City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
REQUIRED DOCUMENTS
INSTRUCTIONS: Please note that all the items covered on this list are your responsibility to
obtain and should be submitted with your background paperwork as indicated. Some of these
documents may take sometime to receive, please begin working on them at once!
Documents to be returned one week after initial background meeting:
□
Personal History Statement (PHS), this document can be downloaded from online at:
www.post.ca.gov
□
Pre-investigative questionnaire, this document can be downloaded from online at:
https://www.hemetca.gov/DocumentCenter/View/6206/Pre-Investigative-Questionnaire
□
Applicant Autobiography.
Documents to be submitted online to background investigator upon request:
□
1. A LEGIBLE copy of your birth certificate (available from the Registrar of Vital Statistics
in the County of your birth, or the State Department of Health).
□
2. If born outside the United States, a copy of your Certificate of Naturalization or proof of
application and eligibility for citizenship.
□
3. Official high school transcripts, whether or not you graduated. (Available from your
school records officer or school district office)
□
4. Official college transcripts (if any) from EACH college and university you have
attended, whether or not you graduated.
□
5. Copy of your high school diploma, G.E.D. Certificate or High School Proficiency.
□
6. Copy of any college diplomas you have earned.
□
7. Copy of any law enforcement training certificates you have received.
□
8. Proof of current automobile insurance. Must reflect effective dates and your name as
insured.
□
9. Written proof of Selective Service registration (if male and born any time other tha
March 30, 1957 through December 31, 1959. You can contact Selective Service by
calling 1-847-688-6888 or on the Internet at
www.sss.gov).
City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
REQUIRED DOCUMENTS - Continued
□
10. A copy of your DD214 if you were in the military, along with any awards, training
certificates or decorations you received.
□
11. A copy of your current CALIFORNIA driver’s license.
□
12. DMV Report- 36 month original driving report.
□
13. A copy of any police reports in which you were arrested. Note: if you are not applying
for a peace officer position, you need furnish only copies of arrest reports which
resulted in a conviction.
□
14. If you have been married, a copy of your County-issued Marriage Certificate for each
marriage (available from the County Registrar).
□
15. For any marriages dissolved, a copy of the final Dissolution/Annulment order for
each
marriage dissolved.
□
16. A true copy of each police accident report taken within the past three (3) years in which
you were named as a DRIVER.
□
17. A copy of any civil judgment against you within the past seven (7) years.
□
18. An official, current credit profile (no more than 30 days old).
□
19. A copy of your signed Social Security Card.
□
20. Copies of any other certificates, awards, evaluations, recognitions, etc. you would like
considered.
□
21. Contact information for three direct neighbors (Typed List: Name, Last name, phone #)
Acknowledgment
I understand that it is my responsibility to arrange for all of the documents above which
apply to me. Failure to provide these documents as specified will result in my application
being disqualified from further consideration for this position.
Signature of Applicant
ADMONISHMENTS
Personal History Statement
There are very few automatic bases for rejection. Even issues of prior misconduct, such as prior illegal
drug use, driving under the influence, theft, or even arrest or conviction are usually not, in and of
themselves, automatically disqualifying. However deliberate misstatements or omissions can and often
will result in your application being rejected, regardless of the nature or reason for the
misstatements/omissions. In fact, the number one reason individuals "fail" background investigations is
because they deliberately withhold or misrepresent job-relevant information from their prospective
employer.
BOTTOM LINE: You are responsible for providing complete, accurate, and truthful responses.
I hereby certify that I have personally completed the Personal History Statement (PHS) and that all
statements made are true and complete to the best of my knowledge and belief. I understand that any
misstatement of material fact may subject me to disqualification; or, if I have been appointed, may
disqualify me from continued employment.
Have you read and do you understand the above PHS admonishment? Yes No
Date
Signature
Printed Name
Pre-Investigative Questionnaire
I understand that as an applicant for this position, I am required to complete a Pre-Investigative
Questionnaire (PIQ). I am aware that any false statements or omissions made on the questionnaire will
cause my name to be removed from the eligibility list or be cause for non-selection. I understand that I am
subject to termination if discrepancies are discovered after I have been appointed. Additionally, I
understand that I am to immediately notify my background investigator or prospective employer of any
changes in information related to my prospective employment. Failure to make notification of these
changes could also be grounds for disqualification and / or non-selection. I also acknowledge that any
records obtained during my background investigation are confidential and will be the property of my
prospective employer.
