RICHMOND POLICE DEPARTMENT

CITY OF RICHMOND, VIRGINIA

BACKGROUND QUESTIONNAIRE – PART I

THIS QUESTIONAIRE MUST BE FILLED OUT COMPLETELY

Position Applied For:

Full Name:

Present Address:
Street Address

City and State Zip Code

Telephone:
Home Business Cellular

Email Address:

When you report for your interview, you will need the following documents:

Birth Certificate or Naturalization Certificate

Marriage and/or Divorce Certificate
College Degree or Transcript showing Graduation
High School Diploma or G.E.D. Certificate
DD-214 (If Veteran)
Virginia or Current State Driver’s License
Social Security Card

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

PERSONAL HISTORY

Legal Name at Birth:

All other names you have used, including nicknames:

Social Security Number:

City or County of Residence:

Date of Birth: Place of Birth:

Current Age:

U.S. Citizen? Yes No If Naturalized, date of Naturalization:

Naturalization Number:

If Divorced or Separated, list all previous Spouses and Dates of Separation or Divorce:
Spouse’s Name Date of Divorce/Separation

Spouse’s Name Date of Divorce/Separation

Spouse’s Name Date of Divorce/Separation

Spouse’s Name Date of Divorce/Separation

Bilingual? Yes No

If YES, list additional languages:

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________________________________

________________________________

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

DRIVING HISTORY
Have you ever received ANY traffic citations (excluding parking tickets) YES_____ NO_____
If YES, list ALL citations (whether convicted or not) for the past ten (10) years:
Date Violation/Charge Location/City Issuing Agency Guilty/Not Guilty, Convicted of:
Prepaid Fine

Have you ever been involved in an automobile accident in which you were the driver? Yes No
If YES, please explain (include any and ALL accidents, whether the police responded or not.)

Report
Date Accident Location Taken Police Agency Details
Y/N
Yes
No

Yes
No

Yes
No

Yes
No

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

DRIVING HISTORY (CONTINUED)

Has your license to drive EVER been suspended or revoked by ANY state? Yes No
If YES, please explain
State Dates Reason

Have you ever been charged with Driving Under the Influence? Yes No
If YES, please explain
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Give the below listed information on ALL operator’s licenses that you have held:

Type State of Issue License Number Dates

List ALL motor vehicles that you CURRENTLY own:

Year Make Model License Number State Insured

Yes
No
Yes
No
Yes
No
List ALL driving schools you have attended
Year City, State Completed
Yes No
Yes No
Yes No

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

DRIVING HISTORY (CONTINUED)

List all instances when you were stopped and detained by a law enforcement officer and DID NOT
receive a citation (i.e. speeding, warning, field sobriety test, etc.)
Approximate Location Police Agency Details/Reason
Date

CRIMINAL HISTORY

Have you ever been the victim or complainant in any crime or incident? Yes No
If YES, please explain in detail including DATE & LOCATION:
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever been charged with ANY criminal offense (whether misdemeanor or felony)?
Yes No
If YES, please list ANY criminal charges either as a juvenile or adult
(whether sealed or dismissed):

Date Charge Location/City Issuing Conviction Disposition

Agency

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

If you checked YES to any of the above, please explain in detail in the space below.
Include the DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have the police ever responded to investigate an incident in which you’ve been involved?
Yes No
If YES, please explain in detail including DATES & LOCATIONS:
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Have you ever been required to furnish bail or bond for an appearance in ANY
court of law? Yes No
Have you ever been pardoned for any crime? Yes No
Have you ever been accused of a crime but not arrested? Yes No
Have you ever been placed on parole or probation for any reason? Yes No
Have you ever been required to appear before a juvenile court judge for an act
which would have been a crime if committed by an adult? Yes No
Is there any action pending against you at this time? (i.e. criminal, traffic, civil) Yes No

If you checked YES to any of the above, please explain in detail in the space below.
Include the DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever committed or participated in or conspired to commit any of the following crimes or
offenses, whether or not you were arrested, charged or detained? Each crime or offense must be
checked YES or NO.

Elder/Adult Abuse Yes No

False Alarm/Fire/Bomb Threats Yes No
Harassment or Threats (In person, via public airways, verbal, or in writing) Yes No
Stalking Yes No
Hunting or Fishing Violations Yes No
Indecent Exposure/Mooning Yes No
Peeping Tom/Voyeurism Yes No
Robbery Yes No
Impersonating a Police Officer Yes No
Auto Theft Yes No
Knowingly Written a Bad Check Yes No
Knowingly Misused a Credit Card Yes No
Stolen Money From Someone Yes No
Tampered with Another Individual’s Food or Beverage Yes No
Intentionally Damaged someone Else’s Property Yes No
Altered/Switched Price Tags Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.

