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Home My WebLink AboutChaplain Application Packet_2017ICPD Chaplain Application Packet: Page 1 of 11 IOWA CITY POLICE DEPARTMENT Chaplain Corps Volunteer Application Today’s Date _____________________ Name ______________________________________________________________________________ Last First Middle Maiden / Other Names ___________________________________________________________ Current Residence Phone _______________________ Business Phone ____________________ Cell phone ______________________ E-mail Address _________________________________ Social Security No. ___ - __ - ____ Driver’s License No. / State _________________________ List all the addresses where you have lived in the past five (5) years, beginning with your present address and list previous addresses. Attached additional sheets if necessary. Address, City, State, Zip Code Date From Date To Month Year Month Year Address, City, State, Zip Code Date From Date To Month Year Month Year Address, City, State, Zip Code Date From Date To Month Year Month Year Address, City, State, Zip Code Date From Date To Month Year Month Year CRIMINAL HISTORY Have you been charged with a felony or misdemeanor crime other than parking or traffic violations? Yes ( ) No ( ) If yes, explain ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ICPD Chaplain Application Packet: Page 2 of 11 SKILLS / EDUCATION Church Affiliation_______________________________________________________________ (Use back or Additional Page for Supplementary Space) Ordination Date _____________ Religious Order Membership __________________________ Education_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (Use Back or Additional Page for Supplementary Space) Additional Training and/or counseling Experience ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you speak or read a foreign language? ____ Which one(s)? ___________________________ EMPLOYMENT HISTORY List all employment you have had over the past ten (10) years, beginning with the most recent. Include military, full and part-time employment and all periods of employment. Attach additional sheets if necessary. Business Name Address, City, State, Zip Code Phone From: Month Year Position Held Supervisor To: Month Year Duties Co-Worker/Reference Reason For Leaving Employment (Explain) [Circle One] Fired Quit Laid -Off Asked to leave Retired Business Name Address, City, State, Zip Code Phone From: Month Year Position Held Supervisor To: Month Year Duties Co-Worker/Reference ICPD Chaplain Application Packet: Page 3 of 11 Reason For Leaving Employment (Explain) [Circle One] Fired Quit Laid -Off Asked to leave Retired Business Name Address, City, State, Zip Code Phone From: Month Year Position Held Supervisor To: Month Year Duties Co-Worker/Reference Reason For Leaving Employment (Explain) [Circle One] Fired Quit Laid -Off Asked to leave Retired PERSONAL REFERENCES List only persons you have known for at least six (6) months. Do not list relatives, current or former employers, teachers or physicians. Name: Last/First/Middle Home Address, City, State, Zip Code Home Telephone Business Name Business Address, City, State, Zip Code Business Telephone Email Address: Name: Last/First/Middle Home Address, City, State, Zip Code Home Telephone Business Name Business Address, City, State, Zip Code Business Telephone Email Address: Name: Last/First/Middle Home Address, City, State, Zip Code Home Telephone Business Name Business Address, City, State, Zip Code Business Telephone Email Address: ICPD Chaplain Application Packet: Page 4 of 11 Additional Questions: Have you ever been convicted of any type of crime involving domestic violence? Yes ( ) No ( ) Have you ever committed an act of domestic violence? Yes ( ) No ( ) If yes explain on page 7. Have you ever been involved in a child abuse or child neglect investigation of any kind? Yes ( ) No ( ) If yes explain on page 7. Have you ever had a Protection Order sworn out against you? Yes ( ) No ( ). Explain on page 7. Have you ever sworn out a Protection Order on any one else? Yes ( ) No ( ) Explain on page 7. Have you ever been a victim of a domestic disturbance? Yes ( ) No ( ) If yes explain on page 7. Have you used marijuana, illegal drugs, or abused prescription drugs? Yes ____ No ____ If yes, name the substance, the frequency of use, and period of uses on page 7. Have you ever bought, sold, distributed, manufactured or abused illegal drugs? Yes___ No____ If yes, name the substance, the frequency of use, and period of uses on page 7. Since the age of sixteen, have you ever taken money or property from an employer or stolen money or property from someone else? Yes ____ No ____ If yes, explain the circumstances, item or amount, and when on page 7. How were you referred to the Iowa City Police Department Chaplain Program? ______________________________________________________________________________ ______________________________________________________________________________ Have you ever been employed or volunteered with the City of Iowa City? Yes ( ) No ( ) . If yes, which Department and when? ______________________________________________________________________________ ______________________________________________________________________________ CERTIFICATION STATEMENT I certify that all of the above questions have been answered to the best of my knowledge, and I understand that any false answers, omissions, or deceptions may be the basis for my rejection or termination from volunteering. I understand before being accepted into this program a criminal history check, personal history check, reference check and personal interview will be conducted. ______________ ________________________________________________ (Date) (Signature) ICPD Chaplain Application Packet: Page 5 of 11 When Using This Additional Space Page Note The Specific Section ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ICPD Chaplain Application Packet: Page 6 of 11 IOWA CITY POLICE DEPARTMENT VOLUNTEER AGREEMENT I, ________________________________, request to serve as a Public Safety Aide (volunteer) with the Iowa City Police Department (ICPD). As a Public Safety Aide, I agree to: • Perform the tasks outlined in my task description to the best of my ability. • Attend any training offered that will enhance my performance within the ICPD. • Report to work on time when scheduled, and to call my supervisor if I am unable to report. • Comply with and follow the same rules and policies as required of all ICPD employees. • Refrain from using my position to attempt to influence anyone in any manner. • Strive to help the Department obtain its goals and objectives. • Notify the Senior Chaplain upon terminating my involvement with the program, and participate in an exit interview/evaluation. I will relinquish to the Chaplain Liaison any and all items or equipment issued to me including, but