POLICE CHIEF’S ADVISORY BOARD MEMBERSHIP APPLICATION
APPLICANT INFORMATION
Full Name:
Date of birth: SSN (last four digits): Sex:
Current home address:
City: State: ZIP Code:
Home Phone: Cell Phone: Personal E-mail:
Own Rent How long?
EMPLOYMENT INFORMATION
Current employer:
Employer address: How long?
Work Phone: E-mail: Occupation:
City: State: ZIP Code:
EMERGENCY CONTACT
Name of a relative not residing with you:
Address: Phone:
City: State: ZIP Code:
Relationship:
HOW DID YOU HEAR ABOUT THE POLICE CHIEF’S ADVISORY BOARD? BRIEFLY EXPLAIN YOUR INTEREST IN SERVING ON THE POLICE CHIEF’S ADVISORY BOARD DO YOU PRESENTLY SERVE ON A BOARD? IF YES, PLEASE LIST:
HAVE YOU EVER BEEN ARRESTED AND/OR CONVICTED OF A CRIME? IF YES, PLEASE EXPLAIN:
PERMISSION TO CONDUCT A CRIMINAL HISTORY BACKGROUND INVESTIGATION As an applicant for the Hercules Police Department’s Police Chi ef’s Advisory Board, I authorize the Hercules Police Department t o conduct a criminal history background investigation. I understa nd this criminal history investi gation is being conducted due t o the sensitivity and confidentiality of the Police Chief’s Advisory Board. I understand that all avai lable police and criminal records will be checked and the information will be used in determining eligibi lity of applicants. By signing and submitting this application, you are confirming that all information in this application is true and correct under PENALTY OF PERJURY. Applications are processed on a first-come, first-served, basis. Submittal of an application d o e s n o t g u a r a n t e e a c c e p t a n c e o n t o t h e P o l i c e C h i e f ’ s A d v i s o r y Board. For more information, please contact the Office of the C hief of Police at (510) 799-8264. You may email this applicatio n to [email protected]
Signature of applicant: Date: