Full Time Police Officer in Buxton

Police Employment Application
Please Print Clearly



Applicants are considered for all positions without regard to race or color, sex, sexual orientation, physical or mental disability, religion, age, ancestry, or national origin.
Applicants must have the right to work in the United States, have a high school diploma or equivalent, a valid driver’s license, and be in good physical and mental condition. Preferences will be given to post-secondary education, law enforcement experience and/or military experience.
Applicants for full time officer positions will be required to pass a written exam (Alert Exam), a physical fitness test, an oral interview, personal background check, a polygraph exam, general physical and psychological exams, and an interview with the Chief of Police.
Applicants for full time officer positions must submit a copy of their successfully completed MCJA Alert Exam results and a copy of their successfully completed physical fitness test (PFT) administered by the MCJA. In order to accept the application, the PFT must have been completed within the year prior to the application. The PFT may be required to be updated prior to hiring. It will be the responsibility of the applicant to submit updated results.
Applicants must submit a completed application form. Please attach a cover letter and resume. Failure to complete all sections and sign the certification will result in delay or non-consideration of your application. Please attach additional pages if more space is necessary to fully answer a question.
Completed applications must be mailed or delivered to the Buxton Police Department at 185 Portland Rd, Buxton, Maine 04093, attention to the Chief of Police.





A. GENERAL INFORMATION

1. Name: _______________________________________________________________
Physical Address: _______________________________________________________________
City/State/ZIP: _______________________________________________________________
Mailing Address: _______________________________________________________________
Telephone home: __________________________________________________________
cell: __________________________________________________________
work: __________________________________________________________
E-mail: _______________________________________________________________
Social Security #: _______________________________________________________________
2. Other names by which you have been known (e.g. nickname, maiden name):
_____________________________________________________________________________________
3. The Town of Buxton Police Department requires all patrol officers to attend the Maine Criminal Justice Academy, Pursuant to 25 M.R.S.A. § 2804-G, an applicant to the Maine Criminal Justice Academy must be 21 years of age or older to qualify for a position as a law enforcement officer unless the applicant has an associate’s degree or 60 credit hours of post-secondary education, in which case the applicant must be at least 20 years of age. Do you meet this requirement?  Yes  No

4. Have you submitted an application to the Town of Buxton Police Department in the past?  Yes  No
If yes, explain:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

5. List all law enforcement agencies to which you have applied in the past or are applying currently:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

B. EMPLOYMENT HISTORY

6. Beginning with your present (or most recent) employment, list all jobs that you have held in the past ten (10) years, including part-time, temporary, seasonal and self-employment.
(This following page may be copied, if necessary)

From: ____________ To: _____________ Full Time  Part Time 
Employer: ________________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip:_____________________________________________________________________
Telephone #: _________________________ Job Title: ____________________________________
Average hours per week: ________________ Weekly Pay: _________________________________
Supervisor: ___________________________ Coworker: ___________________________________
Reason for leaving: _________________________________________________________________
May we contact this employer?  Yes  No

From: ____________ To: _____________ Full Time  Part Time 
Employer: ________________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip:_____________________________________________________________________
Telephone #: _________________________ Job Title: ____________________________________
Average hours per week: ________________ Weekly Pay: _________________________________
Supervisor: ___________________________ Coworker: ___________________________________
Reason for leaving: _________________________________________________________________
May we contact this employer?  Yes  No

From: ____________ To: _____________ Full Time  Part Time 
Employer: ________________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip:_____________________________________________________________________
Telephone #: _________________________ Job Title: ____________________________________
Average hours per week: ________________ Weekly Pay: _________________________________
Supervisor: ___________________________ Coworker: ___________________________________
Reason for leaving: _________________________________________________________________
May we contact this employer?  Yes  No

From: ____________ To: _____________ Full Time  Part Time 
Employer: ________________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip:_____________________________________________________________________
Telephone #: _________________________ Job Title: ____________________________________
Average hours per week: ________________ Weekly Pay: _________________________________
Supervisor: ___________________________ Coworker: ___________________________________
Reason for leaving: _________________________________________________________________
May we contact this employer?  Yes  No