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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever committed or participated in or conspired to commit any of the following crimes or
offenses, whether or not you were arrested, charged or detained? Each crime or offense must be
checked YES or NO.

Vandalism/Tagging/Graffiti Yes No
Forgery Yes No
Pedophilia Yes No
Unauthorized Use of a Vehicle Yes No
Extortion Yes No
Theft/Larceny Yes No
Downloaded Child Pornography Yes No
Shoplifted Merchandise Yes No
Rape/Date rape/Sexual Assault Yes No
Lied or committed perjury in court or other proceeding? Yes No
Lied to anyone in authority or made a false police report? Yes No
Entered any building, business, dwelling, or house without permission? Yes No
Ever received or paid money for any sex act? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever committed or participated in or conspired to commit any of the following crimes or
offenses, whether or not you were arrested, charged or detained? Each crime or offense must be
checked YES or NO.

Have you ever placed a wager/bet by telephone, internet or made a hand-to-hand

transaction with a book maker (bookie or numbers man) on the results of a
professional or collegiate sports event, other than a legitimate lottery, or other
legalized gambling event? Yes No
Do you currently have any outstanding gambling debts? Yes No
Have you ever borrowed money to gamble? Yes No
Have you ever used an employer’s money to gamble? Yes No
Have you ever stolen money with which to g amble? Yes No
Stolen anything from your employer? Yes No
Have you ever been involved in any college, fraternity hazing/initiation
incident/ritual/program? Yes No
Have you ever been involved in arson, a reckless burning/fire
or similar conduct? Yes No
Have you ever been bonded or refused bond upon application? Yes No
Have you ever knowingly filed a false/fraudulent insurance claim with any
insurance company regarding a traffic accident, theft, or other monetary loss? Yes No
Have you ever participated in “street racing”, “quick start racing”, or racing
another vehicle on a public highway? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever committed or participated in or conspired to commit any of the following crimes or
offenses, whether or not you were arrested, charged or detained? Each crime or offense must be
checked YES or NO.
Have you ever, for any reason, eluded a law enforcement official? Yes No
Have you ever purchased alcohol for someone less than 21 years of age? Yes No
Have you ever participated in underage drinking? Yes No
Have you ever consumed alcohol at work? Yes No
Have you ever been under the influence of alcohol at work? Yes No
Have you ever been disciplined as a result of consuming alcohol? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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 Do you or any member of your family belong to any organization with an

anti-government agenda? Yes No
 Have you ever been an officer/member or made a contribution to an
organization dedicated to the violent overthrow of the US Government? Yes No
 Have you ever been involved in or participated in any parade, picket line,
delegation, or demonstration sponsored by any subversive organization(s)? Yes No
 Been involved in or paid, contributed, collected, or solicited any money or
dues to, for, or in behalf of any subversive organization(s)? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever been denied a concealed weapon permit? Yes No
Have you ever been involved in any physical confrontations? Yes No
Have you ever intentionally injured anyone as a result of a fight? Yes No
Have you ever used a weapon of any kind during a fight or altercation? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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Have you ever committed or participated in or conspired to commit any of the following crimes or
offenses, whether or not you were arrested, charged or detained? Each crime or offense must be
checked YES or NO.

Left a restaurant or food establishment without paying for services? Yes No

Helped anyone steal anything? Yes No
Knowingly received stolen property (regardless of values)? Yes No
Falsified or lied on an employment application? Yes No
Provided a discount at your place of employment without permission? Yes No
Used false, fraudulent, or borrowed identification of any kind for any purpose? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

CRIMINAL HISTORY (CONTINUED)

Have you ever committed or participated in or conspired to commit any of the following crimes or
offenses, whether or not you were arrested, charged or detained? Each crime or offense must be
checked YES or NO.

 Given anything to anyone that was not yours to give away? Yes No
 Been accused or arrested for domestic violence or spousal abuse? Yes No
 Been a lookout or driver for someone else while they committed a crime or
criminal act of any kind? Yes No
 Allowed your vehicle to be used in the commission of a crime? Yes No
 Knowingly committed a weapons violation of any kind (ie: illegal
possession, wearing, carrying, transporting, selling, purchasing or modifying)? Yes No
 Been present at, witness to, or involved in any kind of murder, killing,
manslaughter or other unnatural death of a human being? Yes No
 Have you ever committed an undetected illegal act(s) (even as a juvenile)
not previously listed? Yes No
 Have you ever been questioned by the police as a suspect or witness as part of a
criminal investigation or traffic investigation not previously listed? Yes No

If you checked YES to any of the above, please explain in the space below or on the reverse side of
this page. Include DATES & LOCATIONS of all events.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

DRUG USAGE
Each drug must be checked YES or NO.

