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Greene County CriminalJustice Training Academy2960 West Enon RoadXenia, OH 45385Adult Education DepartmentGreene County Career Center(937) 372-6941 ext. 204AUTHORIZATION TO RELEASE INFORMATIONTO WHOM IT MAY CONCERN:I hereby authorize any commissioned agent or representative of the Greene County Criminal JusticeTraining Academy, bearing this release, or a copy thereof, within one (1) year of its date, to obtain anyinformation in your files pertaining to my employment, credit, support obligation records, or educationalrecords including, but not limited to, academic achievement, attendance, personal history, disciplinaryrecords, medical (per HIPPA requirements), fitness reports and military records. I hereby direct you torelease such information upon request to the bearer.This request is executed with full knowledge and understanding that the information is for the official useof the Greene County Criminal Justice Training Academy. Consent is granted for the Greene CountyCriminal Justice Training Academy to furnish such information, as is described above, to third parties inthe course of fulfilling its official responsibilities.I hereby release you, as the custodian of such records, and any government agency, school, college,university, other educational institution, repository of military records, credit bureau, lending institution,consumer reporting agency, police departments or retail business establishment, including its officers,employees or related personnel, both individually and collectively, from any liability for damages ofwhatever kind, which may at any time result to me, my heirs, family or associates because of compliancewith this authorization and request to release information, or any attempt to comply with it. Should therebe any question as to the validity of this release, you may contact me as indicated below.FULL NAME(Signature)DATECURRENT ADDRESSTELEPHONE NUMBERNotary Public In and ForCounty, Ohio My commission expiresWitness DateRevised 02/21/178

Greene County CriminalJustice Training Academy2960 West Enon RoadXenia, OH 45385Adult Education DepartmentGreene County Career Center(937) 372-6941 ext 204MEDIA RELEASEDate:Subject:I do hereby grant and give to Greene County Career Center, its successor and assigns (hereinafter referredto as the school), the right to use, and to permit others to use my name, photograph, testimonial, voiceimage, or likeness on printed material, printed film, film recording, video tape, or other sound and/orvisual device, both single and in conjunction with other persons or objects, for any and all purposesincluding but not limited to, private or public presentations on the radio, television, in theaters,newspapers, outdoor, direct mail, promotional literature, point-of-purchase material, signs, publicity, andpromotion related thereto.I warrant that I have the right to authorize the foregoing uses and to hereby agree to withhold the Schoolharmless of any and all liability of whatever nature which may arise out of or result from such uses.SignaturePrinted NameStreet AddressCity, State, ZipRevised 02/21/179

Greene County CriminalJustice Training Academy2960 West Enon RoadXenia, OH 45385Adult Education DepartmentGreene County Career Center(937) 372-6941 ext. 204DOMESTIC VIOLENCE INFORMATION FORMTitle 18, United States Code, Section 922 (g) (9) makes it illegal for anyone who has been convicted of amisdemeanor crime of Domestic Violence to possess any firearm or ammunition “Misdemeanor Crime ofDomestic Violence” is generally defined as any offense, whether or not explicitly described in a statute asa crime of Domestic Violence, which has, as its factual basis, the use or attempted use of physical force, orthe threatened use of a deadly weapon, committed by the victim’s current or former domestic partner, parentor guardian. The term “convicted” is generally defined in the statute as excluding anyone whose convictionhas been expunged or set aside, or has received a pardon. Any person who has pled guilty or no contest toa lesser charge when the original charge was domestic violence, ORC 2919.25, is not eligible to apply.If you are affected by this statute, you may not possess any firearm or ammunition; therefore, you are noteligible for positions in the uniform forces of the any Police Department. Please answer the following:1.)Have you ever been convicted of a misdemeanor crime of Domestic Violencewithin the meaning of the statute? YESNO2.)If you answered yes to Question 1, provide the following information withRespect to the conviction:Court/Jurisdiction:Docket/Case Number:Statute/Charge:I hereby certify that, to the best of my knowledge and belief, all of the information provided by me is true,correct, complete, and made in good faith. I understand that false or fraudulent information provided hereinmay be grounds for disqualification for the position of Police Recruit with the Greene County CriminalJustice Training Academy.Applicant NamePrint or typeSignature DateWitness DateRevised 02/21/1710