Have you read and do you understand the above PIQ admonishment? Yes No
Do you have any questions about this admonishment? Yes No
Date
Signature
Printed Name
PRE-INVESTIGATIVE QUESTIONNAIRE
CRIMINAL & ARREST INFORMATION
Read and answer the following questions carefully and honestly. If you respond with a “Yes” to any question, you are
required to provide further details on the attached explanation form(s), except for questions marked with an asterisk (*).
Your responses are subject to additional inquiry by an Investigator and verification by a Polygraph Examination.
1. What is your true first name?
2. What is your true last name?
3. Do these names appear on your birth certificate?
4. What is your true date of birth? (MM/DD/YYYY)
.
Have you ever committed any of the following acts?
5.
Arson (Intentionally set a fire)
6.
Burglary (entry of a structure or vehicle to commit theft or other crime)
7.
Robbery (theft from another person utilizing a weapon or force)
8.
Homicide
9.
Theft
10.
Forgery
11.
Kidnapping
12.
Extortion (Blackmail)
13.
Embezzlement (theft of money or other valuables entrusted to you)
14.
Rape (sexual intercourse by force)
Page 1 of 14
Yes No
No
____________________________________________
Yes
PRE-INVESTIGATIVE QUESTIONNAIRE
15.
Child Abuse
16.
Child molestation (any sex act with a child)
17.
Bestiality (any sex act with an animal)
18.
Prostitution (intercourse for money or other considerations)
19.
Soliciting Prostitution (asking for sex in return for money or vice versa)
20.
Soliciting a lewd act in a public place
21.
Pimping (deriving support from a prostitute)
22.
Pandering (encouraging another to be a prostitute)
Provide additional explanation to the following questions (as needed) on the attached explanation form(s).
23.
Have you ever been arrested for an illegal act?
24.
Have you ever had sex with a member of your family (excluding spouse)?
25.
Have you in the past or do you now regularly associate with persons whom you know to have
engaged in and/or been arrested for unlawful sexual activity?
26.
Have you committed any forcible sex act (sodomy, oral copulation, etc.)?
27.
Have you ever committed any violent assault upon another?
28.
Have you ever committed assault upon your spouse, ex-spouse or someone you had a relationship
with?
29.
Have you ever been asked to submit to a polygraph examination?
30.
Has the fact that you want this job caused any conflict with your family?
Page 2 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
31.
Have you ever failed to pass a polygraph examination?
32.
Have you placed any false information on your employment application or personal history
background forms?
33.
Have you deliberately omitted any information on your employment application or personal history
background forms?
34.
When you left high school, did you receive a graduation diploma?
35.
When you left high school, did you receive a GED?
36.
Have you passed the high school equivalency examination?
37.
Would you have any reason to be concerned about an investigation into your past work records?
38.
Were you ever fired from a job?
39.
Were you ever asked to resign from a job?
40.
Did you ever leave a job to avoid being fired?
41.
Have you shown the true and complete reasons for leaving each of your previous jobs?
42.
Did you ever leave any job with hard feelings toward the management or co-workers?
43.
Do you think you could return to work for all of your former employers? If not, explain.
44.
In the past year, how many times have you been late for work?
45.
In the past year, how many days of work have you missed for reasons other than illness?
46.
Have you ever worked for any other law enforcement agency in any capacity?
47.
Have you ever applied at any other law enforcement agency for any type of job?
48.
Have you ever been turned down as unacceptable by any other law enforcement agency?
Page 3 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
49.
Were you ever turned down as unacceptable by the military?
50.
Are you currently registered in the Selective Service System?
51.
Have you ever served in any branch of the Armed Force?(If no, skip to Question 59)
52.
Would you have any reason to be concerned about an investigation into your military record?
53.
While in the service, were you ever placed under military arrest?
54.
While in the service, were you ever court-martialed?
55.
While in the service, did you receive any type of disciplinary action?
56.
While in the service, were you ever reduced in grade or rank?
57.
While in the service, were you ever AWOL?
58.
Would you have any reason to be concerned about an investigation into your arrest record?
59.
As a juvenile, were you ever arrested or cited?
60.
As an adult, were you ever arrested or detained?
61.
Have you ever petitioned any court to seal or expunge a criminal or juvenile record?
62.
Have you ever had a warrant issued for your arrest?
63.
Are you now wanted for any reason by any law enforcement agency?
64.
Have you ever been a suspect in a crime?
65.
Have you ever been charged with a crime?
66.
Other than minor traffic matters, have you ever been fined by a court?
Page 4 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
67.
Have you spent any time, either as a juvenile or an adult, locked up in a jail?
68.
Since you were 18 years old, have you ever shoplifted from a store?
