# North 861 Reservation Road - Shelton, Washington 98584 (2023) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Askokomish%3Aadb29bd860b14a48 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text Skokomish Tribal Police Department North 861 Reservation Road - Shelton, Washington 98584 Emergency Dial 911 - Office (360) 426-4740 — Fax (360) 877-6672 Employment Application me : Department Mission Statement : esate The Skokomish Tribal Police Department has been granted the responsibility and authority to enforce laws and regulations as set forth by the Skokomish Tribal Council. The primary purpose of the department is to provide for the safety and protection of human life and property. When properly carried out, the enforcement of tribal laws and regulations will enhance and strengthen the development of the Tribe’s human resources, encourage the development of the reservation, and support community values and goals for the achievement of self-determination as a Nation. The department further aspires to serve the Skokomish Tribe in a reasonable and prudent manner. The officers of this department are expected to carry out these responsibilities diligently and courteously and take pride in the services in which they provide ee Ba u Pe Age Applicant must be 21 years of age at date of commission Education Applicant must possess a high school diploma or G.E.D. Other Requirements _A citizen by birth or naturalization of the United States An individual who is expressly authorized to work in the United States Must be able to communicate effectively in written and spoken English Some positions may have additional requirements Required Documents —_ A copy of the following documents is required to be submitted with this application * Birth Certificate * High School Diploma or G.E.D. Certificate * Driver’s License (Washington required upon hire) * All applicable education Disqualification Applicants are advised that areas for disqualification from further consideration include, but are not limited to Factors the following. Reasons for disqualification will not be disclosed or discussed. * Current use of non-prescribed prescription or illegal drugs or abuse of prescribed prescription drugs * Any felony conviction and some misdemeanor convictions to include domestic violence charges * Driving record * Outside activities which may be classified as a conflict of interest * Revelation of assaultive behavior via background investigation or by the admission of the applicant * Unsuccessful possession of any of the basic requirements Skokomish Tnbal Police Department Branlammant Anallaceing (CTI AAV Ad anne Skokomish Tribal Police Department Employment Application Page 2 of 9 The application form must be completed in sufficient detail to allow comprehensive review and evaluation. Issuance or acceptance of an application shall not be construed as incurring an obligation by the Department. In no case shall acceptance of an application constitute assurance of consideration, and an applicant may be required to submit additional information for a position Position fot which you applying Job applying for Salary Expected -Petsonal Data First Name Middle Social Security - Address City State Zip Home Phone Daytime Phone Email Address Date of OO Male Birth \ A Sex [] Female Race Height Weight Hair Eye Check one C Single OO Married [1 Separated [] Divorced [] Widowed Spouses Name List any other names you have used (include Maiden Name) Date of Bith \ \ Starting with your present address, list all mailing addresses you have lived for the past ten (10) years. Do not forget to include zip codes. Date Street Address City State Zip From To \_\ \_\ \_\ \_\ \_\ \_N\ \_\ \_\ \_\ \_N\ \_\ \_N\ \_\ \_\ List three (3) references (not relatives, former employers or neighbors) who are responsible adults, and who have known you for at least the last five (5) years. Name Address CO Residence ([] Business How Long Known Occupation City State Zip Home Phone Altemate Phone Email Address Name Address (1) Residence [1] Business How Long Known Occupation City State Zip Home Phone Altemate Phone Email Address Name Address (J Residence [J Business How Long Known Occupation City State Zip Home Phone Alternate Phone Email Address Fmnlavment Anniicatian (SMPS43-01) 01/2005 Skokomish Tribal Police Depattment Employment Application Page 3 of 9 Education 4 Did you receive a high school diploma or G.E.D.? C] Yes [] No List all high schools, colleges, trade schools and universities you have attended in chronological order Diploma, Certificate or Dates