Greene County CriminalJustice Training Academy2960 West Enon RoadXenia, OH 45385TO:Adult Education DepartmentGreene County Career Center(937) 372-6941 ext. 204Child Support Enforcement AgencyRE:Social Security #The above named individual is an applicant for the position of police recruit with the Greene CountyCriminal Justice Training Academy.Would you please verify that this individual is current in his/her alimony and/or child support obligations.If not current, would you please furnish the delinquent amount? A notarized release of information isenclosed.The applicant provided the following information concerning his/her obligations.Obligee:Children:Thank you for your assistance.Sincerely,Michael Hild Sr.Michael Hild Sr.Academy CommanderRevised 02/21/1711

Greene County CriminalJustice Training Academy2960 West Enon RoadXenia, OH 45385TO:Adult Education DepartmentGreene County Career Center(937) 372-6941 ext. 204National Personnel Records Center(Military Personnel Records)9700 Page Blvd.St. Louis Missouri, 63132FROM: Name:Date of Birth:Social Security #:Branch of Service:Dates of Service:The above named individual is an applicant for the position of Police Recruit with the Greene CountyCriminal Justice Training Academy, Xenia, Ohio.Would you please verify the above information and forward his/her complete military history records(excluding medical). The necessary authorization for the release of this information is enclosed.Thank you in advance for your assistance.Sincerely,Michael Hild Sr.Michael Hild Sr.Academy CommanderRevised 02/21/1712

Type or print all informationGREENE COUNTY PEACE OFFICER BASIC TRAININGPERSONAL INVESTIGATION WORKSHEETHOW DID YOU LEARN OF THE CRIMINAL JUSTICE TRAINING ACADEMY? :INSTRUCTIONS: This application is to be filled out in complete detail. Failure toprovide information or give false information could result in yourrejection. If you need to make any corrections, please initial nextto each.YOUR FULL NAME(LAST)(FIRST)(MIDDLE)ANY OTHER NAMES YOU HAVE USEDMAIDEN NAME: NICKNAME:PRESENT ADDRESS:(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)LIST ADDITIONAL ADDRESSES WHERE YOU MAY BE CONTACTED:TELEPHONE NUMBERS: (HOME) (WORK)SOCIAL SECURITY #: BIRTHDATE:BIRTHPLACE:ARE YOU A U.S. CITIZEN: YES NOHAIR COLORHEIGHT WEIGHTEYE COLORSCARS/MARKS/TATTOOES SPECIFY LOCATIONMARITAL STATUS:(MARRIED, SINGLE, SEPERATED, DIVORCED)SPOUSE’S FULL NAME:SPOUSE’S SOCIAL SECURITY #:BIRTHDATE:SPOUSE’S ADDRESS (IF DIFFERENT):(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)SPOUSE’S EMPLOYER:(NAME OF COMPANY)

EMERGENCY CONTACT, NAME AND PHONE NUMBER#1EMERGENCY CONTACT, NAME AND PHONE NUMBER #2CHILDREN’S NAME(S) AND AGES(S):NAMEAGE1.2.3.4.IF PREVIOUSLY MARRIED, LIST FORMER SPOUSE’S NAME & ADDRESSNAME:(LAST)(FIRST)(MIDDLE)ADDRESS:(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)WHEN / WHERE DIVORCED?WHAT METHOD OF PAYMENT WILL YOU BE USING FOR YOUR TUITION?CASHTHREE PAYMENT PLANVISA/MASTERCARDFINANCIAL AID:CHECK IF YOU KNOW WHAT PLAN YOU WILL BE USING OR IF YOU HAVE PREVIOUSLY USED ANYOF THE AT DO YOU SEE YOURSELF DOING ONE YEAR FROM NOW?WHAT DO YOU SEE YOURSELF DOING FIVE YEARS FROM NOW?Revised 02/21/1714

PREVIOUS RESIDENCESLIST IN CHRONOLOGICAL ORDER ALL PREVIOUS ADDRESSES WITHIN THE PAST 5 YEARS.DATES (FROM MONTH/YEAR TO MONTH/YEAR)ADDRESS:(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)OWNED OR RENTED?MORTGAGE HOLDER OR LANDLORD ?DATES (FROM MONTH/YEAR TO MONTH/YEAR)ADDRESS:(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)OWNED OR RENTEDMORTGAGE HOLDER OR LANDLORD ?DATES (FROM MONTH/YEAR TO MONTH/YEAR)ADDRESS:(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)OWNED OR RENTED?MORTGAGE HOLDER OR LANDLORD ?DATES (FROM MONTH/YEAR TO MONTH/YEAR)ADDRESS:(STREET AND APT. #)(CITY)(STATE)(ZIP CODE)OWNED OR RENTED?MORTGAGE HOLDER OR LANDLORD ?