69.
Have you ever falsified an income tax form?
70.
Have you ever falsified an insurance claim?
71.
Have you ever committed fraud by collecting unemployment or welfare benefits (including food
stamps) when you were not entitled to?
72.
Have you ever stolen a motor vehicle?
73.
Have you ever been sent to jail over anything involving a motor vehicle?
74.
Since you.were 18 years old, have you committed any serious undetected crime?
75.
Have you ever made serious plans to commit rape?
76.
Have you ever made serious plans to commit robbery?
77.
Have you ever made serious plans to commit burglary?
78.
Have you ever made serious plans to commit theft?
79.
Have you ever made serious plans to commit murder?
80.
Have you ever made serious plans to commit arson?
81.
Have you, within the past ten years, done anything that you could have been arrested for doing?
82.
Would you have any reason to be concerned about an investigation into your moral background?
83.
Since you were 16 years old, have you committed any type of sexual crime?
84.
Since you were 16 years old, have you thought about committing some type of sexual crime?
Page 5 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
85.
Have you ever paid for sex?
86.
Have you ever received any type of payment for sex?
87.
Have you ever sexually molested a child?
88.
Have you ever committed a sexual act in public?
89.
Would you have any reason to be concerned about an investigation into your use of illegal drugs?
90.
Have you ever smoked or used marujuana?
91.
Within the past 3 years, have you smoked marijuana?
92.
Of your knowledge, do any of your present circle of friends and acquaintances use any type of
illegal narcotics, pills or drugs?
93.
Within the past year, have you been in the presence of anyone using illegal drugs?
94.
Have you ever illegally purchased any type of narcotic, pill or drug?
95.
Have you ever sold any type of narcotic, pill or drug?
96.
Have you ever illegally cultivated marijuana?
97.
Have you ever been involved in the manufacture of any drug?
98.
Have you ever been the "middle man," a "go-between," or "done a favor for a friend" by becoming
involved in an illegal drug transaction?
99.
Has anyone other than a medical person ever injected anything into your body?
100.
Is anyone you are currently living with keeping any illegal drugs or substances at your residence?
101.
In the past 3 years, has anyone you’ve lived with kept illegal drugs or substances at your residence?
102.
Have you ever stolen alcohol?
Page 6 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
103.
Do you object to others using illegal narcotics or drugs?
104.
Would you have any reason to be concerned about an investigation into your honesty?
105.
Have you ever stolen any money from a place where you worked?
106.
Have you ever borrowed money from an employer and not paid it back?
107.
Have you ever embezzled any money from an employer?
108.
Have you ever had a collection or debt turned over to a collection agency?
109.
Have you ever been late paying rent?
110.
Has your salary ever been garnished for non-payment of debts?
111.
Have you ever purchased goods repossessed?
112.
Have you ever filed for bankruptcy?
113.
Have you ever avoided paying any lawful debt by moving away?
114.
Have you ever been late paying your taxes?
115.
Have you ever been late in making child support payments?
116.
Have you ever been late in repaying a student loan?
117.
Have you had a check "bounce" within the past 3 years?
118.
Have you ever borrowed money to gamble with?
119.
Have you ever borrowed money to pay a gambling debt?
120.
What is the most you have ever lost by gambling at one time?
Page 7 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
121.
Do you feel you have a problem with gambling?
122.
Have you ever been a plaintiff or defendant in any civil court action?
123.
Do you presently have any civil actions pending in court?
124.
Would you have any reason to be concerned about an investigation into your drinking habits?
125.
Do you drink any type of alcohol?
126.
Have you ever done anything illegal after drinking alcohol?
126. Have you ever done anything illegal while drinking alcohol?
128.
How many traffic citations have you received in your life?
129.
Have you ever had a warrant issued for your arrest?
130.
Have you ever had a traffic citation that did not show on your California DMV printout?
131.
Have you ever been the driver in any traffic accident?
132.
Has your driver's license ever been suspended or revoked?
133.
Has your auto insurance ever been placed in the assigned risk pool?
134.
Has your auto insurance ever been canceled for cause?
135.
Do you have auto insurance required by the State of California?
136.
Since being licensed to drive, have you ever not had insurance as required by law?
137.
Have you ever caused anyone serious injury by your operation of a motor vehicle?
138.
Have you ever caused the death of anyone by your operation of a motor vehicle?
Page 8 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
139.
Have you ever fled the scene of a hit-and-run accident?
140.
Have you ever driven a motor vehicle while under the influence of alcohol?
141.
Have you ever driven a motor vehicle while under the influence of any type of drug?