Name Address Hours Have you ever been suspended, disciplined or expelled from any high school or institution of higher leaning? [1 Yes [] No If yes, explain Employment | Have you ever been dismissed or asked to resign from any employment? If Yes, Explain: Have you ever applied for any position with any law enforcement agency? [1 Yes [] No Date Position Agency Disposition \_A\ \ ON \_\ \_\ Have you attended a Law Enforcement Academy (1 Yes []No Were you Certified [] Yes [] No Name of Academy Date Attended \_\ Name of Academy Date Attended \ ON Name of Academy Date Attended \_\ Beginning with your present or most recent employer, list all of the places you have worked during the last ten (10) years period. Keep in proper order. List periods of school, military service, unemployment, volunteer service and part-time employment. From \_\ Name Title To \ \ Supervisor Phone Address City State Zip | Starting Salary Ending Salary Reason for Leaving | Describe duties and Functions: Skokomish Tribal Police Department Emnlawment Annlicatian (SMPS33.01) a1 /20ng Skokomish Tribal Police Department Describe duties and Functions: Employment Application Page 4 of 9 From \_\ Name Title To \ \ Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Describe duties and Functions: From VON Name Title To \ \ Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Describe duties and Functions: From \_N\ Name Title To \ oN Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Describe duties and Functions: From \ oN Name Title To \ A Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving ao a Emnlaument Annlicatinn (SMPS33-01) 01/7005 Skokomish Tribal Police Department Describe duties and Functions: Employment Application Page 5 of 9 From \ ON Name Title To XN Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Describe duties and Functions: From \AN Name Title To \ \ Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Describe duties and Functions: From \ ON Name Title To \\ Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Describe duties and Functions: From \_\ Name Title To VN Supervisor Phone Address City State Zip Starting Salary Ending Salary Reason for Leaving Skokomish Tribal Police Devartment Emplovment Application (SDPS33-01) 01/2005 Skokomish Tribal Police Department Employment Application Page 6 of 9 Arrest History The following questions pertain to your experiences in this country and all other countries as both a juvenile and an adult. Do not include minor traffic violations. Have you ever had any contact with any law enforcement official [Yes [LJNo Have youever been convicted of a crime 1 Yes [] No Have you ever been wamed about anything bya law enforcement official [0 Yes [No _ Have youever been booked into jail O1 Yes [No Have you ever been detained bya law enforcement official (J Yes [JNo Have youever received a criminal citation O1 Yes []No Have any relatives or you or your spouse ever been convicted or Have you ever been accused of a crime (1 Yes [No _ held in any detention facility, jail or prison (1 Yes [J] No Have you ever been charged with a crime (Yes [JNo _ Have the police ever been called to your home for any reason (1 Yes [1 No Have you ever been arrested (1 Yes LJ No List Incidents below Date Reason/ Charge Agency Disposition/Sentence \\ \ \ \ \ \ oN \ A \ \ \ \ Se eee ee eee Ore eee De pee eure Nee ee ee ie List all driver’s or chauffeurs licenses you now hold Issue Date Type of License Expiration Date State License Number \_\ \_\ \ A \_\ \_A\ \_A\ Have you ever had a driver’s license canceled, refused, revoked or suspended. (1 Yes [] No Have you ever had driving privileges suspended [C1 Yes [] No Have you ever been charged with Driving Under the Influence of Alcohol or Drugs [C1] Yes [J No Have you ever been charged with a criminal traffic offense (1 Yes [] No Do you exceed the 6-point driving violation limit for the most recent 60 months, when the Skokomish Tribal Police Department standards are applied to your driving history? (Yes [] No Skokomish Tribal Police Department Driving Standards (For 60 month period preceding application) Violation Points Violation Points Revocation of driver’s license 8 Hit and run (unattended) 6 Denial of issuance of driver’s license 8 Driving while license suspended (DWLS) 4 Negligent homicide 8 Speeding in excess of the posted limit Driving while intoxicated (involving accident) 8 0-14 over 2 Driving while intoxicated (no accident involved) 6 15 - 19 over 3 Reckless driving (involving accident) 8 20 - 25 over 4 Reckless driving (no accident involved) 6 Excess