RELATIVESPARENTS’ NAMES AND ADDRESSES:MOTHER’S P CODE)FATHER’S P CODE)TELPPHONE NUMBERS:(MOTHER)(FATHER)DO YOU HAVE ANY RELATIVES CURRENTLY WORKING IN OR RETIRED FROMLAW ENFORCEMENT ?IF SO, PLEASE LIST THEIR NAME AND DEPARTMENT/AGENCY:Revised 02/21/1716

PLEASE LIST SIX REFERENCES INCLUDING NAME, ADDRESS AND TELEPHONE NUMBER:THREE PERSONAL REFERENCES (NOT RELATIVES)THREE PROFESSIONAL REFERENCESPHYSICAL AND PSYCHOLOGICALDO YOU HAVE ANY PHYSICAL OR PSYCHOLOGICAL LIMITATIONS OR INJURIES (RECENT OR OLD)THAT MIGHT RESTRICT YOUR FULL PARTICIPATION IN THE ACADEMY? Yes NoARE YOU DISABLED IN ANYWAY?HAVE YOU EVER RECEIVED MENTAL HEALTH TREATMENT? Yes NoIF YES, PLEASE EXPLAIN:DO YOU SUFFER FROM POST TRAUMATCI STRESS DISORDER (PTSD)?Revised 02/21/1717

EDUCATIONIF YOU PROGRESS TO THE NEXT STEP OF THE HIRING PROCESS, COPIES OF YOUR HIGH SCHOOLTRANSCRIPTS OR GED CERTIFICATE AND COLLEGE TRANSCRIPTS WILL BE REQUIRED.LAST HIGH SCHOOL ATTENDED:ADDRESS:(STREET)(CITY)(ZIP CODE)DATE OF GRADUATION (MONTH/YEAR):IF YOU DID NOT GRADUATE AND OBTAINED A GED PLEASE FURNISH THE FOLLOWINGINFORMATION:DATE RECEIVED: STATE RECEIVED:COLLEGES ATTENDED:NAME:ADDRESS:(CITY)(STATE)DATES ENROLLED:GRADE POINT AVERAGE: CREDIT HOURS EARNED:MAJOR: DEGREE:DATE OF GRADUATION (MONTH/YEAR):NAME:ADDRESS:(CITY)(STATE)DATES ENROLLED:GRADE POINT AVERAGE: CREDIT HOURS EARNED:MAJOR: DEGREE:DATE OF GRADUATION (MONTH/YEAR):LIST ANY ADDITIONAL POST HIGH SCHOOL TRAINING:Revised 02/21/1718

EMPLOYMENTLIST CHRONOLOGICALLY ALL EMPLOYMENT FOR THE PAST 5 YEARS INCLUDING PART-TIME ANDTEMPORARY EMPLOYMENT. ALL TIME MUST BE ACCOUNTED FOR. IF UNEMPLOYED, LIST DATES.ALL ADDRESSES MUST BE COMPLETE, INCLUDING ZIP CODES. PLEASE LIST PRESENT TATE)(ZIP CODE)DATES OF EMPLOYMENT:TYPE OF WORK: SUPERVISOR:REASON FOR ZIP CODE)DATES OF EMPLOYMENT:TYPE OF WORK: SUPERVISOR:REASON FOR ZIP CODE)DATES OF EMPLOYMENT:TYPE OF WORK: SUPERVISOR:REASON FOR LEAVING:Revised 02/21/1719