142.
In the past month have you ever driven a motor vehicle under the influence of alcohol?
143.
In the past month have you ever driven a motor vehicle under the influence of any type of drug?
144.
Have you ever been arrested or cited for driving while under the influence of alcohol or drugs?
145.
Would you have reason to be concerned about an investigation into your loyalty to the United
States?
146.
Are any of your relatives, friends or associates connected to or sympathetic with terrorists or any
organization detrimental to our government?
147.
Are you connected or sympathetic with terrorists or organizations detrimental to our government?
148.
Have you, yourself, ever given any confidential information to any organization or individual that
was detrimental to our government?
149.
Would you have any reason to be concerned about an investigation into your personnel record?
150.
In the past 5 years, have you been in a fight in a bar?
151.
In the past 5 years, have you been in any fight?
152.
In the past 5 years, have you started a fight?
153.
Since you were 18, have you ever struck or injured any person?
154.
Have you ever struck someone you were living with?
155.
Other than in warfare, have you ever caused serious injury to a human being?
Page 9 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
156.
Other than in warfare, have you ever been involved in a violent incident such as a shooting, knifing,
or fight where someone was or could have been seriously injured or killed?
157.
Other than in warfare, have you ever used any weapon against someone?
158.
Other than in warfare, have you ever caused the death of a human being?
159.
Do you frequently lose your temper?
160.
Have you ever fired a firearm when not on a shooting range or while hunting legally?
161.
Are you afraid of firearms?
162.
Have you ever applied for a permit to carry a concealed weapon?
163.
Do you feel you can take orders from your superior officer-without resentment?
164.
Do you have any prejudices?
165.
Do you feel your prejudices might affect your ability to perform this job?
166.
Have you ever maliciously burned any property?
167.
Have you ever turned in a false fire alarm?
168.
Have you ever made an anonymous obscene phone call?
169.
Have you ever in your entire lifetime done anything at all that you are ashamed of?
170.
Is there some undisclosed reason why you want to work with us?
171.
Do you know of any reason why you should not be hired by the department for the position for
which you have applied?
172.
Are you withholding any information that might eliminate you from consideration for this job?
173.
Can you say in complete honesty that you have answered each question truthfully?
Page 10 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
DRUG USE QUESTIONNAIRE
174.
Have you ever injected an illegal drug into your body?
175.
Have you ever sold any illegal drug(s)?
176.
Have you ever participated in the illegal manufacture, cultivation, or production of any drug,
narcotic or controlled substance?
177.
Have you ever acted as a courier by transporting any drug, narcotic or controlled substance for
other than legitimate purposes?
178.
Have you ever told anyone else where to purchase illegal drugs?
179.
Have you held or temporarily stored any drug, or controlled substance for yourself or anyone else?
180.
Have you ever been present when illegal drugs were being used, possessed, or sold? (Not in the
course of your duties as a law enforcement officer.)
181.
Have you ever used illegal drugs or controlled substances? (If “Yes”, explain.)
182.
Page 11 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
183.
Have you ever, during your entire lifetime, used, tried, experimented, or in anyway, ingested into
your body any of the following drugs?
Substance
Date Last Used
Apx. # of
Times
Marijuana or Hashish/Hash Oil
Opiates / Heroin
Cocaine
Barbiturates
Amphetamine (Crosstops, Whites, Bennies,
Uppers)
Methamphetamine (Speed, Crank)
Crack/Ice
LSD or other hallucinogen including mushrooms
PCP (Angel Dust, Sherms)
Steroids
Used a pharmaceutical drug prescribed for another
person Type
Page 12 of 14
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
PRE-INVESTIGATIVE QUESTIONNAIRE
If the answer to any of the following are ''Yes", explain fully on the attached explanation form(s).
195.
Have you ingested (glue sniffing, Jimson weed, etc.) any other illegal drug, narcotic or controlled
substance not listed above.
196.
Are there any illegal drugs in your car?
197.
Are there any illegal drugs in your home?
198.
Are any illegal drugs in your possession?
GANG ACTIVITIES & RELATIONSHIPS
Provide the name of any gang or gangs you have had any kind of contact, relationship, or membership with when
answering these questions in this section.
If the answer to any of the following is ''Yes", provide your age and/or related dates on the attached explanation
form(s).
199.
Have you ever been a member or associate of any street gang?
200.
Has any member of your family ever been a member of a street gang, or knowingly associated with
a member of any street gang?
201.
Have you ever attended a gathering or meeting of any street gang?
202.
Have you ever participated in any gang, or gang related activity, including car washes?