not limited to identification cards, parking permit, etc., at the time of voluntary or involuntary termination. • Notify the Chaplain Liaison of any arrest or citation for any traffic, misdemeanor or felony charge. • I am aware that my Public Safety Aide status may be terminated at any time for failing to follow the rules, procedures, and terms of this agreement. I have read and understand all the conditions of this agreement. Signature __________________________________ Date _____________ Chaplain Liaison _____________________________________ Date _____________ ICPD Chaplain Application Packet: Page 7 of 11 IOWA CITY POLICE DEPARTMENT VOLUNTEER STATEMENT OF CONFIDENTIALITY AND WAIVER I understand that any material omissions and/or false information I record on the application will be sufficient reason for rejection of this application or termination of my Volunteer/Intern status. In addition, I authorize and request former employers, schools, individual agencies, organizations or law enforcement agencies to answer any and all questions that may be asked and do here withhold such persons harmless for giving any information within their knowledge or record. As a condition of acceptance as a Volunteer, I agree to submit documents relating to my identity and employment authorization within prescribed time limits in accordance with the Immigration Reform and Control Act of 1986. I understand that I do not have the right to continue my status or utilize appeal rights as a Volunteer if terminated. Also, I understand that I am not an employee of the City of Iowa City or any department thereof, and am not eligible for any remuneration or benefits of any kind or nature. I understand and agree that in the performance of my duties as a Volunteer with the Iowa City Police Department, I will hold all names and information regarding the Department in the strictest confidence. Further, I understand that intentional or involuntary disclosure of confidential information to unauthorized sources may result in my termination as a Volunteer. I further agree to release the City of Iowa City, its departments, and employees from accountability for any accident, injury, or other liability incurred or suffered by me while carrying out the duties of a Volunteer. Volunteer Signature __________________________________ Date _____________ Chaplain Liaison Signature ____________________________ Date _____________ ICPD Chaplain Application Packet: Page 8 of 11 Iowa City Police Department Emergency Notification Data Date __________________ Name ________________________________________________ (Last/First/MI) Job Classification ________________________ Serial No. ___________ DOB ______________________ Res. Address _______________________________________ Res. Telephone No. _______________ City _________________________ State _________ Zip Code ________________ Primary Contact Name ________________________________________ Relationship _____________________ Res. Address __________________________________ Telephone No. ____________________ Bus. Address __________________________________Telephone No. ____________________ Cellular No. _________________ Pager No. _________________ Other ______________ Secondary Contact Name ________________________________________ Relationship _____________________ Res. Address __________________________________ Telephone No. ____________________ Bus. Address __________________________________Telephone No. ____________________ Cellular No. _________________ Pager No. _________________ Other ______________ ICPD Chaplain Application Packet: Page 9 of 11 YOUR PHYSICIAN INFORMATION ______________________________________________________________________________ Name ______________________________________________________________________________ Address City State Phone Numbers: _____________________ ____________________ _____________________ Business Residence Emergency (Optional) Are you Allergic to any Drugs? ___No ___Yes (specify)______________________________________________________________________ ANY ADDITIONAL INFORMATION YOU WISH TO SUPPLY SO EMERGENCY CARE CAN BE OBTAINED FOR YOU QUICKLY, IF NEEDED, PLEASE MAKE NOTATION IN THIS SPACE ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________ ICPD Chaplain Application Packet: Page 10 of 11 IOWA CITY POLICE DEPARTMENT 410 E Washington St Iowa City, IA 52240 Phone: (319) 356-5275 Fax: (319) 356-5449 Must be witnessed by a Notary Public. Photocopy same as original. Notwithstanding any rights I may otherwise have concerning release of such information, I request and authorize you to release all information concerning my employment application and/or employment records with you to Jody Matherly, Chief of Police, Iowa City Police Department, Iowa City, Iowa, or his representative. This request is related to an investigation to determine my suitability for employment with the City of Iowa City, Iowa City, Iowa __________________________________ __________________ ______________ Signature Date SSN ____________________________________________________________________ Address City / State / Zip Code State of Iowa County of Johnson, Subscribed and affirmed before me this _____ day of _________________, 20 _____ Witness my Hand and Notarial Seal. ______________________________________________ Notary Public ICPD Chaplain Application Packet: Page 11 of 11 IOWA CITY POLICE DEPARTMENT 410 E Washington St Iowa City, IA 52240 Phone: (319) 356-5275 Fax: (319) 356-5449 Must be witnessed by a Notary Public. Photocopy same as original. Dear Sir or Madam: The Iowa City Police Department is presently conducting a pre-employment background investigation of _________________________________________, DOB _______________, who has applied for a position with the City of Iowa City. We ask your cooperation in furnishing this Department with any information showing criminal, traffic tickets, arrests and/or convictions involving this applicant. The indication of a clear record while residing in your jurisdiction is likewise requested. Names of associates, addresses and the general reputation of the candidate in your community and any similar information, which would help the Department evaluate the character of the applicant, would be greatly appreciated. Notwithstanding any rights I may otherwise have concerning release of such information, I request and authorize you to release any and all of the above-requested information to Jody Matherly, Chief of Police, Iowa City Police Department, Iowa City, Iowa, or his representative. _________________________________________ ______________________ Signature Date __________________________________________________________________ Address City / State / Zip Code State of Iowa County of Johnson, Subscribed and affirmed before me this _____day of ______________, 20 ____ Witness my Hand and Notarial Seal. ______________________________________________