Agreement & Acknowledgement forms

Authorization To Release Information
This is to certify that as an applicant for a position with the City of Savannah/Savannah Chatham Metropolitan Police
Department, I do authorize the release of any and all information to the City of Savannah Human Resources
Department/Savannah Chatham Metropolitan Police Department from whomever they may deem it necessary to make
such a request. By my signature, I consent to the release of information to authorized officers, agents and or employees
of the City of Savannah Human Resources Department/Savannah Chatham Metropolitan Police Department which may
include but not be limited to: criminal history records; driving history records, which will be used to determine my eligibility
for employment or continuation of driving privileges after employment; information concerning my past and present work
experience, including my official personnel files, attendance records and performance evaluations; educational records
including transcripts; military service records; law enforcement records and or any other personnel records deemed
necessary. I understand that these records may be obtained at any time after receipt of this authorization. Past
convictions will not automatically exclude an applicant from employment. The relationship of the crime to the position
applied for will be taken into consideration. Further, I authorize the City of Savannah Human Resources
Department/Savannah Chatham Metropolitan Police Department to copy or otherwise reproduce this original document
and to let such copies act as the original instrument. The original document is to be retained on file with the Savannah
Chatham Metropolitan Police Department.
In addition, I consent to authorize appropriate officers, agents and or employees of the City of Savannah Human
Resources Department/Savannah Chatham Metropolitan Police Department to make inquiries of third parties such as
credit bureaus. This disclosure is being provided to you pursuant to the Federal Fair Credit Reporting Act (FCRA), 15
U.S.C.1681 and Federal Trade Commission Regulations contained in 16 C.F.R. Part 601, Appendix C.
__________________________________________
Full Name Printed
______
___________/____________/____________
Social Security Number
________________________________________________
Address
____________________________________
City, State, Zip
____________________________________________________
Signature
______________________________________
Date
The following information is requested for background checks and record keeping only and will not be disclosed
as a part of the employment application. Exclusion of this data will not result in disqualification from
consideration.
Check one: ( ) male ( ) female
Date of Birth _____/_____/__
Check one of the following: (Ethnic Origin)
( ) White
( ) African American ( ) Hispanic
( ) Asian
( ) Native American
( ) Other
Are you a disabled individual (in accordance with Americans with Disability Act)? ( ) yes ( ) no
Are you a veteran? ( ) yes ( ) no
If yes, please attach a copy of your Form DD214 indicating type of
separation. The copy of the Form DD214 is required for 5 points preference claim, if eligible, and also serves as a
record of employment. If you are a disabled veteran, in addition to your Form DD214, please attach a copy of the
award notice or other evidence, dated within the last six months, that you are in receipt of compensation based
on a disability rated at 10% or more by the Veterans’ Administration for 10 points preference claim.
For Use by Savannah Chatham Metropolitan
Police Dept.
______________________________________
Revised June 2011
*A
Applican
nt signatu
ure at thee bottom of this page is req
quired*
BAC
CKGROU
UND STA
ANDARD
DS
D
DRIVER’S LICENSE HISTORY
H
CANNOT
T CONTAIN
N:
 D
DUI/DWI chaarge with the disposition of Nolo Conten
ndre, convicttion, or plea w
within the passt five years, aand no
ttwo in the passt seven yearss.
 S
Suspensions in the past three years (except for one In
nsurance Canccellation) andd no two susppensions in thee past
sseven years.
 M
More than thrree (3) moving
g violations in
n the past tw
wo years and m
more than sixx (6) in the past seven yeaars.
 V
Vehicular Hom
micide or Hitt and Run chaarge/arrests.
 F
Fleeing or Atttempting to Elude
E
the Policce charge/arreests.
C
CRIMINAL
L HISTORY
Y CANNO
OT CONTAIN:
 P
Pending Crim
minal cases.
 C
Convictions, Nolo
N
Contend
dre or pleas in
nvolving Sexu
ual Offenses, Domestic Viiolence Act orr Impersonatiion a
P
Police Officerr, Perjury or False
F
Statemeents.
 F
Felony convicctions and No
olo Contendree or pleas invo
olving felony arrests inclu
uding First Offfender pleas.
