–– INSTRUCTIONS –– Answer Each Item Completely

8/14/2019 INSTRUCTIONS Answer Each Item Completely

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Last First Middle

7. Are you a resident fo Warren County? Yes________ No________ (Indicate County of Residency) __________________________

8. Sex: Male________ Female______

9. National Origin: United States________ Non-United States (Please Specify) ___________________________________________

_______________________________________________________________________Date________________________________

12. Please indicate your source of information concerning this job:

Newspaper Ad_____ State Job Service_____ NAACP/Human Rights_____ City Personnel Office_____ City Employee_________

Internet________ Other (Please Specify)_______________________________________________________________________

13. Position(s) for which you are applying?_________________________________________________________________________

Applicant: Please Read These Instructions Before Answering Any Questions On This Card.

This information is requested by the City of Bowling Green in an effort to accumulate information necessary to evaluate the

Citys recruitment program as required by the Equal Employment Opportunity Act of 1972, Section 709, paragraph C. Since

Federal, State and local law prohibits discrimination in employment practices because of sex, age, race, color, religion, or

national origin, THIS INFORMATION WILL NOT BE USED TO DETERMINE EMPLOYMENT.

1. Full Name________________________________________________________________________________________________

10. Race: White________ Black________ Hispanic________ Asian________ American Indian________ Other__________________

11. Are you a veteran? Yes________ No________

2. Social Security Number________________________________________ 3. Date of Birth _________________________________

4. Present Address ___________________________________________________________________________________________

__________________________________________________________________________________________________________

5. Permanent Address (if different from present address) _____________________________________________________________

__________________________________________________________________________________________________________

6. Are you a resident of Kentucky? Yes_ No_ (Indicate State of Residency)_______________________________________________


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PUBLIC SAFETY EMPLOYMENT APPLICATION SUPPLEMENT

YOUR APPLICATION IS NOT COMPLETE WITHOUTSIGNATURES ON THE FRONT & BACK OF THIS FORM

APPLICANT'S NAME:_________________________ _____________________ __________(Please Print) LAST FIRST MIDDLE

DRIVER'S LICENSE NUMBER __________________________ STATE ________________

PHYSICAL AGILITY TEST LIABILITY RELEASE

PLEASE READ AND SIGN THE FOLLOWING:

This certifies that I have read the description of the physical agility/practical skills test requirements (provided inapplication packet) for the position(s) for which I have applied. I hereby release the City of Bowling Green fromany and all liability and/or injuries that might result from my participation in the described physical agility/skillstest(s) conducted by the City.

Date: ____________________ Signature: ______________________________________

PLEASE MAKE SURE TO SIGN THIS SECTION AS WELL AS THAT ON THE BACK.

TESTDATE-- All Times are Central Time

Police Applicants: Saturday, February 13 has been scheduled for testing, beginning at 8:00 A.M. Note that

if you successfully complete testing, non-Kentucky certified officers will have to return either February 25 or26 (overflow day) to complete State fitness and psychological testing. This will be scheduled when you test onFebruary 13.

_____ CERTIFICATION: If currently a certified police officer, check here and make sure to enclose a copy ofyour certification with your application. If not currently employed as a police officer, enclose documentationof your most recent in-service training. REQUIRED TO BE EXEMPT FROM WRITTEN TEST.

ADA: Notify Human Resources Director by application deadline if any accommodations are needed for eitherthe written or fitness test due to qualifying disability, and specify the necessary accommodation(s).

ON THE BACK: PLEASE READ AND COMPLETE THE "AUTHORITY FOR RELEASE OFINFORMATION". The background investigation cannot be completed without this authorization.

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City of Bowling Green, Kentucky

PERSONAL INQUIRY WAIVERAUTHORIZATION FOR RELEASE OF INFORMATION

I authorize a review of and full disclosure of all records concerning myself to any duly authorized agent of theCity of Bowling Green, Kentucky, or to any authorized agent of a criminal justice agency or any private agencyupon request of the City of Bowling Green, whether the records are of a public, private, or confidential nature. Iauthorize copies of these records to be given to the City of Bowling Green or its agents.

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, records of commercial orretail credit agencies, including credit reports and/or ratings, and other financial statements and recordswherever filed; medical and psychiatric treatment and/or consultation, including hospitals, clinics, privatepractitioners, and the U.S. Veterans Administration; and employment and pre-employment records, includingbackground reports, performance evaluations, complaints or grievances filed by or against me and the recordsand recollections of Attorneys at Law, or other counsel, whether representing me or another person in anycase, either criminal or civil, in which I presently have an interest.

I understand that any information obtained by a personal history background investigation, which is developeddirectly or indirectly, in whole or in part, upon this release authorization, will be considered only in determiningmy suitability for employment by the City of Bowling Green. I also certify that any person or organization whomay furnish such information concerning me shall not be held accountable for giving truthful information, and Irelease the person and organization from any and all liability which may be incurred as a result of furnishingsuch information.

A photocopy of this release form will be valid as an original even though the photocopy does not contain anoriginal writing of my signature.

Please Print

Applicants Name: _____________________________________________________________

Address: ____________________________________________________________________

City: _________________________________ State: ________ Zip: __________________

Date of Birth: __________________ Social Security Number: _________________________

Applicants Signature: ____________________________________ Date: _______________

Witness Name (Print): _________________________________________________________

Witness Signature: ____________________________________________________________

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KENTUCKY LAW ENFORCEMENT COUNCIL

FORM T - 1 MEDICAL RELEASE - PHASE I TESTING

FORM T - 1 a PHYSICIANS MEDICAL RELEASE FORM

All candidates who are not presently Kentucky Certified police officers must complete andsubmit Form T-1 with their application. Make sure to sign this form.

If you answer yes to any of questions 1 through 11, you must also have Form T-1acompleted by a physician licensed to practice in Kentucky.

(If out of state, have a licensed physician sign the form, and indicate licensing state).

These forms must be completed and submitted in order to be scheduled for the Kentucky LawEnforcement Physical Fitness Testing described in this packet.

Your application is not complete if these forms are not completed and signed.

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–– INSTRUCTIONS –– Answer Each Item Completely

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