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GENERAL INFORMATION <br /> Note: Your answers to the following general information questions may be verified by checks of <br /> records kept by police agencies, courts, and social service agencies, and by interviews with <br /> persons acquainted with you. If you deliberately give false or misleading answers, you may be <br /> disqualified. <br /> I1. What is the reason that you are completing this questionnaire?(MARK ONE ANSWER ONLY) <br /> a. Job application <br /> b. Special assignment evaluation <br /> c. Job promotion <br /> d. Fitness for duty evaluation <br /> e. Other <br /> 12. What is the position for which you are applying or being evaluated? (MARK ONE ANSWER <br /> ONLY.) <br /> a. Police officer/sheriff's deputy/state trooper(sworn,weapon carrying officer) <br /> b. Reserve officer/reserve deputy (sworn, weapon carrying officer) <br /> c. Communications dispatcher/Call taker <br /> d. Firefighter and/or EMT <br /> e. Corrections officer(non-patrol) <br /> f. Probation Department: officer, counselor <br /> g. Juvenile Hall Counselor <br /> h. Security officer(not sworn) <br /> i. Other position <br /> j. I am not applying for any position. <br /> 13. Are you a United States citizen? <br /> a. Yes, I am a United States citizen <br /> b. No, I am not a United States citizen <br /> 14. Have you ever used or been known by any last name(surname)other than the one you <br /> used on this questionnaire(including a maiden name)? <br /> a. No <br /> b. Yes <br /> 15. Do you have any tattoos? <br /> a. No <br /> b. Yes <br /> 16. Do you have any body piercing (other than ears)? <br /> a. No <br /> b. Yes <br /> 17. Do you have any prejudices that you are aware of against any group? <br /> a. No <br /> b. Yes <br /> 18. How many physical fights have you been in, since the age of 18? (DO NOT COUNT FIGHTS <br /> THAT OCCURRED IN THE LINE OF DUTY AS A LAW ENFORCEMENT OFFICER OR OTHER PUBLIC <br /> SAFETY WORKER.) <br /> a. None <br /> b. 1 <br /> c. 2 <br /> d. 3 or more <br /> PSS/LEPS PLLC 86 <br />