 S
Serious Misdeemeanor Conv
victions, Nolo
o Contendre, or pleas inclu
uding First O
Offender pleass.
A
APPLICAN
NTS WILL BE
B DISQUA
ALIFIED ON
O THE FO
OLLOWING
G:








U
Untruthfulnesss or the omission of inform
mation throug
ghout the appllication proceess.
A
Anything otheer than an Honorable Disch
harge from Armed
A
Forces..
M
Membership or
o association
n with any hatte or terrorist group.
U
Unsatisfactory
y work history
y within the past
p three yeaars.
U
Unsatisfactory
y information
n derived from
m extensive baackground invvestigation.
P
Possession orr sale of drugs/a controlled
d substance.
M
Marijuana usee within the past
p two yearrs.
U
Use of any co
ontrolled substtance includin
ng marijuana; however, anny use of a coontrolled substance, includiing
m
marijuana, wh
hich is deemed to be experrimental will be
b reviewed oon a case by ccase basis.
T
THOSE WIITH PRIOR
R LAW ENF
FORCEMENT EXPER
RIENCE:
 A
Any pending disciplinary action
a
or interrnal investigaation.
 C
Currently und
der investigatiion by certifying agency (i.e. POST).
 A
Any disciplinaary action or sustained com
mplaint for offfenses of a seerious nature,, which includdes, but is nott limited
tto sexual haraassment, untru
uthfulness, inssubordination
n, or use of foorce.
________________
___________
____________
___________
____
Appllicant Signatu
ure
_________________________
D ate
TRUTHFULNESS AGREEMENT
Thank you for applying to the Savannah-Chatham Metropolitan Police Department. We are extremely proud of our
Department and our reputation. We view our personnel decisions as one of our most critical tasks. We are very selective
and only hire the best and the brightest. Even if you meet our standards and pass our hiring requirements, your
selection for employment is not guaranteed.
One of the most critically important issues that define the effectiveness of any organization is the perception that it is a
credible organization. Central to that image is the integrity and truthfulness of the Department’s employees, from the
newest entrant to the top-level managers.
The need for honest, impartial and accurate representation of facts is nowhere more vital than within a police agency,
where success or failure rests with the degree of public support it receives. Police officers have unique power that rests on
the foundation of their honesty and integrity. Public support can quickly erode where there is a lack of credibility in
existence within an organization. The other elements of the criminal justice system that rely on truthful testimony from
officers are instantly compromised when one of our members is less than forthright.
The very basis of an individual’s integrity, as perceived by the public, friends and fellow workers is at stake whenever the
truth is not told. The loss of integrity can quickly erode where there is a lack of credibility in existence within an
organization.
It is the responsibility of all members of this Department to maintain the effectiveness of their Police agency as a viable
law enforcement organization. This document serves notice that the employees of the SCMPD will not tolerate lying
of any kind, either by their co-workers or by SCMPD applicants. As an applicant, you have been forewarned: All
information disclosed or gleaned during the application process WILL be verified by means of a polygraph examination
and background investigation. Any statements or omissions, either written or verbal that are given by any applicant with
the intent to deceive will result in rejection from further consideration for employment with the Savannah-Chatham
Metropolitan Police Department. There are NO second chances. There is simply no substitute for the truth.
I acknowledge that I have read and understand the statement provided above.
_______________________________________
Applicant Name
______________________________________________
Applicant Signature
_________________________________
Date
NO USE OF TOBACCO AGREEMENT
In accepting employment with the City of Savannah, GA, Savannah Chatham Metropolitan Police Department
as a sworn officer, I ______________________________________________________
acknowledge, understand, and accept the following terms, conditions, and expectations of that employment.
A sworn Officer hired, as of April 1, 1998, to work for the City of Savannah, in the Savannah Chatham
Metropolitan Police Department cannot use tobacco in any form whatsoever. The employee shall remain free
from the use of tobacco products throughout the term of employment. Furthermore, the use of tobacco products
after employment, or any false or materially misleading representation by the employee as to being a nonsmoker or non-user of tobacco products at the time of employment, shall constitute grounds for termination of
employment.