203.
Have you ever been present when any kind of gang activity, lawful or unlawful, took place?
204.
Have you ever violated any law while associating with a member of a street gang?
205.
Have you ever been detained, or questioned by any law enforcement agency while in the company
of a member or members of a street gang?
206.
If a records check was made of files containing known street gang members, or persons associating
with street gang members, would your name, or nickname, appear?
Page 13 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE
CERTIFICATIONS
I hereby certify that all statements made and information provided to background investigators in this questionnaire are
true, accurate, and complete. I have not withheld or failed to disclose any information. I understand that any misstatement
of material facts, deception of any kind, or making/providing any misleading statements, will subject me to
disqualification or dismissal.
Date
Candidate Signature
Printed Name
Page 14 of 14
PRE-INVESTIGATIVE QUESTIONNAIRE - EXPLANATION FORM
Candidate Name
Date
Please use the following blank document for further explanation, as needed or required, on the Pre-Investigative
Questionnaire. Reference page and question number in your responses. Add page numbers as needed.
Page
of
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of
City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
Applicant Autobiography Instrutions
Using the following pages, please hand-write a two (2) to three (3) page autobiography outlining
your life experiences. Your autobiography should include all of the applicable topics from the
list below.
1. When and where you were born
2. Places where you have lived and reason for relocating
3. Schools attended
4. Activities participated in (i.e- sports, clubs, and organizations- during and after
school)
5. Military history
6. When your interest in the position you are appliying for commenced
7. In summary: all of your life history to present
Your autobiography should be printed in black ink (one sided only, do not print on both sides of
paper), and may only be completed by you, the applicant. Incomplete or missing forms will
result in application process disqualification.
HEMET POLICE DEPARTMENT
Applicant Autobiography
NAME DATE
Please write a minimum two-page autobiography that outlines your life experiences.
Please print in ink. DO NOT TYPE. This autobiography may ONLY be completed by you, the
Applicant. Failure to comply may be grounds for disqualification.
LIVE SCAN
FINGERPRINT
INSTRUCTIONS
(During COVID-19 Pandemic)
1. Complete the “Applicant Information” section on the attached Request
for Livescan Service form (outlined in black).
2. Applicants for employment have the option to process their prints at any
other listed local areas. Note- rolling fees do apply per location. Please follow
this link to find a location near you.
https://oag.ca.gov/fingerprints/locations?county=Riverside
3. If processing your prints through an outside agency, take the completed
form with you to your appointment.
4. If processing your prints through our agency, please send the
completed form to
Jtorres@cityofhemet.org
along with a copy of your Driver
License (front and back) 24 hrs prior to your appointment to minimize
exposure and person to person contact.
Per DOJ Best Practices to Live Scan, we require that all applicants wear a
face mask into the facility and throughout the process (Mask(s)/ face
cover(s) will not be provided to the applicant). Applicants will be required
to wash and sanitize their hands prior to the rolling process.
Applicants will be asked a series of COVID-19 related questions prior to the
rolling process. Live Scan Operators will cancel any appointments if applicant
does not possess a face mask/cover.
NOTE TO LIVESCAN OPERATOR:
THE INDIVIDUAL BEARING THIS DOCUMENT IS CURRENTLY
PROCESSING WITH THE HEMET POLICE DEPARTMENT FOR
EMPLOYMENT. PLEASE DO NOT CHARGE A ROLLING FEE.
Best Practices for Live Scan Sites During the COVID-19 Outbreak
The California Department of Justice (DOJ) will continuously process live scan fingerprint
background checks for Applicant Agencies to continue providing essential services within our
state during this unprecedented outbreak of the Coronavirus Disease 2019 (COVID-19).
Many of our live scan site partners are open and committed to providing live scan fingerprinting
services. In order to protect the health and safety of all parties, we recommend the following
best practices:
All Parties
Do not enter any live scan facility if you have any COVID-19 symptoms (fever, cough,
trouble breathing, etc.), are awaiting the results of a COVID-19 test, or have been
advised to self-quarantine.
Applicants/Customers
Practice social distancing by maintaining a 6’ distance between other customers.
Wear a face mask into the facility and throughout the process.
Be patient, as wait times between customers may be longer than normal.
Limit any personal items brought into the site. Please have the appropriate form(s) of
identification and payment ready and in hand.
Live Scan Operators
Consider an appointment only schedule.
Instruct the customer to wash or sanitize their hands thoroughly.
Use gloves and face masks throughout the entire process.
Maintain a 6’ distance from the customer, while inputting their personal data.
