Law Enforcement Candidate Initial Information
Please fill out everything in this form.
What date and time is your appointment with us?
First name
Last name
Address
Phone Number
Email
What is your current occupation?
What position are you applying for?
What is your sex?
Male
Female
What is your height?
What is your birthdate?
What is your age?
What is your marital status? (Choose all that apply)
Single
Going Steady
Married
Separated
Divorced
Widowed
Education (Last grade completed)
Do you have a college degree?
No
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
PhD, PsyD, EdD etc.
Do you have any other type of training
Rate your health (check)
Very Good
Good
Average
Declining
What is your approximate weight (lbs.)
Have you had weight unusual changes recently?
Lost
Gained
None
List all important present or past illnesses or injures or handicaps:
Approximate date of last medical examination
Was your last medical examination report
Good
Average
Poor
What is your physician's name (If you do not have a physician input "N/A")
What is your physician's address or location? (If you do not have a physician input "N/A")
Are you presently taking any medication? If so, what?
Have you ever used drugs for other than medical purposes? If so, what? (Explain)
Have you ever had a severe emotional upset? If so, for what?
Have you even been arrested? If so, for what?
Have you recently suffered the loss of someone who was close to you? If so, who and when?
How much is religion and/or God a source of strength and comfort to you?
None
1
2
3
4
5
Great Deal
Do you pray?
Yes
No
How often do you pray?
Never
Monthly
Weekly
Daily
Does your faith play an important role in your life?
Yes
No
Do you attend regular religious services?
Never
Monthly
Weekly
More Than Once A Week
Does your religious faith or spirituality influence how you take care of yourself and your health?
Yes
No
Which religion do you practice?
Have you ever had any psychotherapy or counseling before?
Yes
No
If yes, what was the outcome?
It Helped
It did not help
Not Applicable
Check any of the following words which best describe you now.
Active
Ambitious
Self-confident
Persistent
Nervous
Hardworking
Impatient
Impulsive
Moody
Often-blue
Excitable
Imaginative
Calm
Serious
Easy-going
Good-natured
Introvert
Extrovert
Likable
Leader
Quiet
Hard to get to know
Submissive
Lonely
Self-conscious
Sensitive
How many older brothers do you have?
How many older sisters do you have?
How many younger brothers do you have?
How many younger sisters do you have?
Have you ever felt people were watching you?
Yes
No
Do people’s faces ever seem disoriented?
Yes
No
Do you ever have difficulty distinguishing faces?
Yes
No
Are you sometimes unable to judge distance?
Yes
No
Have you ever had hallucinations?
Yes
No
Are you afraid of being in a car?
Yes
No
Is your hearing exceptionally good?
Yes
No
Do you have problems sleeping?
Yes
No
Name of Spouse (if applicable) (if not application input "N/A")
Have you ever been separated from your spouse?
Yes
No
Not applicable
Date of marriage (if not application input "N/A")
How long did you know your spouse before marriage? (if not application input "N/A")
Length of steady dating with spouse ? (if not application input "N/A")
Length of engagement with spouse ? (if not application input "N/A")
How many children from current marriage? (if not application input "N/A")
How many previous marriages? (if not application input "N/A")
How many previous marriages? (if not application input "N/A")
How many children from previous marriage(s)? (if not application input "N/A")
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