DPS BASIC ACADEMY REGISTRATION FORM

DPS BASIC ACADEMY REGISTRATION FORM SWORN PEACE OFFICER APPLICANTS

DIRECTIONS: PLEASE COMPLETE AND SUBMIT FOR APPLICATON.

Last Name: First Name: Middle Name:

Social Security No: Date of Birth: Age:

mm/dd/yyyy

Current Street Address:

City: State: Zip Code:

Driver License Number: State of Issue:

Email Address: Phone No:

Certified ILEA Other names previous used: Peace Officer?

ATTENTION: Providing false or misleading information to the Department of Public Safety at any time during the application process will be cause for disqualification.

YES NO 1. Do you understand and agree that the answers to all of the following questions must be truthful, honest and accurate to the best of your ability?

YES NO 2. Are you a citizen of the United States and a resident of Iowa or intend to become a resident upon hire?

YES NO 3. Are you or will you be at least eighteen (18) years of age on or before Nov. 15, 2021?

YES NO 4. Do you possess a valid driver’s license issued by the State of Iowa or be eligible to obtain one upon hire?

YES NO 5. I have verified that the social security number (SSN) submitted with this application is correct.

There will be strict adherence to the DPS minimum hiring qualifications. Any applicant not meeting the DPS minimum hiring qualifications throughout the entire selection process will not be considered for employment as a sworn peace officer with the Iowa Department of Public Safety.

I have met all of the DPS minimum hiring qualifications. A COMPLETE APPLICATION INCLUDES THIS DPS BASIC ACADEMY REGISTRATION FORM & THE IOWA DPS PRE-EMPLOYMENT QUESTIONNAIRE. BOTH FORMS MUST BE SUBMITTED AT THE TIME OF NEOGOV APPLICATION.

DPS APPLICANT SURVEY

Iowa state government is committed to the principles of Equal Employment Opportunity and Affirmative Action. To evaluate the success of our EEO/AA program we must collect information about job applicants. Please share some information about yourself to assist us in doing this. This information is used only for program evaluations and reporting requirements. The completion of this survey is optional.

PLEASE WRITE YOUR NUMBERED RESPONSES TO ITEMS A THROUGH H IN THE CORRESPONDING BOXES.

A Gender

B Age

C Education

D Ethnicity

E State

Employee

F Previous Applicant

G Veteran

H Referral

A. What is your gender? D. Of which racial/ethnic group(s) do you consider yourself amember? (Multiple responses are acceptable.)

0. Male 0. White1. Female 1. Black or African American2. I identify my gender as: 2. Asian

3. Native Hawaiian or Other Pacific IslanderB. What is your age? 4. Native American

0. 18 or younger 5. Hispanic or Latino1. 19 - 29 6. Alaska Native2. 30 - 393. 40 - 49 E. Are you currently a state employee?4. 50 - 59 0. No5. 60 - 69 1. Yes6. 70 or over

F. Have you previously applied for a peace officer position with the Iowa Department of Public Safety?

C. What is the highest level of education you have attained? 0. No0. 0 - 8 years 1. Yes1. 9 - 12 years, but not a high school graduate If yes, provide date(s) of previous application(s).2. High school graduate or GED3. Post high school vocational or business school training4. Some college, less than BA or BS degree5. BA, BS or similar undergraduate degree6. MA, MS or similar graduate degree7. Ph.D., JD or similar professional degree8. MD or similar professional degree

G. Do you qualify for veteran’s preference? In order to qualify for veteran’s preference, you must have served in the militaryduring one of the following periods:

0. Persian Gulf/Iraq Conflict August 2, 1990 - (End date has yet to be determined by Congress) 1. Panama Service December 20, 1989 through January 31, 1990 2. Lebanon or Granada Service August 24, 1982 through July 31, 1984 3. Viet Nam Conflict February 28, 1961 through May 7, 1975 4. I do not qualify for veteran’s preference.

H. Were you referred to apply to the Department of Public Safety by a current DPS employee?0. Yes1. NoName of DPS Employee:

DPS Form 80 (Updated 10/2020) 10-A

H. Please indicate below how you first became aware the Iowa DPS was hiring.

Choice Event Name of individual or source of INITIAL

contact:

1.

