Goshen Police District
Goshen Twp. - Beloit Village - Green Twp.
14003 W. South Range Rd.
Salem, Oh 44460-9127
330-332-1235 / 330-332-3411 (F)
Chief Steven T. McDaniel
General Information
(Please print legibly with blue or black ink)
Position Applying For: ______Date of Application Submission: ______
Name: ______
(Last) (First) (Full Middle Name)
Address: ______
(Street) (City/State) (Zip)
Phone: (Home) ______(Cell)______(Work) ______
(Please indicate which is best contact number)
E-Mail Address: ______
Have you ever completed an application here before? Yes No Is Yes, when? ______
Are you a U.S. Citizen? YesNoIf no, what Country are you a citizen of? ______
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment) Yes No
Are any of your relatives (to include by marriage) employed by Goshen Township, Green Township or Beloit Village? Yes No If so, what Department/Division? ______
NOTE: The Goshen Police District conducts a background investigation of criminal history. A criminal conviction does not constitute an automatic bar to employment. Each case is considered individually and based on job requirements. However, failure to answer truthfully may result in disqualification or termination of employment with the township.
Have you ever been convicted of a felony, regardless of whether the conviction was later set aside or expunged, in any domestic, foreign or military court? Yes No
Are you pending charges, trial or other court proceeding for any felony, in any jurisdiction, at this time? Yes No
If you answered Yes to either or both of these questions, please give details including the offense(s) for which you were convicted or are currently pending charges, date of conviction, and jurisdiction (court, city, county, and state). If an offense have been set aside or expunged, please give date of action. ______
What work status are you available to work: Full-Time Part-Time Reserve
(Please check all that apply) Days Evenings Nights Rotating
If appointed, when could you start work? ______
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Education
Did you obtain a High School Diploma or GED? Yes No
If yes, from what school or institution? ______
College/University / City/State / Major / Degree(s) CompletedDo you have a Valid Driver's License? / State: / CDL / Driver’s License #:
Yes No / Yes No
List any license endorsements:
Professional certifications, licenses, or memberships: ______
______
List any specialized training you may have received that relates to this position (include number of hours and course content): ______
______
List any computer software training you have received: ______
______
List any equipment that you are able to operate or use that relates to this position: ______
______
Language Proficiency
(Any language other than English)
Language: / Speak: / Read: / Write:Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Experience
Begin with your present or most recent position. List all jobs held, paid or volunteer over the last ten years. Your qualifications will be evaluated on the basis of the information provided in this application. You may attach a separate sheet if additional space is needed, or to include applicable experience prior to ten years ago.
Resumes may not be substituted for the requested information.
Employer Name/Address / Position Held / Hourly Rate / Date Began / Date EndedSupervisor: ______Phone Number: ______
May we contact this employer? Yes No If no, why? ______
Primary Job Duties: ______
______
Reason for leaving: ______Total Time Worked: _____ Years _____ Months
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Employer Name/Address / Position Held / Hourly Rate / Date Began / Date EndedSupervisor: ______Phone Number: ______
May we contact this employer? Yes No If no, why? ______
Primary Job Duties: ______
______
Reason for leaving: ______Total Time Worked: _____ Years _____ Months
Employer Name/Address / Position Held / Hourly Rate / Date Began / Date EndedSupervisor: ______Phone Number: ______
May we contact this employer? Yes No If no, why? ______
Primary Job Duties: ______
______
Reason for leaving: ______Total Time Worked: _____ Years _____ Months
Employer Name/Address / Position Held / Hourly Rate / Date Began / Date EndedSupervisor: ______Phone Number: ______
May we contact this employer? Yes No If no, why? ______
Primary Job Duties: ______
______
Reason for leaving: ______Total Time Worked: _____ Years _____ Months
Employer Name/Address / Position Held / Hourly Rate / Date Began / Date EndedSupervisor: ______Phone Number: ______
May we contact this employer? Yes No If no, why? ______
Primary Job Duties: ______
______
Reason for leaving: ______Total Time Worked: _____ Years _____ Months
Employer Name/Address / Position Held / Hourly Rate / Date Began / Date EndedSupervisor: ______Phone Number: ______
May we contact this employer? Yes No If no, why? ______
Primary Job Duties: ______
______
Reason for leaving: ______Total Time Worked: _____ Years _____ Months
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References
Personal References: List at least three people who have known you over one year, excluding relatives or former employers, who can answer questions concerning your past conduct and character as it applies to your meeting the minimum standards for employment.
Name / Street Address, City, State, Zip / Phone Number / Alt. Phone Number / Yrs. KnownExcluding family members, list all persons you have lived with during the past five years.
Name / Street Address, City, State, Zip / Phone Number / RelationshipFamily References: List at least three immediate relatives (parents, spouse, children, etc.) who could attest to your character and past conduct.
Name / Relationship / Age / Street Address, City, State, Zip / Phone NumberResidences: List all residences during the past five years. Use additional sheet if necessary.
From / To / Address / City / State/Countypage 4 of 5
READ THIS APPLICATION AND VERIFY YOUR ANSWERS BEFORE SIGNING BELOW
By signing this application, I certify all information on this form is true to the best of my knowledge, and any omissions or misstatements of facts may be cause for rejection of this application.
I do hereby authorize any and all individuals, partnerships, corporations, civilian and government agencies, military agencies, law enforcement agencies and private, municipal, State and Federal entities, to furnish the Goshen Police District (Ohio) with any and all available information, to include medical information, regarding me in order that my suitability for law enforcement/criminal justice administration work may be determined. I further authorize the Goshen Police District to make inquiry of my past and present employers, associates, and acquaintances regarding my character, integrity and reputation, and waive any and all claims of confidentiality against anyone who may have knowledge of my fitness for employment with this police department.
Additionally, I agree to hold the Goshen Police District, its agents and employees, harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the department. I understand that the background information obtained will be shared with the Goshen Police District and further, if information of a serious criminal nature surface from the background investigation, such information may be turned over to the appropriate authorities.
I understand that I will not receive and I am not entitled to a copy of the background investigation report or to know its contents. I further understand that the contents will be used in evaluation process for employment with the Goshen Police District. I also understand that no documents submitted by me will be returned to me and no copies of any other reports or documents utilized for or during my application for employment will be furnished or given to me. It is my responsibility to keep the Goshen Police District advised of changes of address or phone number.
Signature: ______Date: ______
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