Have you ever tried, used or experimented Date First Date Of Total Times
Used Last Use Used
with:

Marijuana Yes No
Cocaine Yes No
Crack Yes No
Hashish Yes No
LSD Yes No
Heroin Yes No
PCP Yes No
Ecstasy Yes No
Steroids Yes No
Synthetic drug (salvia, Spice, K2, bath salts,) Yes No
Hallucinogens/Mushrooms Yes No
Methamphetamines Yes No
Tranquilizers Yes No
Amphetamines Yes No
Inhalants (i.e. whippets, nitrous oxide, huffing,
Yes No
sniffing?

Have you ever used any prescription drug that was not specifically prescribed to you? Yes No
If so, please explain including dates of first and last use, and number of times used:
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Have you ever used any illegal drug not listed above? Yes No
If so, please explain including dates of first and last use, and number of times used:
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Would you submit to a polygraph? Yes No

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

EMPLOYMENT HISTORY
Begin with your PRESENT employment and work back. Please include ALL employments and all
periods of unemployment:

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

EMPLOYMENT HISTORY (CONTINUED)

Start with your PRESENT employment and work back. Please include ALL periods of unemployment:

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

EMPLOYMENT HISTORY (CONTINUED)

Start with your PRESENT employment and work back. Please include ALL periods of unemployment:

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

EMPLOYMENT HISTORY (CONTINUED)

Start with your PRESENT employment and work back. Please include ALL periods of unemployment:

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

to
Employment Dates Name of Employer Telephone #

Complete Address Including Zip Code Position Held

Yes No
Reason for Leaving Did you give adequate notice?

Supervisor Email

If additional space is needed, please use additional sheet.

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

EMPLOYMENT HISTORY
If you DID NOT provide adequate notice to any previous employment please explain why in the
space below or on the reverse side of this page.
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 Were you ever fired, laid off, or asked to resign from a job? Yes No
 Have you ever resigned (quit) while anticipating that your employer Yes No
intended to discharge (terminate) you for any reason?
 Have you ever resigned (quit) from a job by mutual agreement following Yes No
allegations of misconduct?
 Have you ever resigned (quit) from a job by mutual agreement following Yes No
allegations of unsatisfactory work performance?
 Have you ever walked off (left) a job without giving proper notice? Yes No
 Have you ever been the subject of a citizen, client or co-worker complaint? Yes No
If you checked YES to any of the above, provide which employer and detail the circumstances in
the space below or on the reverse side of this page.
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Have you ever been disciplined or warned (either verbally or in writing)
while working in any position? Yes No
If you checked YES, provide the DATE & EMPLOYER and detail the circumstances in the space
below or on the reverse side of this page.
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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

MILITARY HISTORY
Have you ever been a member of the Armed Forces, U.S. or Foreign? Yes No
If yes, please list below:

Branch of Service:
Dates of Service: to
Service Number: Rank at Discharge:
Type of Discharge:
Reason for Discharge:

Branch of Service:
Dates of Service: to
Service Number: Rank at Discharge:
Type of Discharge:
Reason for Discharge:

List all DATES and DUTY STATIONS, including the City or County of the Duty Station

Dates Duty Station City/County, State

Dates Duty Station City/County, State

Dates Duty Station City/County, State

Dates Duty Station City/County, State

Dates Duty Station City/County, State

Dates Duty Station City/County, State

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

MILITARY HISTORY (CONTINUED)

If you are a member of the National Guard or any Military reserve Unit, List the following;

UNIT ADDRESS DESCRIBE OBLIGATION

UNIT ADDRESS DESCRIBE OBLIGATION

UNIT ADDRESS DESCRIBE OBLIGATION

Were you ever subjected to any disciplinary action (judicial or non-judicial) while in the Armed Forces?
Yes No
If you checked YES, detail the circumstances in the space below or on the reverse side of this page.
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Have you ever received a discharge which was less than Honorable?
Yes No
If you checked YES, detail the circumstances in the space below or on the reverse side of this page.

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Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

MISCELLANEOUS INFORMATION
Have you ever applied to another law enforcement agency? Yes No
If yes, list the approximate date, agency and disposition below.