Disinfect your live scan system (laptop, keyboard and scanner) and any surrounding
high-touch surfaces after serving each customer. Always consult your DOJ Certified Live
Scan Vendor for recommended cleaning products and techniques, so as not to
inadvertently damage your equipment.
LIVE SCAN
FINGERPRINT
INSTRUCTIONS
1. Complete the “Applicant Information” section on the
attached Request for Live Scan Service form (outlined in
black).
2. Contact the Hemet Police Department Records
Bureau at (951) 765-2410 and make an appointment to
have your fingerprints done. Be sure to tell them that you
are an applicant for employment with the Hemet Police
Department. Rolling fees do not apply to applicants.
3. Take these instructions and the completed form
attached with you to your appointment. Any questions can
be directed to Jorge Torres at 951-765-2425.
NOTE TO LIVESCAN OPERATOR:
THE INDIVIDUAL BEARING THIS DOCUMENT IS
CURRENTLY PROCESSING WITH THE HEMET
POLICE DEPARTMENT FOR EMPLOYMENT.
PLEASE DO NOT CHARGE A ROLLING FEE.
THANK YOU!
Applicant Submission
ORI (Code assigned by DOJ)
Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box
City ZIP Code
Contact Name (mandatory for all school submissions)
Contact Telephone Number
Applicant Information:
Last Name
First Name Middle Initial
Suffix
Other Name
(AKA or Alias)
Last
First
Suffix
Date of Birth
Sex
Male
Female
Driver's License Number
Height
Weight Eye Color
Hair Color
Place of Birth (State or Country)
Social Security Number
Home
Address
Street Address or P.O. Box City ZIP Code
Billing
Number
(Agency Billing Number)
Misc.
Number
(Other Identification Number)
Your Number:
OCA Number (Agency Identifying Number)
Level of Service:
DOJ FBI
If re-submission, list original ATI number:
(Must provide proof of rejection)
Original ATI Number
Employer (Additional response for agencies specified by statute):
Employer Name
Street Address or P.O. Box
City
ZIP Code
Mail Code (five digit code assigned by DOJ)
Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
PAGE 1 of 2
BCIA 8016
(Rev. 05/2018)
REQUEST FOR LIVE SCAN SERVICE
(If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI)
State
State
State
CA0330800
NON-SWORN LEA PERSONNEL
HEMET POLICE APPLICANT-
HEMET POLICE DEPARTMENT
00395
450. E. LATHAM AVENUE
HEMET 92543
JORGE TORRES
(
951
)
765-2425
130145
N/A
N/A
CA
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS)
Division in the Department of Justice (DOJ) collects the information requested on this form as authorized
by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and
22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522,
1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code
sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112,
17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code
sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes
and regulations. The CJIS Division uses this information to process requests of authorized entities that
want to obtain information as to the existence and content of a record of state or federal convictions to
help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for
adoption or purposes of a license, certification, or permit. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's
general privacy policy is available at
http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ
that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan
service to help determine the suitability of a person applying for a license, employment, or a volunteer
position working with children, the elderly, or the disabled, we may need to share the information you give
us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
 With other persons or agencies where necessary to perform their legal duties, and their use of
your information is compatible and complies with state law, such as for investigations or for
licensing, certification, or regulatory purposes;
Â
To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may contact the
Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
[email protected], or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
PAGE 2 of 2
BCIA 8016
(Rev. 05/2018)
REQUEST FOR LIVE SCAN SERVICE
City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
CREDIT REPORTS
Under the Fair and Accurate Credit Transactions Act (FACT Act) consumers can request and
obtain a FREE credit report ONCE EVERY 12 MONTHS from each of the three nationwide
consumer credit reporting companies. AnnualCreditReport.com is the only service
authorized by Equifax, Experian and TransUnion for this purpose. It was created by the
three nationwide consumer credit reporting companies, Equifax, Experian and TransUnion and
provides consumers with a secure means to request their free credit reports. Please note that,
as a security precaution, consumers should never provide their personal information to any other
company or person in connection with requesting free annual credit reports under the FACT Act.
If you wish to contact any of the three nationwide consumer credit reporting companies
individually, please see below for contact information:
www.experian.com www.equifax.com www.transunion.com
(888) 397-3742 (800) 685-1111 (800) 888-4213
You can request a FREE annual credit report online or
by phone by visiting AnnualCreditReport.com. If you
order it online, you will be able to see and print your
report immediately – it’s easy and secure.
To request a FREE annual credit report by phone you
can call 1-877-322-8228. You will go through a simple
verification process over the phone. Your report will
be mailed to you.
