Personal Reference Verification Questionnaire

2. Applicant's Name*

3. Who is your Background Investigator?*
   -- Select One --Officer Chris BoruchOfficer Hobie YoungSergeant Mike Elkins

5. Your Full Name (Legal):*

6. Phone Number (Best)*

8. Please provide your email address:*

10. Are you related to the applicant? (This includes being a relative through marriage)?*

    1. Yes

    1. No

12. What is the relationship?*

14. How long have you known the applicant? *

    (Years)

15. In what capacity?*

    (Neighbor, friend, co-worker, etc…)

17. How did you become acquainted with the applicant?*

19. Do you consider the applicant trustworthy with confidential information?*

    1. Yes

    1. No

21. Please explain why or why not:*

23. Would you say the applicant is dependable?*

    1. Yes

    1. No

25. Please explain why or why not:*

27. To your knowledge, has the applicant ever exhibited extreme nervousness or loss of temper (to include domestic disputes)?*

    1. Yes

    1. No

29. Please explain why or why not:*

31. Are you aware of any circumstances which might disqualify the applicant for public service?*

    1. Yes

    1. No

33. Please explain why or why not:*

35. Are you aware of any current illegal substance abuse (alcohol and/or drug use) by the applicant? *

    1. Yes

    1. No

37. If yes, please explain:*

39. Have you seen the applicant display bias or prejudice toward any racial, ethnic, or religious groups?*

    1. Yes

    1. No

41. If yes, please explain:*

43. Please give any additional information you may think helpful to our consideration of this person:

45. Please suggest other people who might know or have information about the applicant? (Please include names and phone numbers):

47. Please sign this questionnaire by printing your full legal name in the box below. By signing this questionnaire you are promising that the information you entered is true to the best of your knowledge. *

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field