Forms • Dodge City • CivicEngage

Police Officer Background Waiver & Honesty Statement Form

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During the hiring process you will be asked to provide extensive information regarding many aspects of your life. Every item of information that you provide will be subject to verification. Any incorrect information or omitted information may disqualify you from employment with the City of Dodge City and/or prohibit your certification as a law enforcement officer by the State of Kansas. Truthful statements to any requested information will not necessarily exclude you from consideration, unless such information constitutes an
automatic disqualifier.

We require you to tell the truth, completely and accurately, at all times and to maintain the highest level of integrity. If you provide false or incomplete information, or engage in deception during any part of the hiring process, you will be permanently disqualified from further consideration.

Applicant acknowledgement--
I have read the above and understand the need for full disclosure and the highest integrity. I agree to proceed in the hiring process having this in mind. I have read and understand the automatic disqualifications included with this Honesty Statement, and I believe that none of the disqualifiers apply to me.*

Yes

DODGE CITY POLICE DEPARTMENT
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I do hereby authorize a review of and full disclosure of all records concerning myself to any duly authorized agent of the City of Dodge City Police Department, whether the said records are of a public, private and confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions, financial or credit institutions, including records of loans, the records of commercial or retail credit agencies (including credit reports and/or
rating): and other financial statements and records wherever filed; medical and including hospitals, clinics, private practitioners, and the U.S. Veteran’s Administration; employment and pre-employment records, including background reports, efficiency ratings,
investigations of complaints or allegations of misconduct , and grievances filed by or against me and the records and recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had interest.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or part, upon this release authorization will be considered in determining my suitability for employment by the City of Dodge City
Police Department. I also certify that any person(s) who may furnish such information concerning me, including opinions of my performance, reliability or integrity, shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information.*

Name: First, Middle Initial, Last *

Maiden Name (if applicable)

Physical Address: *

City, State, Zip Code*

Phone or Cell Phone No. *

Date of Birth*

Social Security No. *

Driver's License No.*

State Driver License Issued In:*

E-mail address*

Electronic Signature:*

Date Signed*

* indicates required fields.

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