Attachment%20C%20Background%20Packet.pdf

Facility Protection Officer

Background Packet

Tennessee Department of Safety and Homeland Security

For use with the hiring of Facility Protection Officers

Instructions

A Background Review is an essential element in determining a person’s qualifications for employment within State of Tennessee Facilities as an armed security officer with limited police authority. The information requested in this packet is a vital part of that process. As the applicant, it is your responsibility to ensure that all necessary information is provided in order for this review to be conducted in a reasonable amount of time and with the least amount of difficulty possible. Therefore, make sure that all sections are completed prior to submitting this packet. Each question must be answered. If there are questions that are not applicable to you, please indicate this fact by the notation “N/A” in the appropriate space. Should you need additional space to provide the requested information, attach sheets of the same size as this packet and specify continuation of a particular block of information. The packet should be typed or completed in black ink and must be clear and legible.

You are reminded that providing false information or failing to provide information could result in failing to be allowed to work in a State of Tennessee Facility as an armed guard with limited police authority, or your dismissal should you be hired and the Background Review reveals the falsification.

COMMON AREAS OF OMISSION: We find that some applicants exclude middle names of relatives, personal references, and acquaintances. If a person does not have a middle name, indicate (NMN), meaning “No Middle Name.” If you are unable to furnish complete information concerning your relatives or acquaintances, give sufficient explanation. Nicknames should not be used.

If you have ever served in the Armed Forces, indicate in Section 2 by each address if you lived on or off base, including overseas tours.

SECTION 1: PERSONAL HISTORY

Last Name First Name Middle Name Maiden name

List below all other names you have used, including nicknames. If you have ever used any surnames other than your true name, during what period and what circumstances were these names used? If you have ever legally changed your name, give date, place and court.

Birth Date: City & State of Birth:

Age:

Gender:

Male

Female Social Security Number:

Driver License Number: State:

Ethnicity:

White Hispanic American Indian

Black Asian Other

# of Children: (Include biological, step and adopted children)

Marital Status: Single Married Separated Widowed Divorced

State date, place, and reason for all separations, divorces, or annulments:

Are you a U.S. Citizen? Yes No

Are you willing to reside anywhere in Tennessee? Yes No

Do you understand that you are not eligible to request a transfer to another post, except in extreme hardship cases, for one year?

Yes No

SECTION 2: RESIDENCES

Home Street Address

City: State: Zip:

Home Phone (including area code):

Work Phone (including area code):

In the event this information becomes invalid, indicate the name and phone number of a relative through whom you may be reached or who could furnish your current address and phone number.

Name:

Relationship:

Phone # (including area code):

If you have not lived at your current residence for (1) one year, explain the reason.

ACTUAL PLACES OF RESIDENCE FOR PAST FIVE (5) YEARS

Any applicant must list all residences for the past five (5) years. Include address while at college and in military, as well as family-owned vacation homes if applicable. For college on-campus residences, give dorm name, city, and state. If residences in military service cannot be shown as street address, indicate complete military unit designation and location by city, state, and country. If post office box, give location of post office.

From

(Month/Year)

To

(Month/Year) Apt. # Street Address City State

SECTION 3: EDUCATIONAL BACKGROUND

High School (attach copy of diploma)

Name of High School:

Address: (City & State)

Telephone Number (including area code):

Graduated: Yes No Date: (Month & Year)

GED (attach copy of GED)

Issuer of GED:

Testing Location: (City & State)

GED: Yes No Date: (Month & Year)

College/University (attach transcript – certified)

Name of College City State Major Yrs Attended Graduated

(Y/N) To From

Technical Schools (attach transcript – certified)

Name of School City State Study/

Specialty

Yrs Attended Graduated

(Y/N) To From

SECTION 4: EMPLOYMENT HISTORY

NOTE: LIST MOST RECENT EMPLOYMENT FIRST. Please list each job you have held for the last five (5) years.