From: ____________ To: _____________ Full Time  Part Time 
Employer: ________________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip:_____________________________________________________________________
Telephone #: _________________________ Job Title: ____________________________________
Average hours per week: ________________ Weekly Pay: _________________________________
Supervisor: ___________________________ Coworker: ___________________________________
Reason for leaving: _________________________________________________________________
May we contact this employer?  Yes  No

C. EDUCATION

9. Name of high school:
Did you Graduate from high school?  Yes  No
If not, have you passed a GED exam?  Yes  No
Highest grade of high school completed: 09, 10, 11, and 12
10. Advanced degrees:
List any schools attended, starting with the most current, stating the number of years completed, and degree earned, if any:
School # Years Degree




11. Have you ever been subject to any disciplinary action, such as scholastic probation, suspension, or expulsion during your scholastic career?  Yes  No
If yes, explain:
__________________________________________________________________________________________________________________________________________________________________________
12. List any extracurricular activity that you think helped prepare you to become an officer or gave you skills that will be useful:
__________________________________________________________________________________________________________________________________________________________________________
D. SPECIAL SKILLS / QUALIFICATIONS
13. List any special license you hold (e.g. pilot, radio operator, SCUBA, etc.) including licensing authority, date of issue and date of expiration:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
14. If you are fluent in a foreign language (or sign language), indicate the language and degree of fluency (Excellent, good, or fair).
Language Reading Speaking Comprehension Writing



15. List any other special skills, work experience, training, or qualifications you possess that you think will be beneficial:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. CRIMINAL BACKGROUND / MOTOR VEHICLE HISTORY
16. Have you ever been convicted or plead “guilty” or “no contest” to a crime?  Yes  No
If yes, explain below:
Crime Police Agency / State Date




Further details: ________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
17. Have you ever committed an illegal act or done anything that would have been considered unlawful if caught?  Yes  No
If yes, explain: _________________________________________________________________________
_____________________________________________________________________________________
18. Have you ever failed a police background investigation in the past?  Yes  No
If yes, when? __________________________________________________________________________
To whom did you apply? _________________________________________________________________


19. Has your driver’s license ever been suspended or revoked (in any state)?  Yes  No
If yes, explain: ________________________________________________________________________
____________________________________________________________________________________
20. List any court action to which you have been a party, including divorce: ______________________
____________________________________________________________________________________
____________________________________________________________________________________
21. List all states in which you have resided or held a driver’s license. ____________________________
____________________________________________________________________________________

F. PERSONAL DATA
22. Are you eligible to be lawfully employed in the United States?  Yes  No
• Proof of citizenship or immigration status will be required upon employment.
23. List all individuals with whom you have resided during the past five (5) years, excluding family members: ____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
24. List any family members presently employed by the Town of Buxton in any capacity (including spouse, parents, children, siblings, uncles, aunts, nephews, nieces, and any of the same related as in-laws, step-relations, or half-relations):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
25. In what activities do you participate to keep yourself in good physical condition?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

26. List any activities in which you regularly volunteer:
_________________________________________________________________________________
_________________________________________________________________________________
27. Have you ever applies to carry a concealed weapon?  Yes  No
If yes, when? ____________________________ Where? __________________________________

28. List any organization in which you have been a member, excluding memberships that would reveal your race or color, sex, sexual orientation, physical or mental disability, religion, age, ancestry, national origin, or other protected status.
Name & Address Type (Social, fraternal, Professional etc.) From To





29. This job requires that a person: (A) Stand for long periods of time, climb, balance, stoop, kneel, crawl, crouch etc.; (B) frequently lift or move objects up to 50lbs, and occasionally move objects up to 165lbs; (C) adjust vision. Focus in the use of firearms and the operation of motor vehicles; and (D) communicate effectively. Work may occur (A) during all weather conditions, including temperature extremes and wet environments; (B) during day and night; (C) under emergency, stressful, and dangerous situations; and (D) with possible exposure to loud noises, such as alarms and gunfire, smoke, noxious odors, fumes, chemicals, etc.
Do you have the full physical, mental, emotional, and medical ability to do this job, whether with or without a reasonable accommodation?  Yes  No
30. State any additional information that you would like us to consider:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


