Human Resources Division4/1/2009
Optional Qualifications/Claims Form
2009 Police Officer / State Trooper / MBTA Transit Police Examination
Name: ______
Street: ______
City, State, Zip: ______
Veteran’s Status(Proof required) / Please check here if you are applying for Veteran’s Status: ______
(You should bring a copy of your DD214 Member-4 Form to the exam site)
Please check here if you are applying for Disabled Veteran’s Status ______
(You should bring a copy of you DD214 Member-4 Form andwritten confirmation from the US Veterans Administration of a continuing service-incurred disability rated not less than 10% based on wartime service)
Language Fluency
(other than English) / I am fluent in: ______
EMT Status / Please check whichever EMT status applies to you:
EMT-Basic ______EMT-Intermediate ______EMT-Paramedic ______
MA DPH License Number: ______Expiration Date: ______
402 Status
(Proof required) / The son or daughter of a Firefighter or Police Officer employed in Massachusetts who was killed or died of injuries received in the performance of duty, or who was permanently disabled as a result of injuries received in the performance of duty, is entitled to certification preference under the provisions of Chapter 402 of the Acts of 1985.
Please check here if you are applying for 402 status: ______(You will be contacted by HRD)
412 Status
(Proof required) / Chapter 22C, Section 11: If you are the son or daughter of a uniformed member of the State Police who was killed or sustained injuries in the line of duty which resulted in the member's death, you may qualify for preference under Section 11 of Chapter 412 of the Acts of 1991. For these purposes, a uniformed member shall mean members of the Division of State Police of the Department of Public Safety, Metropolitan Police Department, Capitol Police or Division of Law Enforcement of the Registry of Motor Vehicles.
Please check here if you are applying for 412 status: ______(You will be contacted by the State Police)
Education Background / Please indicate the highest level of education you have attained: ______
(e.g. High School, Some College, Associates Degree, Bachelor’s Degree)
Please indicate the academic major for the highest degree you enrolled in or attained:
______
Indicate the type of school you last attended (beyond high school):
Public 2-year college ______Private 2-year college ______
Public 4-year college ______Private 4-year college ______
PublicGraduateSchool ______PrivateGraduateSchool ______
The following sections are optional for this exam. Failure to enter information may impact your standing on the eligible list and/or employment opportunities. For additional information please visit