Include chronological history of employment starting with current or most recent position. Account for all periods, including casual employment and all periods of unemployment. Be sure to include military experience, if applicable. If additional space is needed, attach additional sheets using same format. Be sure to provide all of the required information.

Job A (Current Job)

Name of Business:

Address:

City: State:

Telephone Number (including area code):

Type of Business

Period of Employment (Month/Year): From: To:

Position Held:

Supervisor:

Reason for leaving this employment:

While employed, did you face any type of disciplinary action (e.g., suspension, reprimands)? Yes No

If you answered yes to the above question concerning disciplinary action during previous employment, below provide a detailed description of the events.

Job B

Name of Business:

Address:

City: State:

Telephone Number (including area code):

Type of Business

Period of Employment (Month/Year): From: To:

Position Held:

Supervisor:

Reason for leaving this employment:

While employed, did you face any type of disciplinary action (e.g., suspension, reprimands)? Yes No

If you answered yes to the above question concerning disciplinary action during previous employment, below provide a detailed description of the events.

Job C

Address:

City: State:

Telephone Number (including area code):

Type of Business

Period of Employment (Month/Year): From: To:

Position Held:

Supervisor:

Reason for leaving this employment:

While employed, did you face any type of disciplinary action (e.g., suspension, reprimands)? Yes No

If you answered yes to the above question concerning disciplinary action during previous employment, below provide a detailed description of the events.

Job D

Name of Business:

Address:

City: State:

Telephone Number (including area code):

Type of Business

Period of Employment (Month/Year): From: To:

Position Held:

Supervisor:

Reason for leaving this employment:

While employed, did you face any type of disciplinary action (e.g., suspension, reprimands)? Yes No

If you answered yes to the above question concerning disciplinary action during previous employment, below provide a detailed description of the events.

Job E

Address:

City: State:

Telephone Number (including area code):

Type of Business

Period of Employment (Month/Year): From: To:

Position Held:

Supervisor:

Reason for leaving this employment:

While employed, did you face any type of disciplinary action (e.g., suspension, reprimands)? Yes No

If you answered yes to the above question concerning disciplinary action during previous employment, below provide a detailed description of the events.

Job F

Name of Business:

Address:

City: State:

Telephone Number (including area code):

Type of Business

Period of Employment (Month/Year): From: To:

Position Held:

Supervisor:

Reason for leaving this employment:

While employed, did you face any type of disciplinary action (e.g., suspension, reprimands)? Yes No

If you answered yes to the above question concerning disciplinary action during previous employment, below provide a detailed description of the events.

In any previous employment (not just employment in last five (5) years) have you been terminated and/or disciplined for any misconduct, behavior problems, etc.?

Yes No

If you answered yes to the above question, provide a detailed description of events and the results of all disciplinary actions taken by the employer.

OWNERSHIP/PROPRIETORSHIP/CONTRACTS WITH THE STATE OF TENNESSEE

Do you have any interest in, engage in, have a financial interest in, are the sole proprietor, a partner

(limited or otherwise) in any non-profit agency, for-profit agency, business or corporation?

No

Yes – please list below the name of the business, the type of business, the services/products produced by this business and if any contracts for the purchase of materials, supplies, equipment or services with the State of Tennessee are active.

Do you receive gifts, money, or anything of value whatsoever directly or indirectly from any person, firm or corporation who has a contract for the purchase of materials, supplies, equipment or services with the

State of Tennessee?

No Yes – please list below the name of the person, firm or corporation, the type of business, and the services/products produced by this business.