G. REFERENCES
31. List any five (5) personal references who know you well enough to provide current information about you, excluding relative and former employers:
_____________________________________________________________________________________
Personal Reference 1
Relationship: _________________________________________________________________________
Years known: _________________________________________________________________________
Name: _______________________________________________________________________________
Street Address: ________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________

Personal Reference 2
Relationship: _________________________________________________________________________
Years known: _________________________________________________________________________
Name: _______________________________________________________________________________
Street Address: ________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________


Personal Reference 3
Relationship: _________________________________________________________________________
Years known: _________________________________________________________________________
Name: _______________________________________________________________________________
Street Address: ________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________
Personal Reference 4
Relationship: _________________________________________________________________________
Years known: _________________________________________________________________________
Name: _______________________________________________________________________________
Street Address: ________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________
Personal Reference 5
Relationship: _________________________________________________________________________
Years known: _________________________________________________________________________
Name: _______________________________________________________________________________
Street Address: ________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
32. List five (5) work references that are qualified to describe your abilities, character and fitness for the job of police officer:

_____________________________________________________________________________________
Work Reference 1
Name: _______________________________________________________________________________
Employer: ____________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________
Work Reference 2
Name: _______________________________________________________________________________
Employer: ____________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________
Work Reference 3
Name: _______________________________________________________________________________
Employer: ____________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________


_____________________________________________________________________________________
Work Reference 4
Name: _______________________________________________________________________________
Employer: ____________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________
Work Reference 5
Name: _______________________________________________________________________________
Employer: ____________________________________________________________________________
Business Address:______________________________________________________________________
City/State/ Zip: ________________________________________________________________________
Telephone: home:___________________________ work: ______________________________________
_____________________________________________________________________________________
33. Have you ever passed an Alert Test from MCJA?  Yes  No
If yes, date taken: _____________________________________
34. Have you ever passed the Physical Fitness Test from MCJA?  Yes  No
If yes, date taken: _____________________________________
35. Have you completed the Law Enforcement Pre-Service Course (LEPS)?  Yes  No
If yes, date taken: _____________________________________
36. Are you a MCJA graduate?  Yes  No
If yes, date of graduation: _______________________________

Please attach certificates.


H. CERTIFICATION

37. Applicants must read and sign below prior to submitting this application.

I certify that the information in this application, supplement and all attachments is true and complete. I understand and agree that false statements, misrepresentations, or omissions of information in this application and any supplements and attachments may result in rejection of this application, removal from an eligibility list, or, if hired, dismissal.
The Buxton Police Department is expressly authorized to investigate all statements contained in this application, supplement, or attachments. I consent to the release of information about my ability and fitness for employment by current and previous employers, schools, law enforcement agencies, and other individuals and organizations to investigators, recruiters, and other authorized employees of the Buxton Police Department. Further, I authorize the Buxton Police Department to conduct an investigation into my background, which may include, but is not limited to, a consumer report, social security number verification and credit check; criminal background check; sex offender registry check and driving records check, if applicable. I understand and agree that this background investigation also may include written evaluations, oral boards, or polygraph, and upon a conditional offer of employment, psychological examination, medical examination, drug screen, agility or skill evaluation and other appropriate investigations. I understand and agree I may be disqualified from further consideration should I fail any of the testing or background processes. I hereby release, hold harmless, and indemnify you. Your organization, including officers, agents, and employees, both individually and collectively, and all others from liability or damages of any kind, including all costs and attorney fees incurred for the furnishing of the information described above.

Name: ________________________________ DOB: _____________________ SS#: ________________
Address: ______________________________ City: ______________________ State: _______________
Telephone: _________________________________ Work: ____________________________________
Signature: __________________________________ Date: _____________________________________



Notarized by: _______________________________ Date: _____________________________________





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