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Dates Agency Disposition

Have you ever attended a criminal justice academy? Yes No

If yes, explain below:

Have you ever applied for employment with the City of Richmond? Yes No
If yes, list date, department and disposition below:

Dates Department Disposition

Dates Department Disposition

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

List all professional licenses and/or certifications that you currently hold or previously held:

Type Issuing License Number Date Issued Status

State/Agency

FINANCIAL INFORMATION
List your current indebtedness, including obligations for which you have co-signed:

NAME COMPLETE ADDRESS ACCOUNT # AMOUNT

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

RESIDENTIAL HISTORY
Beginning with your PRESENT address, list all previous places of residence. Include dates, address and
City/County and State:
FROM TO
ADDRESS, CITY & STATE
(MO/YR) (MO/YR)

EDUCATIONAL HISTORY
List all high schools and colleges/universities that you have attended:
DEGREE
DATES
NAME OF SCHOOL COMPLETE ADDRESS OR
(Start/End)
DIPLOMA

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

FAMILY AND HOUSEHOLD

DATE DATE
ADDRESS
NAME RACE OF OF
(INCLUDING ZIP CODE)
BIRTH DEATH
Father

Mother

Spouse/
Fiancé

Brothers
/Sisters

Children

List all persons currently living with you not listed above.
DATE OF
NAME RACE SEX
BIRTH

Police Applicants ONLY:

Spouse Employer:
Address: Telephone:

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

PERSONAL REFERENCES
List five (5) personal references. Do not include relatives or employers:

Name:
Address:
City: State: Zip Code:
Telephone #:
Email:

Name:
Address:
City: State: Zip Code:
Telephone #:
Email:

Name:
Address:
City: State: Zip Code:
Telephone #:
Email:

Name:
Address:
City: State: Zip Code:
Telephone #:
Email:

Name:
Address:
City: State: Zip Code:
Telephone #:
Email:
Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

26
 RICHMOND POLICE DEPARTMENT
CITY OF RICHMOND, VIRGINIA

AFFIDAVIT
I hereby certify that all statements contained in this questionnaire are true and complete to the best of my
knowledge. I have neither withheld nor misrepresented any facts contained herein.

I authorize the Richmond Police Department and its agents to conduct a complete and comprehensive
investigation into my background for the purposes of determining my fitness and qualifications for the
position(s) I am seeking.

I also understand that my omission or misstatement of material facts may be grounds for rejection of my
application or for dismissal from City employment.

Date Applicant’s Signature

NOTARIZATION
Commonwealth/State of

City/County of

Subscribed and sworn before me this day of , 20

Notary Public

My commission expires , 20

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

27
 CITY OF RICHMOND
POLICE DEPARTMENT
PERSONNEL & RECRUITMENT UNIT
200 W. GRACE STREET
RICHMOND, VIRGINIA 23220
(804) 646-6733

CONSUMER REPORT AUTHORIZATION

“This shall authorize the procurement of a consumer report by the Richmond Police Department as part
of the pre-employment background investigation. If hired, this authorization shall remain on file and
shall serve as an ongoing authorization for the Richmond Police Department to procure consumer
reports at any time during my employment period.”

Date Applicant’s Signature

Date Witness

NOTARIZATION

COUNTY/CITY OF______________________________________________________________
COMMONWEALTH/STATE OF_________________________________________________
CERTIFIED THIS____________DAY OF __________________,_______________

_________________________________
NOTARY PUBLIC

MY COMMISSION EXPIRES:____________________________________________________

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

28
 CITY OF RICHMOND
POLICE DEPARTMENT
PERSONNEL & RECRUITMENT UNIT
200 W. GRACE STREET
RICHMOND, VIRGINIA 23220
(804) 646-6733

AUTHORITY FOR RELEASE OF INFORMATION

Applicant’s Name:

Position:

I respectfully request and authorize you to furnish the City of Richmond Police Department, ANY and
ALL information that you have concerning my employment record, educational record, military record,
reputation, character, financial and credit status. Please include any and all polygraph results,
application information and other information of a confidential nature, and Photostats or copies of same.
This information is to be used to assist the Richmond Police Department in determining my
qualification and fitness for the position I am seeking. A reproduction of this release form will be valid
as an original hereof and shall expire twelve (12) months from the date of this acknowledgement.

I hereby release you, your organization or others from any and all liability or damage, which may result
from furnishing the information requested. I further understand that the sources of information, as well
as the information itself cannot be revealed to me.

Applicant’s Signature Date

Addres Date of Birth

City, State, Zip Code Social Security #

Witnessed By

Investigator County/City of Richmond

Richmond Police Department Commonwealth/State of Virginia
Personnel & Recruitment Division Certified this ____day of________,____
(804) 646-6733 Notary Public______________________
My commission expires:
Notary Registration:

Official document of the Richmond Police Department, NOT to be changed, altered or reprinted, except in its original context

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