SECTION 5: MILITARY SERVICE

Are you registered for Selective Service? Yes No

If yes, list location (city and state) Have you served in any branch of the U.S. Armed Services Yes No

Complete Section Below for Each Period of Service

(Begin with most recent)

Attach DD-214 Member 4 Copy or NGB-22 for Each Period of Service

Period of Service A Army Air Force Marine Corp Navy Coast Guard

Army Reserve Air Force Reserve Marine Corp Reserve Navy Reserve Coast Guard Reserve

Army National Guard State- Air National Guard State-

Dates of Service From (Month/Year): To (Month/Year):

Date of Discharge:

Type of Discharge:

Last Duty Station:

Were you ever disciplined while in military service? (Includes Court-Martial, Article 15, Captains

Mast, etc) Yes No

If you answered yes to the above question concerning being disciplined while in the military, below provide a detailed account of the incident. Be sure to include dates, locations, and circumstances.

Period of Service B

Army Reserve Air Force Reserve Marine Corp Reserve Navy Reserve Coast Guard Reserve

Army National Guard State- Air National Guard State-

Dates of Service From (Month/Year): To (Month/Year):

Date of Discharge:

Type of Discharge:

Last Duty Station:

Were you ever disciplined while in military service? (Includes Court-Martial, Article 15, Captains

Mast, etc) Yes No

If you answered yes to the above question concerning being disciplined while in the military, below provide a detailed account

Period of Service C

Army Reserve Air Force Reserve Marine Corp Reserve Navy Reserve Coast Guard Reserve

Army National Guard State- Air National Guard State-

Dates of Service From (Month/Year): To (Month/Year):

Date of Discharge:

Type of Discharge:

Last Duty Station:

Were you ever disciplined while in military service? (Includes Court-Martial, Article 15, Captains

Mast, etc) Yes No

If you answered yes to the above question concerning being disciplined while in the military, below provide a detailed account

SECTION 6: ORGANIZATION MEMBERSHIPS

(Excluding organizations the name or character of which indicates the race, color, religion, national origin, or ancestry of its members.)

Are you now, or have you ever been a member of any club, society or organization?

Yes No

If yes, please list below: Do Not Abbreviate.

Name of Organization City State Former / Present If Present, list position & Extent of Activity

Former Present

SECTION 7: SPECIAL QUALIFICATIONS AND SKILLS

Do you have foreign language ability? Yes No

If yes, indicate your proficiency in each phase of each foreign language.

Name of Language Speak Understand Read Write

Slight

Good

Fluent

Slight

Good

Fluent

Slight

Good

Fluent

Slight

Fluent

Fluent

Slight

Good

Fluent

Slight

Good

Fluent

Slight

Fluent

Fluent

Slight

Good

Fluent

Slight

Good

Fluent

Slight

Good

Fluent

Are you a member of the bar? Yes No Date: State(s):

Are you a licensed pilot? Yes No Ratings Held:

Post Certification Number?

State:

Please list any other licenses or certifications you possess:

SECTION 8: COURT RECORD

Have you ever been arrested, indicted, charged with or convicted of a criminal or disorderly offense or instance of domestic violence? (For the purpose of this question, the words “arrested” or “indicted” etc., include any detaining or taking into custody by any law enforcement authorities.)?

Yes No

Have you ever entered a guilty plea, including a conditional guilty plea to a charge that was ultimately dismissed, and/or expunged through a diversionary or other program such as judicial diversion, conviction, expulsion, or expulsion of pardon? If so, please state your version of the facts of the charge for which you were arrested, the jurisdiction where the arrest occurred, and the disposition of the case, including the court of disposition and the case number (if known). Yes ______ No ______

I acknowledge that I have read and understand the above statement. I fully understand what information is required of me and that failure to supply accurate information will be considered willful falsification of my application which is adequate cause for removal from the register.

Applicant Signature Date

If yes, type of charge: Felony Misdemeanor Not Sure

If you answered yes to the previous questions concerning being arrested, or entering a guilty plea, provide a detailed account of the circumstances below. Be sure to include dates, locations, and types of charges. Add additional sheets, if necessary.

Have you ever been incarcerated, in jail, prison, or military stockade? Yes No

If you answered Yes to the previous question concerning incarceration, below give a detailed account of the situation. Be sure to include dates, locations, and circumstances.