By accepting employment with the City of Savannah, Savannah Chatham Metropolitan Police Department and
signing this Agreement, I certify that, as of this date, I do not use any tobacco products in any form whatsoever
and, in consideration of my employment with the Department, I agree not to use any tobacco products at any
time so long as I am employed with the Department, whether on or off duty, and that my failure to comply shall
constitute grounds for termination of my employment. I further agree that, if at any time during the term of my
employment with the Department, I begin to use tobacco products in any form whatsoever, I will inform the
Chief of Police of this fact and tender my resignation.
The intent of this Agreement is to identify some specific terms, conditions, and expectations of my employment
with the Savannah Chatham Metropolitan Police Department. Failure to comply with these terms, conditions,
and expectations of my employment shall constitute grounds for termination of my employment with the
Savannah Chatham Metropolitan Police Department.
_______________________________________
Applicant Name
______________________________________________
Applicant Signature
_________________________________
Date
SHIFT WORK EXPECTATIONS ACKNOWLEDGEMENT
By signing this form, you are acknowledging your understanding that as a Police Officer with Savannah
Chatham Metro Police Department you will be expected to work various shifts. The current departmental shift
structure is 6:30 AM to 3:00 PM, 2:30 PM to 11:00 PM, and 10:30 PM to 7:00 AM. The morning and evening
shifts rotate. Your shift assignment will not be one of your choosing, but rather assigned to you according to
what shift needs covered. Police Officers are expected to work 5 days a week with two days off, with your days
off probably not falling on Saturday and Sunday. In some cases, such as big City events, you will be required to
work beyond your assigned shift days and times.
As an Officer, you will not be granted the same holidays that the rest of the City employees. You more than
likely will not have any major holidays off such as Thanksgiving or Christmas. You will not be permitted to
take vacation until after your 1 year probation as a Police Officer is over, and even then, it will be approved at
the discretion of your supervisor.
I ________________________________________ acknowledge and understand the terms and conditions of a
Police Officer’s work schedule and, if chosen for employment, agree to abide by the aforementioned terms and
conditions, along with any other situation that might arise regarding my work schedule.
_______________________________________
Applicant Name
______________________________________________
Applicant Signature
_________________________________
Date
TATTOOS AND BODY ART ACKNOWLEDGEMENT
By submitting an application with the City of Savannah Chatham-Metropolitan Police Department as a sworn officer or
police officer trainee, I
_________
, acknowledge, understand, and accept the following terms,
conditions and expectations of that employment.
As a sworn officer or trainee applicant, I understand that in order to work for the City of Savannah, in the Savannah
Chatham Metropolitan Police Department I must comply and agree to the tattoo and body art policy listed below:
Tattoos and Body Art
1. SCMPD employees will not have any tattoos or body art visible during duty hours, anytime in uniform or
while performing a department function or representing the department in any capacity.
a. Tattoos may be concealed either by utilizing makeup matching the skin color, a band aid, wearing a
long sleeve shirt or wearing a commercially available device known as “Tat Jacket”.
b. Any costs associated with compliance to this policy will be incurred by the employee.
The SCMPD Office of Professional Standards Recruiting Unit will ensure that all applicants are aware of this policy prior
to acceptance of their application. Supervisors and Managers are responsible to ensure employees comply with this
directive.
By accepting employment with the City of Savannah, Savannah Chatham-Metropolitan Police of Department and signing
this agreement, I certify that, as of this date, I agree and comply with the Department, and that my failure to comply shall
constitute grounds for termination of my employment. I further agree that, if at any time during the term of my
employment with the Department, if I obtain any visible tattoos that are against the Department’s policy in any form
whatsoever, I will inform the Chief of Police of this fact and comply with this directive.
The intent of this Agreement is to identify some specific terms, conditions and expectations of your employment with the
Savannah Chatham Metropolitan Police Department. Failure to comply with these terms, conditions and expectations of
your employment shall constitute grounds for termination of your employment with Savannah Chatham Metropolitan
Police Department.
_______________________________________
Applicant Name
______________________________________________
Applicant Signature
_________________________________
Date