EMPLOYER:ADDRESS:(#)(STREET)(CITY)(STATE)(ZIP CODE)DATES OF EMPLOYMENT:TYPE OF WORK: SUPERVISOR:REASON FOR ZIP CODE)DATES OF EMPLOYMENT:TYPE OF WORK: SUPERVISOR:REASON FOR LEAVING:HAVE YOU APPLIED FOR EMPLOYMENT WITH A POLICE DEPARTMENT?IF YES, LIST NAME OF DEPARTMENT AND DATE OF APPLICATION:DEPARTMENTDATE OF APPLICATIONHAVE YOU EVER BEEN DENIED EMPLOYEMENT ANYWHERE ?FROM WHERE ?PLEASE EXPLAIN:Revised 02/21/1720

MILITARY (ACTIVE DUTY ONLY)BRANCH: DATES OF ACTIVE SERVICE:LAST DUTY STATION:(NAME)(CITY)(STATE)SERIAL #: HIGHEST RANK ATTAINED:DISCIPLINARY ACTION / TYPE:IF YOU ARE A FORMER OR CURRENT MEMBER OF THE RESERVES OR NATIONAL GUARD PLEASEANSWER THE FOLLOWING:BRANCH: HIGHEST RANK ATTAINED:PRESENT DUTY STATION:DATES OF SERVICE:ARE YOU REGISTERED WITH SELECTIVE SERVICE ?IF YOU ARE A MILITARY VETERAN AND PROGRESS TO THE NEXT STEP IN THE HIRING PROCESS, ACOPY OF YOUR DD214 WILL BE REQUIRED. ALSO, PERSONS REQUIRED TO BE REGISTERED WITHSELECTIVE SERVICE WILL BE REQUIRED TO FURNISH PROOF OF REGISTRATION.Revised 02/21/1721

FINANCIAL HISTORY STATEMENTS1.HAVE YOU EVER HAD YOUR WAGES ATTACHED OR GARNISHED?2.3.HAVE YOU EVER BEEN A DEFENDANT IN SMALL CLAIMS OR OTHERCIVIL ACTION?DO YOU HAVE ANY CIVIL ACTION PENDING AGAINST YOU?4.HAVE YOU EVER HAD A JUDGEMENT RENDERED AGAINST YOU?5.HAVE YOU EVER BEEN REFUSED AN INSURANCE POLICY?6.HAVE YOU EVER HAD AN INSURANCE POLICY CANCELLED?7.HAVE YOU EVER BEEN REFUSED CREDIT?8.HAVE YOU EVER HAD ANY PROPERTY REPOSSESSED?9.DO YOU CURRENTLY HAVE ANY ACCOUNTS UP FOR COLLECTION?10.IF YOU ARE OBLIGATED TO PAY CHILD SUPPORT AND/OR ALIMONY,ARE YOU CURRENT IN YOUR PAYMENT?YESNOIF YOU ANSWERED YES TO ANY OF THE PREVIOUS QUESTIONS (1-10) OR NO TO #10 PLEASE EXPLAINBELOW:Revised 02/21/1722

TRAFFIC RECORDINCLUDE A LEGIBLE COPY OF YOUR DRIVER’S LICENSEDRIVERS LICENSE # STATE ISSUEDLIST ALL TRAFFIC VIOLATIONS (EXCEPT PARKING TICKETS) FOR WHICH YOU HAVE BEENCONVICTED IN THE PAST 10 YEARS:DATEPOLICE AGENCYCHARGECOURT OFDISPOSITIONHAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED?IF YES, PLEASE EXPLAIN:DO YOU OWN AN AUTOMOBILE, OR HAVE ONE AT YOUR DISPOSAL?IF YES, PLEASE ANSWER THE FOLLOWNG QUESTIONS:YEAR MAKE MODELINSURANCE COMPANY/AGENTTYPE OF COVERAGE HIGH RISK?CRIMINAL RECORDHAVE YOU EVER BEEN ARRESTED? DATE OF ARRESTREASON FOR ARREST?LIST ALL CRIMINAL VIOLATIONS FOR WHICH YOU HAVE BEEN CONVICTED OR ADJUDICATED:DATERevised 02/21/17POLICE AGENCYCHARGECOURT OFDISPOSITION23