Are you now, or have you ever been involved as a plaintiff, defendant, petitioner, or respondent in any civil action?

Yes No

If you answered Yes to the previous question concerning involvement in a civil action, below give an account of the circumstances. Be sure to include the date, county, court and type of action.

Are you currently on any form of Probation from any jurisdiction, i.e. Federal, State, and

Local?

Yes No

If you answered yes to the previous question concerning probation, below provide a detailed account of the circumstances.

Be sure to include dates and locations.

Have you ever been issued a citation for a misdemeanor charge, other than a traffic violation? Yes No

If you answered Yes to the previous question concerning being issued a citation, below provide a detailed account of the circumstances. Be sure to include dates, locations, and type of charges.

Have you ever had an order of protection against you? Yes No

If you answered Yes to the previous question concerning having an order of protection against you, below provide a detailed account of the circumstances. Be sure to include dates and locations.

To your knowledge, has any member of your immediate family ever been convicted of a crime for anything other than a minor traffic violation?

Yes No

If you answered Yes to the previous question concerning a member of your immediate family being convicted, below provide a detailed account of the circumstances. Be sure to include relatives’ names, relationships, dates, locations, and type of charges.

SECTION 9: REFERENCES & SOCIAL ACQUAINTANCES

Give four (4) references (NOT relatives, former or present employers, fellow employees, or school teachers) who are responsible adults of reputable standing in their communities, such as property owners, business or professional men or women including your physician, if possible, who have personally known you for at least the past five (5) years. If retired, give former occupation.

External influence in hiring is strictly forbidden. Manipulating the hiring process to accommodate political influence is a policy and integrity violation. Such unethical behavior will result in removal from consideration for any position.

I acknowledge that I have read and understand the above statement.

Reference/Social Acquaintance #1

Full Name:

Address:

City: State: Zip:

Home Phone (including area code):

Business Phone (including area code):

Other Contact Number, (e.g., cell phone, pager (including area code)):

What is the best time to contact this person? Day Evening Night

How long have you known this person?

What is your relationship with this person?

Reference/Social Acquaintance #2

Full Name:

Address:

City: State: Zip:

Home Phone (including area code):

Business Phone (including area code):

Other Contact Number, (e.g., cell phone, pager (including area code)):

What is the best time to contact this person? Day Evening Night

Reference/Social Acquaintance #3

Address:

City: State: Zip:

Home Phone (including area code):

Business Phone (including area code):

Other Contact Number, (e.g., cell phone, pager (including area code)):

What is the best time to contact this person? Day Evening Night

Reference/Social Acquaintance #4

Address:

City: State: Zip:

Home Phone (including area code):

Business Phone (including area code):

Other Contact Number, (e.g., cell phone, pager (including area code)):

What is the best time to contact this person? Day Evening Night

SECTION 10: RELATIVES EMPLOYED BY THE GOVERNMENT

List the complete names of any relatives (including in-laws) who are employed by any local, state, or federal government.

Complete Name Relation Agency By Which Employed Location (City/State)

SECTION 11: FRIENDS OR ACQUAINTANCES EMPLOYED BY ANY LAW

ENFORCEMENT AGENCY

List the complete names of any relatives (including in-laws) who are employed by any local, state, or federal government.

Complete Name Years

Known Employed By Location (City/State)

SECTION 12: PERSONAL DECLARATIONS

Do you consume intoxicating liquors? Yes No

If you answered Yes to the previous question, please complete the following questions:

Please indicate the type of intoxicating liquors you consume. You may indicate more than one type.

Beer Wine Liquor Other

Please indicate the frequency you consume these intoxicating liquors.