Initially referred/influenced by Iowa Department of

Public Safety Employee : (no substitutes will be made at a later date; DPS civilian or sworn supervisors are not eligible for Referral Bonus)

Name of DPS Employee:

2. www.dpscareers.com

3. College Career/Job Fair/Handshake 4. High School Presentation/Representative

5. Iowa Department of Administrative Services (DAS)

6. Iowa State Fair

7. Iowa Workforce Development Center/Advisor

8. Radio/Television Advertising

9. Public Resource Officer (PRO) Presentation

10. Civic Organization (KIWANIS, Rotary, etc.)

11. Newspaper/Periodical Advertising

Online Advertising

12. Facebook

13. Indeed.com

14. LinkedIn

15. Twitter 16. Instagram 17. Police/Law Enforcement Web Site

18. College Job Board (List College Name)

19. Digital Streaming Media (List Company)

Military Sources

20. HomeBase Iowa

21. Recruitmilitary.com

22. Military Newspaper (Name of newspaper)

23. Military Recruiter (Name of Recruiter)

24. Military Unit Representative (Name)

25. Military Career Fair (Name)

Other – Please Identify Source

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DPS Form 81 (9/2020) INITIAL:

IOWA DEPARTMENT OF PUBLIC SAFETY

Pre-Employment Questionnaire

Level 1

The information from this form will be utilized throughout the entire selection process.

The personal characteristics of honesty and integrity are crucial for employees of the Department of Public Safety. All applicants must answer the following questions honestly and indicate this by providing their initials at the bottom of each page.

Any applicant who is discovered to have misrepresented their answers in completing this questionnaire will be found unsuitable for employment.

Peace officer applicants for law enforcement officer positions with the Iowa Department of Public Safety must consent to a pre-employment polygraph evaluation.

Please type or print legibly.

NAME:

DATE OF BIRTH: SOCIAL SECURITY #:

The information on this questionnaire and anything derived from it is the property of the Iowa Department of Public Safety and is for the exclusive use of the Department.

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ALL QUESTIONS MUST BE ANSWERED HONESTLY AND TRUTHFULLY.

Questions answered YES must be explained further.

All applicants must answer the following questions and initial at the bottom of each page.

PART ONE: GENERAL HISTORY YES NO

1. Have you ever been asked to take a polygraph evaluation? If yes, explain:

2. Have you ever been subpoenaed in any court proceeding? If yes, explain:

3. Have you ever been party to a protection order either as the subject of OR the protected party? Is yes, explain:

4. Have you ever been called to testify, be questioned, interviewed or deposed in a criminal or civil matter? If yes, explain:

5. Has anyone ever been injured as a result of your actions? If yes, explain:

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YES NO

6. Have you ever been barred or trespassed from any property/location? If yes, explain:

7. Have you ever received a pardon? If yes, explain:

8. Have you ever received a deferred judgment or deferred prosecution on any matter? Ifyes, explain:

9. List all professional licenses, permits, certifications (i.e. pilot, medical, accounting,financial, real estate, insurance). Have any of these been cancelled for any reason? If yes, explain:

10. Have you ever caused the death of a person? If yes, explain:

11. Have you ever caused a person to be hospitalized? If yes, explain:

12. Have you ever participated in or committed domestic abuse, child abuse or dependentadult abuse? If yes, explain:

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YES NO

13. Have you ever participated in or committed any crime when a weapon was used? If yes,explain?

14. Have you ever committed or participated in any of the following illegal acts?

a. Unlawful sex involving a minor, forced sex, incest, bestiality, etc.? If yes, explain:

b. Steal anything in your entire life, including shoplifting? If yes, explain:

c. Possessed any stolen property or property you thought could be stolen? If yes,explain:

d. Steal a motor vehicle? If yes, explain:

e. Steal anything from someone’s home? If yes, explain:

f. Forcibly steal from a person? If yes, explain:

g. Murder? If yes, explain:

h. Manslaughter? If yes, explain:

i. Counterfeiting? If yes, explain:

j. Arson? If yes, explain:

k. Sabotage/vandalism? If yes, explain:

