Name:      Date:

Address:     Telephone

City:     State:     Zip:     Work Phone:

Federal Law does not require applicants to furnish social security number and date of birth.  We are requesting them for the purpose of identification and compliance with wage and pension laws.

Social Security Number:  Date of Birth:     

Place of Birth      State:

Position Applied For:     Desired Wage:

Date you are Available:    No. of Dependents:

Have you Suffered a Serious Injury? Yes  No  If yes, Give date and nature of injury.

Have you ever been convicted of a crime? Yes  No If yes, Please give Circumstances.

Education:  High School, Name and Date of Graduation

College, Name, Degree, Date of Graduation

Other

References

(1) Name:

Address:

City:     State:     Zip:     

Home Phone:      Work Phone:

(2) Name:

Address:

City:     State:     Zip:     

Home Phone:      Work Phone:

(3) Name:

Address:

City:     State:     Zip:     

Home Phone:      Work Phone:

PREVIOUS EMPLOYMENT RECORD

Name of Employer:

Date of Employment:

Reason For Leaving:

Name of Employer:

Date of Employment:

Reason For Leaving:

Are you certified by the NJ POLICE TRAINING COMMISSION  Yes  No 

If Yes, Name Academy and Graduation Date.

Driver License Number:    State:  

I hereby certify that all questions on this application have been answered correctly.  I understand that my employment is subject to investigation and hereby authorize the release of all information and records held by any agency or individual for use by the Fanwood, New Jersey, Police Department.

Signed_________________________________    Date ____________

PLEASE ENCLOSE  A COPY OF YOUR RESUME', WITH THE APPLICATION.