Application for:

____ Dispatcher ____ SLEO I

PRINT ALL INFORMATION IN BLACK INK

NAME Last (Suffix Jr. Sr. III Etc.! "irst Mi##le

MAIDEN NAME $OME ADD%ESS Nu&'er ( Street or %.D. Nu&'er *ount+ $OME ,ELE/$ONE N0M1E% E2MAIL ADD%ESS DA,E O" 1I%,$ State Apt. ) *it+ or ,o-n

.ip *o#e *ELL /$ONE N0M1E%

D%I3E%S LI*ENSE N0M1E% SE5

S,A,E ISS0ED %A*E

SO*IAL SE*0%I,4 N0M1E%

$a6e +ou e6er 'een arreste#7 4es or No ________________ If +es 8i6e #etails 'elo-.
Date Location %eason Disposition

/lease fill in infor&ation re9ueste# 'elo- on all &otor 6ehicle tic:ets or su&&ons +ou ha6e recei6e#:

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Date

Location

3iolation ,+pe

,ic:et Nu&'er

Status

Na&e: ___________________________________________ =of <

/hone: ____________________________ 4es

;. $a6e +ou e6er 'een con6icte# of a ;st =n# >r# or ?th #e8ree cri&e or are +ou presentl+ un#er in#ict&ent for sa&e7 (,his applies to expun8e# con6ictions!@.. =. $a6e +ou 'een con6icte# of a #isor#erl+ persons or pett+ #isor#erl+ persons offense in the last >A &onths7@@@@@@@@@@@@@@@@@@@@. >. $a6e +ou e6er 'een con6icte# of an+ #o&estic 6iolence offense7@@@@@@ ?. $a6e +ou 'een con6icte# of t-o or &ore offenses of Dri6in8 Bhile Intoxicate# (DBI! or %efusal to ,a:e a 1reathal+Cer ,est7@@@@@@@@@@@@@ <. $a6e +ou 'een con6icte# of a DBI or %efusal Offense -ithin the last < +ears7... A. Are +ou currentl+ on pro'ation or ha6e +ou 'een on pro'ation -ithin the last > +ears7@@@@@@@@@@@@@@@@@@@@@@@@@@@@@.. D. Are +ou currentl+ in #efault of an+ pa+&ents for ali&on+ or chil# support7@@ E. Is +our #ri6in8 pri6ile8e re6o:e# in Ne- Jerse+ or in an+ other state7@@@@. F. $a6e +ou e6er 'een #ishonora'l+ #ischar8e# fro& an+ 'ranch of the &ilitar+ or an+ la- enforce&ent a8enc+7@@@@@@@@@@@@@@@@@@@@. ;G. $a6e +ou 'een a#Hu#icate# #elin9uent in the last < +ears7 (IA#Hu#icate# #elin9uentJ &eans 'ein8 foun# 8uilt+ of an in#icta'le offense -hile +ou -ere a Hu6enile.!@@@@@@@@@@@@@@@@@@@@@@@@@@@@. ;;. Are +ou currentl+ a fu8iti6e fro& Hustice7@@@@@@@@@@@@@@@. ;=. $a6e +ou e6er renounce# +our citiCenship of the 0nite# States7@@@@@@.. ;>. Do +ou ha6e a hi8h school #iplo&a or KED7@@@@@@@@@@@@@@

No

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Records Release Authorization Form

,o all *ourts /ro'ation Depart&ents Selecti6e Ser6ice 1oar#s /h+sicians $ospitals E&plo+ers E#ucational an# other Institutions an# A8encies -ithout exception. I __________________________________________ a& &a:in8 application for appoint&ent to the Lon8 1ranch /olice Depart&ent. As a result an in6esti8ation is 'ein8 con#ucte# to #eter&ine &+ eli8i'ilit+. ,herefore +ou are authoriCe# to release to the Lon8 1ranch /olice Depart&ent or its representati6es an+ an# all infor&ation #ocu&ents or other recor#s pertainin8 to &e that the+ &a+ re9uest. I #o here'+ release #ischar8e an# exonerate the Lon8 1ranch /olice Depart&ent its a8ents an# representati6es an+ person so furnishin8 infor&ation fro& an+ an# all lia'ilit+ of e6er+ nature an# :in# arisin8 out of the furnishin8 inspection or collection of such #ocu&ents recor#s an# other infor&ation or the in6esti8ation &a#e '+ the Lon8 1ranch /olice Depart&ent.

A photo static cop+ of this authoriCation -ill 'e consi#ere# as effecti6e an# 6ali# as the ori8inal.

_________________________________________ __________________
Si8nature Date

Si8ne# an# Seale# 'efore &e on this __________ #a+ of ___________ =G_______.

_________________________________________
LNotar+ /u'licM

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Criminal History Release

I ___________________________________ here'+ authoriCe that &+ fin8erprints an# na&e 'e chec:e# '+ +our #epart&ent an# the Ne- Jerse+ State /olice. I further authoriCe that a cop+ of &+ fin8erprint recor# if an+ 'e for-ar#e# to the Lon8 1ranch /olice Depart&ent. I here'+ release an# for8o an+ an# all ri8hts re&e#ies an# or causes of action -hich I &a+ ha6e a8ainst the Ne- Jerse+ State /olice the Ne- Jerse+ Depart&ent of La- an# /u'lic Safet+ their respecti6e a8ents officers an# representati6es the *it+ of Lon8 1ranch the Lon8 1ranch /olice Depart&ent an# their respecti6e a8ents officers an# representati6es -hich &a+ result fro& the searches an# chec:s perfor&e# '+ an+ of these la- enforce&ent a8encies.

____________________________________
Si8nature of Applicant

____________________________________
Street A##ress of Applicant

____________________________________
*it+ an# State

____________________________________
Date

Si8ne# an# Seale# 'efore &e on this ________ #a+ of __________________ =G_______.

__________________________________________
LNotar+ /u'licM

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