourqualifications.
Name and rank: (first name, last name) / Agencywhereemployed or retired from
Relationshipto you:(relative, family friend, etc) / Howlong haveyou knownthis person?
Years:
Contactnumber: ()
(Homeorcell)Areacode / Besttimetocall: / DaytimeEvening
Name and rank: (first name, last name) / Agencywhereemployed or retired from
Relationshipto you:(relative, family friend, etc) / Howlong haveyou knownthis person?
Years:
Contactnumber: ()
(Home or cell)Areacode / Besttimetocall: / DaytimeEvening

Print clearlyand use blackink only

Investigator’sinitials

List allof your residencesfor the last seven (7) years. Beginwith your current residence.Whenlisting military bases, includenearest city, state, and zip code.When listing addresses,include street,avenue,drive,court, north,south, east, and west.Includeunitnumberand/orapartmentnumberwhereapplicable.Includename ofapartmentcomplexif applicable.Youmust listtwo(2)neighbors foryourcurrentresidenceand one (1) formerneighborforeach ofyour formerresidences.

Current Residence

Number,street and apartmentnumber / City / State / Zipcode
Name of apartmentcomplex if applicable / Resident since
/
Month / Year
With whomdo you resideand what istheir relationshiptoyou?

If you are currently renting,provide the information required below. You mustinclude a contact name and a contact telephonenumber.If you arenot onthelease,enterthename,contacttelephonenumberandthe relationship toyouoftheperson(s)on thelease.

In whose name(s) (first name,last name) is the lease? Name,relationship toyouand contact telephone number.

Name of leaseholder:(If you arenotonthelease)

Contactnumber: (

(Home orcell)Areacode

Relationshiptoyou:

)

Best timetocall:DaytimeEvening

Name(first name,last name) of resident manager, propertymanager, or landlordandcontacttelephone number.
Name:
Contactnumber: ( / ) / Besttimetocall: / Daytime / Evening
(Home or cell)Areacode

CurrentNeighbor 1

Name (first name, last name) / Current Address
Contactnumber: ( )Besttimetocall:DaytimeEvening(Homeor cell)Areacode

Current Neighbor 2

Name (first name, last name) / Current Address
Contactnumber: ( )Best timetocall:DaytimeEvening(Homeor cell)Areacode
Print clearlyand use blackink only

Formerresidence 1

Investigator’sinitials

Streetaddressincluding unit numberand/orapartment number. Also includename of apartment complex.
Dates of residence:From:
Month / / / Year / To: / Month / /
Year

N/A Not renting

Name of leaseholder:
(If youwerenotonthelease)

Contactnumber:( )

(Homeor cell)Areacode

Name of residentmanager:

Best timetocall:DaytimeEvening

Contact number: (

(Home orcell)Areacode

)

Best time tocall:DaytimeEvening

FormerNeighbor

Name (first name, last name) / Current Address
Contactnumber:( ) Best timetocall:DaytimeEvening(Home orcell)Areacode

Formerresidence 2

Streetaddressincluding unit numberand/orapartment number. Also includename of apartment complex.
Dates of residence:From:
Month / / / Year / To: / Month / /
Year

N/A Not renting

Name of leaseholder:
(If youwerenotonthelease)

Contactnumber:(

(Home or cell)Areacode

Name of residentmanager:
)

Best timetocall:DaytimeEvening

Contact number: ()

(Home orcell)Areacode

Best timetocall:DaytimeEvening

FormerNeighbor

Name (first name, last name) / Current Address
Contactnumber: ()Best time tocall:DaytimeEvening(Home orcell)Areacode
Print clearlyand use blackink only

Formerresidence 3

Investigator’sinitials

Streetaddressincluding unit numberand/orapartment number. Also includename of apartment complex.
Dates of residence:From:
Month / / / Year / To: / Month / /
Year

N/A Not renting

Name of leaseholder:
(if youwerenotonthelease)

Contactnumber:( )

(Homeor cell)Areacode

Name of residentmanager:

Best timetocall:DaytimeEvening

Contact number: (

(Home orcell)Areacode

)

Best time tocall:DaytimeEvening

FormerNeighbor

Name (first name, last name) / Current Address
Contactnumber:( ) Best timetocall:DaytimeEvening(Home orcell)Areacode

Formerresidence 4

Streetaddressincluding unit numberand/orapartment number. Also includename of apartment complex.
Dates of residence:From:
Month / / / Year / To: / Month / /
Year

N/A Not renting

Name of leaseholder:
(If youwerenotonthelease)

Contactnumber:( )

(Home or cell)Areacode

Name of residentmanager:

Best timetocall:DaytimeEvening

Contact number: ()

(Home orcell)Areacode

Best timetocall:DaytimeEvening

FormerNeighbor

Name (first name, last name) / Current Address
Contactnumber: ()Best time tocall:DaytimeEvening(Home orcell)Areacode
Print clearlyand use blackink only

Formerresidence 5

Investigator’sinitials

Streetaddressincluding unit numberand/orapartment number. Also includename of apartment complex.
Dates of residence:From:
Month / / / Year / To: / Month / /
Year

N/A Not renting

Name of leaseholder:
(If youwerenotonthelease)

Contactnumber:(

(Homeor cell)Areacode

Name of residentmanager:
)

Best timetocall:DaytimeEvening

Contact number: (

(Home orcell)Areacode

)

Best time tocall:DaytimeEvening

FormerNeighbor

Name (first name, last name) / Current Address
Contactnumber:( ) Best timetocall:DaytimeEvening(Home orcell)Areacode