DRUG HISTORYEXAMINE THE FOLLOWING LIST OF DRUGS AND SUBSTANCES TO DETERMINE YOUR ILLEGALUSAGE, IF ANY, IN EACH PARTICULAR CATEGORY. PLEASE CHECK APPROPRIATE RESPONSE TOEACH QUESTION:Drug TypeHALLUCINOGENIC DRUGSMARIJUANAHASHISH/HASH NE (ALL FORMS)AMPHET AMINESDEPRESSANTSBARBITURATESTRANQUILIZERSOTHER NARCOTIC IDDEMEROLHARMFUL INTOXICANTSORGANIC SOLVENTS(THINNER, CLEANING FLUID,GASOLINE, PLASTIC CEMENT,ETC.)ANY AEROSOL PROPELLANTANY FLUOROCARBONREFRIDGERANTANY ANESTHETIC GASOTHER SUBSTANCES NOT PREVIOUSLY SPECIFIED[TYPE(S)]Revised 02/21/1724

PLEASE ANSWER THE FOLLOWING QUESTIONS CONCERNING YOUR ILLEGAL DRUG ACTIVITIES. IFYOU HAVE NEVER USED DRUGS ILLEGALLY, GO DIRECTLY TO QUESTION #11. (IF A QUESTIONDOES NOT APPLY, INSERT DNA):1. AT WHAT AGE DID YOU FIRST USE DRUGS/TYPE(S)?2. DATE (MONTH/YEAR) YOU LAST USED DRUGS/TYPE(S)?3. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER PURCHASED/TYPE(S)?4. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER SOLD/TYPE(S)?5. WHAT IS THE LARGEST AMOUNT OF DRUGS YOU HAVE EVER TRANSPORTED/TYPE(S)? WHEN?6. HAVE YOU EVER CULTIVATED MARIJUANA?AMOUNT? WHEN?7. HAVE YOU EVER ILLEGALLY OBTAINED ANY PRESCRIPTION DRUG AND IF SO,LIST TYPE AND HOW OBTAINED?8. HOW MANY CLOSE FRIENDS DO YOU KNOW WHO USE DRUGS AND WHATTYPES OF DRUGS DO THEY USE?9. HOW MANY TIMES HAVE YOU GIVEN OTHERS MONEY TO BUY DRUGS?WHAT TYPE(S)?Revised 02/21/1725

10. EXTENT OF ILLEGAL DRUG USAGE (List specific drug at the bottom of this page):Drug CategoryMorethan 50times20 to50times10 to 20times2 to 10timesOnetimeHALLUCINOGENIC DRUGSSTIMULANTSDEPRESSANTSOTHER NARCOTIC SUBSTANCESHARMFUL INTOXICANTS11. DO YOU CONSUME ALCOHOLIC BEVERAGES?12. IF YOU ANSWERED YES TO #11, WHAT IS YOUR CONSUMPTION?:PER WEEK TYPE(S)?13. HAVE YOU EVER SUCCESSFULLY COMPLETED A SUPERVISED DRUG AND/ORALCOHOL REHABILITATION PROGRAM? (IF YES, YOU WILL BE REQUIRED TOFURNISH PROOF OF SUCCESSFUL COMPLETION UPON REQUEST)14. IF YOU ANSWERED YES TO #13, HAVE YOU REMAINED ALCOHOL AND/OR DRUGFREE SINCE THE COMPLETION DATE OF YOUR PROGRAM:IF NO, PLEASE EXPLAIN:IF NECESSARY, USE THE FOLLOWING SPACE TO EXPLAIN OR ADD TO YOUR ANSWERS. MAKEREFERENCE TO THE PARTICULAR PAGE NUMBER, SECTION, AND QUESTION:Revised 02/21/1726

CERTIFICATIONI CERTIFY THAT THE STATEMENTS HEREIN CONTAINED ARE TRUE TO THE BEST OF MYKNOWLEDGE AND UNDERSTAND THAT ANY FALSE STATEMENTS OR OMISSIONS OF INFORMATIONMADE IN THIS APPLICATION MAY BE CAUSE FOR DISAPPROVAL OF MY APPOINTMENT OR FORDISCHARGE AFTER APPOINTMENT.(SIGNATURE)(DATE), appeared before me on theday ofyear.(NOTARY)Notary Public in and forRevised 02/21/17County, Ohio. My commission expires27

Greene County Criminal Justice Training Academy c/o Greene County Career Center Adult Education Building 2960 West Enon Road Xenia, Ohio 45385-9545 Applicants will receive a letter indicating the location, date and time they will need to be available for the Physical Assessment entry examination and oral interview. .