Savanna Police Dept.
Initial Application


101 Main St.
Savanna, IL 61074
(815)273-2246 Fax (815)273-2523


1.Last Name: First Middle
2.Address
   City State Zip Code
3.Date of Birth
4. Drivers License Number and state
5. Present Employer (name)
    Address
    City State Zip Code
    Phone number
6. Have you ever served or currently serving in the United States Armed Forces or Reserves (list branch)
    YES NO
7. Place of Birth: City State County
8. Sex MALE FEMALE
    Height Weight Eye Color
11. Have you ever been arrested for a crime that was a Felony or Misdemeanor? YES NO
12. Has your driver's license been suspended, revoked, or cancelled? YES NO
13. Are you capable, or do you now possess a Foid Card? YES NO
14. Are you willing to relocate within 10 miles of The City of Savanna upon being hired? YES NO
15. Signature
Please Fill out and print the required Background Waiver Form:

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I, , do hereby authorize there release, review of full disclosure of all records concerning myself to the Savanna Police Department, whether the said records are of a public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure f records of educational institutions; financial or credit institutions including records of loans, the records of commercial or retail credit agencies (including credit reports, and/or ratings); and other financial statements and records; employment and pre-employment records, including background reports, and performance ratings, but excluding information relating to medical conditions and medical history (unless a conditional offer of employment has been made); and, all records maintained by any criminal justice or corrections agency including, but not limited to, incident reports, arrest records and criminal history information.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the City of Savanna. I also agree to hold harmless any person(s) who may furnish such information concerning me; and I hereby release said person(s) from any liability which may be incurred as a result of furnishing such information.

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

I have read and full understand the contents of this "Authorization for Release of Personal Information". I understand that all information and documents turned over to the Savanna Police Department become the property of the Savanna Police Department and will not be returned to me.

SIGNATURE

ADDRESS

PHONE NUMBER

DATE OF BIRTH

SOCIAL SECURITY NO.

WITNESS

DATE