Daily Weekly Monthly Special Occasions

Have you ever used narcotics, drugs, or marijuana in an illegal or recreational manner? Yes No

If Yes, list below what type you used:

Marijuana Controlled Substance Narcotics

If you answered YES to the previous question concerning the use of drugs, in the space provided below, provide a detailed description of the drugs, the circumstances, surrounding the use, and the time period they were used. If you answered No enter Not Applicable (N/A) below.

Have you ever declared, or are you about to declare bankruptcy, or do you have any debt items that have been reported to collections agencies?

Yes No

If you answered Yes to the previous question, please proved date, location, and circumstances.

List the names of federal, state, or local departments, agencies or offices (including law enforcement) to which you have applied for employment, including date and status of application. If rejected or disqualified, explain why.

If, to your knowledge, any of the above agencies have conducted an investigation of you, indicate the name of the agency and the approximate date of the investigation.

Are you now or have you ever been delinquent in payment of alimony or child support? Yes No

If yes, please provide date, location, and circumstances.

A review will be conducted of all information listed on this application. Because of this, are you aware of any information about yourself or any person which you are or have been closely associated

(including relatives and roommates) which might tend to reflect unfavorably on your reputation, morals, character, ability, or loyalty to the United States? YES ______ NO_______

If Yes, please attach a separate piece of paper, giving your version of this/these incidents.

ADVISEMENT TO APPLICANTS

The overall purpose of the pre-employment review is to verify that your application and any statements you have made to your prospective employer concerning your qualifications are true.

Tennessee employers have a legal duty to know the persons whom they employ. In some cases, laws may mandate a background review before employment, while in other cases it is merely a case of public policy or prudence before placing someone in a position of public trust. Both State and Federal courts have also held that there is an absolute necessity for public employees to be truthful. You must understand that a lack of truthfulness or deception of any type on your part will automatically and irrevocably result in your application being rejected from further consideration.

For some people, there may be one or more incidents or occurrences in their background which they regret or may feel some embarrassment. A prospective employer will not make inquiries into areas of a person’s background that have no legitimate bearing on their qualifications for the job. You should understand that the mere presence of so-called “negative” information in your background is not automatically disqualifying. For example, an applicant may have engaged in petty thievery as a child, used illegal drugs, been fired or been convicted of a crime as an adult. These things in and of themselves may not automatically remove that person from consideration for a job, but lying about them will.

A pre-employment background review is not intended to be an intimidating experience or an unwarranted invasion into your privacy. Your background reviewer may contact persons who know you, including present and/or former employers, and will examine official documents and records concerning you to ensure that you have been honest in your application and fulfill the legal mandates imposed by the courts and legislature. The more forthright you have been, the greater the likelihood that your review can be completed in a timely and successful manner.

I understand that any false statement and/or deliberate misrepresentations, whether by omission or commission, will result in my application being automatically and irrevocably rejected from further consideration. I certify that I have read the above statement and understand its contents.

Applicant Print Full Legal Name

Authorization for Release of Information

I, ______________________________________________, do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized Agent of the Tennessee Department of Safety and

Homeland Security, whether the said records are of a public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of records of educational institution; financial or credit institutions, including records of loans, records of commercial or retail credit agencies (including credit reports and/or ratings); and other financial statements and records wherever filed;

medical and psychiatric treatment; employment or pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me; and records or lawsuits, criminal or civil, in which I presently have, or have had, an interest.

I also certify that any persons who may furnish such information concerning me shall not be held responsible for giving this information; and I do hereby release said persons from any and all liability which may be incurred as a result of furnishing such information. I further release the Tennessee Department of Safety and Homeland

Security and the State of Tennessee from any and all liability which may be incurred as a result of collecting such information.

I have read and fully understand the contents of this Authorization for Release of Information.

Print Full Name of Applicant

(Include maiden name, if applicable)

Street Address

Social Security Number City State Zip

Date of Birth Phone Number (including area code)

Personal Email Address Mobile Phone Number

(including area code)

Witness Signature Date

SF-1561 RDA-SW04