City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
AUTHORIZATION TO RELEASE INFORMATION AND WAIVER
INFORMED CONSENT TO RELEASE AND HOLD HARMLESS FOR CONFIDENTIALITY
OF PRE-EMPLOYMENT BACKGROUND INVESTIGATION INFORMATION
PRINT FULL NAME:_________________________________________________________
I fully recognize that as an applicant for a position with the Hemet Police Department, I am required to furnish
information for use in determining my qualifications, moral character, honesty and suitability. I fully recognize that
under California law, individuals must clearly demonstrate their personal, medical and psychological fitness to
serve in the position of a peace officer. I further recognize that the Hemet Police Department has both a legal and
moral obligation to take every reasonable effort to insure that I will conform to the very highest standards and I am
authorizing an intensive investigation into all aspects of my personal, medical, and psychological fitness. I
understand that persons and/or organizations may feel reluctant in furnishing legitimate information unless the
confidentiality of their information can be guaranteed on a permanent basis. I have been informed that all
responses, whether solicited or unsolicited, enjoy absolute privilege under the law, pursuant to California Civil
Code 47. This information may be shared with the Hemet Police Department or any other governmental agency
upon authorization. I hereby request and authorize the full disclosure of any and all records, files, reports, notes,
opinions, or any other information you may have concerning me, whether sealed or unsealed, including information
of a confidential or privileged nature to an authorized Background Investigator of the Hemet Police Department.
This includes, but is not limited to, the release of all employment files or records, performance evaluations,
disciplinary records, background investigation files, polygraph reports, psychological reports, medical records, all
internal affairs investigations, complaints or grievances filed by or against me, training files, educational or school
records and transcripts, credit history, all military records, driving records, arrest or criminal records including any
investigative files or reports, detention reports, booking information, court records, probation reports, traffic
citations. This includes photocopies of the above material or documents if requested by the Hemet Police
Department.
NOTE TO EMPLOYERS: Section 1031.1 of the Government Code has been amended to require employers to
disclose employment information relating to a current or former employee, upon request of a law enforcement
agency. The section also states that no employer shall be subject to any civil liability for any relevant cause of
action by virtue of releasing employment information required pursuant to this section. A photocopy of this
notarized release form is to be considered as valid as an original waiver even though it does not contain an original
or my signature. The authorization to release information is valid for a period of six months from the date of
signature. I further understand that I waive any right or opportunity to read or review any information provided in
the background investigation report prepared by the Hemet Police Department or its attachments, including but not
limited to, the psychological or polygraph report or the identity of any person or organization who may have
supplied information in the course of this investigation, as well as the substance of any such information supplied
which might identify that person or organization.
I exonerate and hereby release you, your organization, representatives, agents and all others, including the Hemet
Police Department, from any and all liability whatsoever including any claims and/or damage which may result
from furnishing the above information whether in law or in equity on behalf of myself, my heirs, or agents because
of compliance with this authorization. I have had adequate time to review this form. I understand its purpose and I
know I have a right to receive a copy if I desire.
SIGNATURE: DATE:_____________________
(MUST BE NOTARIZED
ACKNOWLEDGMENT
State of California
County of _____________________________)
On _____________________
____ before me, _________________________________________
(insert name and title of the officer)
personally appeared ______________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature ______________________________ (Seal)
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
AUTHORIZATION TO RELEASE INFORMATION AND WAIVER
INFORMED CONSENT TO RELEASE AND HOLD HARMLESS FOR CONFIDENTIALITY
OF PRE-EMPLOYMENT BACKGROUND INVESTIGATION INFORMATION
PRINT FULL NAME:_________________________________________________________
I fully recognize that as an applicant for a position with the Hemet Police Department, I am required to furnish
information for use in determining my qualifications, moral character, honesty and suitability. I fully recognize that
under California law, individuals must clearly demonstrate their personal, medical and psychological fitness to
serve in the position of a peace officer. I further recognize that the Hemet Police Department has both a legal and
moral obligation to take every reasonable effort to insure that I will conform to the very highest standards and I am
authorizing an intensive investigation into all aspects of my personal, medical, and psychological fitness. I
understand that persons and/or organizations may feel reluctant in furnishing legitimate information unless the
confidentiality of their information can be guaranteed on a permanent basis. I have been informed that all
responses, whether solicited or unsolicited, enjoy absolute privilege under the law, pursuant to California Civil
Code 47. This information may be shared with the Hemet Police Department or any other governmental agency
upon authorization. I hereby request and authorize the full disclosure of any and all records, files, reports, notes,
opinions, or any other information you may have concerning me, whether sealed or unsealed, including information
of a confidential or privileged nature to an authorized Background Investigator of the Hemet Police Department.
