Please fill out this form online.

PERSONAL INFORMATION

Legal Name (Last, First Middle): Date of Birth:

Street Address: City: State: Zip Code:

Home Phone: Cell Phone: Work Phone: Pager:

SSN: Amateur Radio Call Sign: Driver’s License #: State:

Sex: Race: Height: Weight: Hair Color: Eye Color:

E-mail address:

ARREST INFORMATION

Haveyou been arrested or criminally cited?

Ifyes,please describe:

Please list any skills or interests you would like to use in your volunteer work with us. ***If you have any specialized training (EMT, nurse, doctor, etc.), please include a photocopy of your current certification or license.***
PERJURY STATEMENT

Ideclarethatthe aboveinformationistrueandaccurate.Igrant the University of Washington Police Department permissionto conductacriminalhistory backgroundcheckusingtheaboveinformation. Iunderstandthatmy participationinthisprogramiscontingentupontheaccuracyoftheaboveinformationandmy following alllawsandallpoliciesandproceduresestablishedbythe UWPDoritsagentswithregardtothe activitiesofitsvolunteers.

Signed: ______Date: ______

Please send in this form with your signature to:

University of Washington Police Department VIPS Program

1117 NE Boat St

Seattle, WA 98105

Or through campus mail to Box 355200

Or via fax at 206.685.8042

UWPD Use Only
Application Received / Background Completed / NIMS Completed / ID Card Issue Date / Volunteer DEM #

WAIVER OF LIABILITYCONSENT TO RELEASE INFORMATION

To Whom It May Concern:

I am an applicant for a position with the University of Washington Police Department. The departmentneeds to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied. I have authorized the department to gather all available information regarding my employment background, personal history and other information, which may be of a confidential or privileged nature.

I consent to your release of any and all public and private information that you may have concerning my work record, my background and reputation, my military service records (not to include disability-related records), educational records, credit history and any information contained in investigation files. I further specifically consent to the Washington Department of Revenue’s release of (1) any tax returns, as defined by RCW, filed by, on behalf of, or with respect to me, and (2) any tax information as defined by RCW, that pertains to me. I request your cooperation in supplying this information to the University of Washington Police Department in response to a request from that department.

I hereby agree to release you and those who supplied you with the above information, your company or organization, and the University of Washington, its employees and the University of Washington Police Department, from any and all liability for any damage which may result from furnishing the requested information.

To any Federal Employer, Agency and Department, and the Military:

I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those rights with the understanding that information furnished will be used by the University of Washington Police Department in conjunction with employment procedures.

______/ ______
Printed Name / Signature
______
Date
Subscribed and sworn before me on the ______day of ______, 20___.
______
Notary Public in and for the State of Washington
Residing in: ______
My Commission expires on: ______
Note: A photocopy reproduction of this request shall be for all intents and purposes as valid as the original. You may retain this form in your files.

POSITION APPLIED FOR: VOLUNTEER IN POLICE SERVICE - UWPD

University of Washington Police Department

“Safeguarding the Academic Community”

Rev. 10/12