Formerresidence 6

Streetaddressincluding unit numberand/orapartment number. Also includename of apartment complex.
Dates of residence:From:
Month / / / Year / To: / Month / /
Year

N/A Not renting

Name of leaseholder:
(If youwerenotonthelease)

Contactnumber:(

(Home or cell)Areacode

Name of residentmanager:
)

Best timetocall:DaytimeEvening

Contact number: ()

(Home orcell)Areacode

Best timetocall:DaytimeEvening

FormerNeighbor

Name (first name, last name) / Current Address
Contactnumber: () Best time tocall:DaytimeEvening(Home orcell)Areacode
Print clearlyand use blackink onlyInvestigator’sinitials

Begin with your currentormost recent employment. List seven(7) years of employment in chronological order. List everyposition,includingactivemilitary, reserve, andNationalGuardservice. Employmentincludes self-employment andvolunteerpositions includingvolunteer fire and rescue. If you are or were employed bya temporary agency andworkedat multiple joblocationsplease liststhename, titleand telephonenumber for youragencycontactperson inaddition toyouractualjob locationsand supervisors.If unemployed,list those periodsin sequenceand enter dates.

You must list two (2) co-workerswith your currentemployerandone (1) co-workerfor each formeremployer.

Currently Unemployed / Yes / No / Unemployment start date / Month / /
Year
Employment start date / Name of currentemployer
Month / /
Year

Full timePart-TimeTemporaryMilitarySelf-EmployedVolunteerInternship

Would youhave a problem withyourInvestigatorinterviewingyourcurrent employer?YesNo

Current employer’smailing address / If not the sameas mailingaddress, list youractual worklocation
Current employer’stelephone numberfor employment verification (Personnel) / Yourannual salary
Telephone number ()
Areacode

Your title or position

Supervisor’sname / Supervisor’s title
Telephone numberwhereyour supervisormay be reachedand timeavailabletotakecalls (work orcell phone)
Telephonenumber( / Areacode / )
(workorcellphone) / Best time to call: / Daytime / Evening
Haveyou everreceived or do you haveany pending disciplinary actions?Explain insectionbelow;continue onpagetwenty-nine(29) if necessary. / YesNo
Firstco-worker’s name: (first name, last name) / Telephone numberwhereco-workercan be reached
()
Area code(homeorcellphone) / Best time to call: / Daytime / Evening
Second co-worker’s name: (first name,last name) / Telephone Number
(
Areacode / ) / (homeorcellphone) / Best time to call: / Daytime / Evening
Print clearlyand use blackink only

1stformeremployer orperiod of unemployment

Investigator’sinitials

Name of formeremployer / Formeremployer’smailingaddress
Start Date / Month / /
Year / End Date / Month / /
Year

Full timePart-TimeTemporaryMilitarySelf-EmployedVolunteerInternshipUnemployed

Formeremployer’stelephone number for employmentverification (Personnel) / Your title orposition
Telephonenumber( / Areacode / )

Reason forleavingemployment

Resigned totake better positionLay offContractexpiredReturnto schoolTerminated(fired)

Completionof military serviceResignedto avoid beingterminatedResigned whileunderinvestigation

Quit without giving notice as required by company policyReasonnot listed, explain below

Explainreason forleavingemployment; continue onpage twenty-nine (29)if necessary

Do youfeel thisformeremployerwould rehireyou?If you answered“No” explain below; continue onpage twenty-nine (29) if necessary. / YesNo
Supervisor’s name (first name, last name) / Supervisor’s title
Telephone numberwhereyourformersupervisormay be reached and time available totake calls
Telephone number (
Areacode / )
(workorcellphone) / Best time to call: / Daytime / Evening
Did youever receivedordo you haveany pendingdisciplinaryactions?Explainbelow;continue ontwenty-nine (29) if necessary. / YesNo
Co-worker’sname: (first name, last name) / Telephone numberwhereco-workercan be reached
()
Areacode / (homeorcellphone) / Besttime tocall: / Daytime / Evening
Print clearlyand use blackink only

2ndformeremployeror period of unemployment

Investigator’sinitials

Name of formeremployer / Formeremployer’smailingaddress
Start Date / Month / /
Year / End Date / Month / /
Year

Full timePart-TimeTemporaryMilitarySelf-EmployedVolunteerInternshipUnemployed

Formeremployer’stelephone number for employmentverification (Personnel) / Your title orposition
Telephonenumber( / Areacode / )

Reason forleavingemployment

Resigned totake better positionLay offContractexpiredReturnto schoolTerminated(fired)

Completionof military serviceResignedto avoid beingterminatedResigned whileunderinvestigation

Quit without giving notice as required by company policyReasonnot listed, explain below

Explainreason forleavingemployment; continue onpage twenty-nine (29)if necessary

Do youfeel thisformeremployerwould rehireyou?If you answered“No” explain below; continue onpage twenty-nine (29) if necessary. / YesNo
Supervisor’s name (first name, last name) / Supervisor’s title
Telephone numberwhereyourformersupervisormay be reached and time available totake calls
Telephone number (
Areacode / )
(workorcellphone) / Best time to call: / Daytime / Evening
Did youever receivedordo you haveany pendingdisciplinaryactions?Explainbelow;continue ontwenty-nine (29) if necessary. / YesNo
Co-worker’sname: (first name, last name) / Telephone numberwhereco-workercan be reached
()
Areacode / (homeorcellphone) / Besttime tocall: / Daytime / Evening
Print clearlyand use blackink only

3rdformeremployeror period of unemployment

Investigator’sinitials

Name of formeremployer / Formeremployer’smailingaddress