This includes, but is not limited to, the release of all employment files or records, performance evaluations,
disciplinary records, background investigation files, polygraph reports, psychological reports, medical records, all
internal affairs investigations, complaints or grievances filed by or against me, training files, educational or school
records and transcripts, credit history, all military records, driving records, arrest or criminal records including any
investigative files or reports, detention reports, booking information, court records, probation reports, traffic
citations. This includes photocopies of the above material or documents if requested by the Hemet Police
Department.
NOTE TO EMPLOYERS: Section 1031.1 of the Government Code has been amended to require employers to
disclose employment information relating to a current or former employee, upon request of a law enforcement
agency. The section also states that no employer shall be subject to any civil liability for any relevant cause of
action by virtue of releasing employment information required pursuant to this section. A photocopy of this
notarized release form is to be considered as valid as an original waiver even though it does not contain an original
or my signature. The authorization to release information is valid for a period of six months from the date of
signature. I further understand that I waive any right or opportunity to read or review any information provided in
the background investigation report prepared by the Hemet Police Department or its attachments, including but not
limited to, the psychological or polygraph report or the identity of any person or organization who may have
supplied information in the course of this investigation, as well as the substance of any such information supplied
which might identify that person or organization.
I exonerate and hereby release you, your organization, representatives, agents and all others, including the Hemet
Police Department, from any and all liability whatsoever including any claims and/or damage which may result
from furnishing the above information whether in law or in equity on behalf of myself, my heirs, or agents because
of compliance with this authorization. I have had adequate time to review this form. I understand its purpose and I
know I have a right to receive a copy if I desire.
SIGNATURE: DATE:_____________________
(MUST BE NOTARIZED
ACKNOWLEDGMENT
State of California
County of _____________________________)
On _____________________
____ before me, _________________________________________
(insert name and title of the officer)
personally appeared ______________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature ______________________________ (Seal)
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
City of Hemet Police Department 450 E. Latham Avenue Hemet, CA 92543
Phone: (951) 765-2400 Fax: (951) 765-2412
Excellence In Service Since 1910
Eddie J. Pust
Chief of Police
ADVISEMENT TO APPLICANTS
You are about to undergo a pre-employment background investigation for a position of public trust. Fundamental to
this process is your integrity and trustworthiness. The number one reason individuals “fail” background
investigations is because they attempt to withhold job-relevant information from their prospective employer.
Everyone acknowledges that an intensive pre-employment background investigation may appear intrusive and
even embarrassing. However, inquiries which are made are made either pursuant to law or are otherwise job-
relevant in nature. Background investigators do not make inquiries which have no relationship to the position of
public trust for which you have applied. They are also discreet and professional in the manner in which this
information is treated.
While much publicized events in the public arena may suggest that quibbling, hair-splitting, or out-and-out
untruthfulness is to be tolerated by public officials, this form is in place to assure you that such conduct is not
acceptable and will not be tolerated. Deliberate deception of any type will disqualify you if for no other reason than
your application for employment becomes an official document, and filing false documents with the government
can constitute a criminal offense. Don’t lie! Don’t withhold information, even if you think it may be negative.
Virtually everyone has one or more issues in their background over which they feel some embarrassment,
remorse, or discomfort. There are no “perfect” applicants; indeed, there are no “perfect” people. The Hemet Police
Department evaluates issues in your past, both positive and negative, for their impact on your qualifications for the
position you are being considered for. However, if you attempt to withhold information, we have no other option but
to assume that you are attempting to obtain this position by fraud.
While issues of prior misconduct, including such things as prior having been fired or disciplined at work, being
behind in your bills, prior illegal drug use, driving under the influence, theft, or even an arrest or conviction may
trouble us, they are many times not, in and of themselves, automatically disqualifying. However, lying about those
issues will absolutely, positively, cause your application to be rejected.
You are strongly encouraged to be as complete, accurate and candid as possible when completing your
background application paperwork. It is to your ultimate advantage to be as truthful and forthcoming as possible.
CERTIFICATION BY APPLICANT
My signature below attests to the fact that I have read this form carefully, and I understand that any attempt
whatsoever, whether by commission or omission, to withhold job-relevant information from the Hemet Police
Department will result in my being disqualified. This includes misstatements, deliberately non-responsive answers,
and misrepresentations of any type.
Print Full Name: ____________________________________________
Signature: ___________________
__________________________ Date: ___________________