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YES NO

l. Blackmail? If yes, explain:

m. Purse snatching? If yes, explain:

n. Robbery? If yes, explain:

o. Prostitution? If yes, explain:

p. Pimping? If yes, explain:

q. Bribery? If yes, explain:

r. Assault? If yes, explain:

s. Kidnapping? If yes, explain:

t. Child stealing? If yes, explain:

u. Extortion? If yes, explain:

v. Burglary? If yes, explain:

w. Fraud? If yes, explain:

x. Weapons violation? If yes, explain:

y. Perjury? If yes, explain:

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YES NO

z. Forgery? If yes, explain:

aa. Written “no account” checks? If yes, explain:

15. Have you been involved in any fight since age sixteen (16)? If yes, how many? Explain:

16. Were you ever involved in a fight where weapons were used? If yes, explain:

17. Has anyone ever tried to blackmail you? If yes, explain:

18. Have you ever participated in a break in? If yes, explain:

19. Have you ever participated in a crime or been an accomplice to a crime, either before orafter the fact, without taking part in the criminal act? If yes, explain:

20. Do you now or have you ever owed any illegal gambling debt? If yes, explain:

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YES NO

21. Do you now or have you ever owed any bar debts? If yes, explain:

22. Have you ever sold, given, and/or furnished confidential government information tounauthorized individuals? If yes, explain:

23. Have you ever been sued? If yes, explain:

24. Have you ever knowingly bought or sold any stolen items? If yes, explain:

REQUIRES WRITTEN RESPONSES:

25. What is the most serious crime you have ever committed? Explain:

26. What is the most expensive item you have ever stolen from anyone? Explain:

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PART TWO: DRUG HISTORY

YES NO

1. Have you ever been arrested for any drug violation? If yes, explain:

2. Have you used marijuana and/or THC products within the last two (2) years?Last date used:Explain:

3. Have you ever used any other illegal drug at all in the past three (3) years (includinganabolic steroids after February 27, 1991)? If yes, explain:

4. Have you used any other illegal drug more than a total of five (5) times in your life(including anabolic steroids after February 27, 1991)? If yes, explain:

5. Have you ever used an illegal drug (no matter how many times or how long ago) while ina law enforcement, public safety or prosecutorial position, or in a position which carrieswith it a high level or responsibility or public trust? If yes, explain:

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YES NO

6. Have you ever unlawfully sold any type of drug(s)? If yes, explain:

7. Have you ever unlawfully bought any type of drug(s)? If yes, explain:

PART THREE: DRIVING RECORD

1. Have you ever been licensed under a name other than what you are currently using? Ifyes, what name, state and year?

2. Has your driver’s license ever been suspended, denied, revoked or cancelled? If yes,explain: (Give specific date and state)

3. Have you ever been involved in a motor vehicle accident as a driver? If yes, explain:

4. Have you ever been sued as the result of a traffic accident? If yes, explain:

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YES NO

5. Have you ever been involved in a hit and run accident? If yes, explain:

6. Have you ever operated a motor vehicle, boat, snowmobile, or all-terrain vehicle whileunder the influence of alcohol or drugs? If yes, how many times in the last year?Explain:

7. Have you ever been convicted of operating a motor vehicle while under the influence ofalcohol or drugs? If yes, explain:

8. Have you ever had your license taken away for refusal to be tested for driving under theinfluence of alcohol or drugs? If yes, explain:

9. Do you have any unpaid traffic tickets? If yes, explain:

REQUIRES WRITTEN RESPONSES:

10. List all of the states in which you have been issued a driver’s license:

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11. How many traffic violations have you had in the last three (3) years? Explain:

PART FOUR: EMPLOYMENT HISTORY

YES NO

1. Have you omitted any place(s) of employment as required on your employmentapplication form (DPS Form 80)? If yes, explain:

2. Have you ever been fired from any job or been asked to resign rather than being fired?If yes, explain:

3. Have you ever had employment-related disciplinary action taken against you? If yes,explain:

4. Have you ever walked off a job without giving notice? If yes, explain:

5. Have you ever quit a job without giving notice? If yes, explain:

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YES NO

6. Have you ever been turned down by a bonding company? If yes, explain:

7. Have you ever stolen cash from any employer regardless of the amount? If yes, explain:

8. Have you ever stolen anything other than cash from an employer? If yes, explain:

9. Have you ever served in the Armed Forces? If yes, identify branch and job class:

10. Have you ever owned a business? If yes, explain:

11. Have you ever been involved with the management or operation of a business? If yes, explain:

12. Do you or your spouse/partner have ownership of more than five (5) percent in any group, firm, corporation or any other business? If yes, please list:

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YES NO

13. Have you ever applied for an alcoholic beverage license? If yes, explain:

14. Do any of the persons listed under the relatives section of your employment application (DPS Form 80) own a business? If yes, explain:

PART FIVE: DRINKING HABITS

1. Have you ever been intoxicated in a public place? If yes, explain:

2. Have you ever operated a motor vehicle, boat, snowmobile, or all-terrain while under the influence of alcohol or drugs? If yes, explain:

PART SIX: GENERAL INFORMATION

1. Are you aware of any reason why you cannot perform the essential functions of the position you applied for with or without a reasonable accommodation as stated in the Americans with Disabilities Act of 1990? Explain:

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YES NO

2. Do you feel it is necessary for all peace officers and DPS employees to be honest? If yes, explain:

3. Did you answer all questions on your employment application (DPS Form 80) and this questionnaire (DPS Form 81) truthfully and accurately?

4. Are you aware of anything about yourself that you feel may disqualify you for this position? If yes, explain:

5. If applicable, are you current on your child support payments? If no, explain:

6. Have you ever lied to obtain a driver’s license or state ID? If yes, explain:

7. Do you have a USA passport? If yes, please provide your passport number:

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***If yes, have you traveled outside the USA in the last ten (10 years)? Explain below:

Country Visited Reason for Visit Dates Individuals Contacted (excluding tourism)

PART SEVEN: SWEAR AND AFFIRM

If you are NOT a certified law enforcement officer, please complete the Swear and Affirm section below. When all of the questions have been answered completely and the Swear and Affirm section has been signed and dated, your DPS Form 81 is complete.

If you ARE a certified law enforcement officer, you must continue to Part Seven on page sixteen (16). You will complete the Swear and Affirm section on page seventeen (17).

SWEAR AND AFFIRM

I hereby swear and affirm that each statement and all information provided in this questionnaire are COMPLETE, TRUE, AND ACCURATELY recorded. I understand that providing FALSE, MISLEADING and/or INCOMPLETE information on this questionnaire is grounds for exclusion from the selection process or discharge if discovered subsequent to employment.

Signature Date

16


THIS SECTION IS TO BE COMPLETED BY PRESENT OR FORMER LAW ENFORCEMENT/FIREFIGHTER or PUBLIC SAFETY PERSONNEL ONLY

In conjunction with your duties as a law enforcement officer, public safety official or firefighter:

YES NO

1. Have you ever solicited or accepted a bribe? If yes, explain:

2. Have you ever solicited or accepted a gift over $3.00? If yes, explain:

3. Have you ever stolen from a person in custody? If yes, explain:

4. Other than evidence, have you ever taken anything from a crime or fire scene? If yes, explain:

5. Have you ever discharged a firearm, other than for hunting, target practice or weapon qualification? If yes, explain:

6. Have you ever stolen anything from a law enforcement or fire agency, including found items and/or evidence? If yes, explain:

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YES NO

7. Have you ever improperly disclosed information on a case? If yes, explain:

8. Have you ever had a disciplinary action taken against you? If yes, explain:

9. Have you ever been suspended from a job, with or without pay? If yes, explain:

10. Have you ever done anything for which you could have been fired or suspended? If yes, explain:

11. Have you ever used an illegal drug while serving in a law enforcement, public safety or prosecutorial position, or in a position which carries with it a high level of responsibility or public trust? If yes, explain:

When all of the questions have been answered completely and the Swear and Affirm section has been signed and dated, your DPS Form 81 is complete.

SWEAR AND AFFIRM

I hereby swear and affirm that each statement and all information provided in this questionnaire are COMPLETE, TRUE, AND ACCURATELY recorded. I understand that providing FALSE, MISLEADING and/or INCOMPLETE information on this questionnaire is grounds for exclusion from the selection process or discharge if discovered subsequent to employment.

Signature: Date:

Documents

DPS BASIC ACADEMY REGISTRATION FORM