of 25 over 6 Negligent driving (involving accident) 6 Convictions or forfeitures for other moving violations Negligent driving (no accident involved) 4 Each violation involving an accident 4 Hit and run (attended) 8 Each violation not involving an accident 2 Gambling Do you now, or have you ever had any gambling debts |] Yes [No Have you ever worked for a gambling operation or booked any bets _ 1] Yes [] No Clealnwiah Teéhal Dalian Danatmant Bemnlarmant Annlieatian (STYDC32.91) 01 /9NNG Skokomish Tribal Police Department Employment Application Page 7 of 9 Have you ever used an employer's money to gamble O Yes [No Liquor and Narcotics Do you drink Alcoholic beverages C1 Yes [J No What kind How much Have you ever had difficulty with your family or employment due to drinking (1 Yes [No Have you ever tried or used any narcotic or dangerous drug without a doctors prescription (1 Yes []No Tf you have tried, used or ingested any of the following drugs listed below, check the yes box. If you have not, check the no box. Include the number of times used and dates Substance Times Used Times since 21: birthday Dates Marijuana O1 Yes —] No Inhalants C] Yes [] No Thai Sticks OJ Yes [] No Barbituates (1 Yes [1 No Amphetamines (1 Yes (] No Hashish 0 Yes [] No: Cocaine 0 Yes [] No Heroin 1 Yes [] No Opium CJ Yes [] No Injectable Steroids 0 Yes (] No Hallucinogens (1 Yes (1 No If you have tried or used any of the drugs listed above or if you have tried or used any other drug without a doctor’s prescription, explain in detail below. Skokomish Tribal Police Department Employment Application (SDPS33-01) 01/2005 Skokomish Tribal Police Department Employment Application Page 8 of 9 : Military Status Have you ever served in the Army, Navy, Air Force, Mannes, Cost Guard, R.O.T.C, or any other military or semi-mulitary organization L] Yes [] No Date Entered Branch or Organization Discharge Date Type of Discharge Rank \_\ \_\ \_\ \_\ \_\ \\ List all military service numbers Selective service number Current military status Did you ever receive any disciplinary action while serving in the military O1 Yes [] No If answered yes, explain ae Read the following statement carefully and sign Application is invalid unless signed by the applicant The application is invalid unless signed by the applicant. The Skokomish Tribal Police Department’s community oriented philosophy is to treat our public, clients, visitors and co-workers with respect. All employees are required to adopt and demonstrate through performance their dedication to this philosophy. I hereby certify that the facts set forth on this application are true and complete and that any misrepresentation, falsification or willful omission herein shall be sufficient reason for dismissal or refusal of employment. T authorize the Skokomish Tribal Police Department and any agent acting on its behalf to conduct an inquiry into any information related to my potential or continued employment with the Department. I also authorize the release of any such information including but not limited to any criminal conviction an my record. I hereby release from liability Skokomish Indian Nation and its agents acting on its behalf for seeking, gathering and using such information, as may be allowed by law, and all other persons, employers, corporations or organizations for furnishing such information. I recognize that any and all inquiries made by the Skokomish Tribal Police Department and any agents acting on its behalf and any verbal or written statements gathered there from shall remain solely the property of the Skokomish Tribal Police Department. Talso understand that if accepted for employment, I shall be required to sign a loyalty oath in addition to providing proof of identity and eligibility to work in the United States. Signature Date Skokomish Tribal Police Department Employment Application (SDPS33-01) 01/2005 Skokomish Tribal Police Department Employment Application Page 9 of 9 [ Authorization for Release of Information | Read the authorization of information listed below. Your completion of this document allows the Skokomish Tribal Police Department to investigate your background and gives your permission for the release of information from the below listed sources. After affixing your signature to the release form, you must print your name beneath your signature. To whom it may concern I respectfully request and authorize you to provide the Skokomish Tribal Police Department and/or any representative thereof any and all information that you may have concerning the following: 1. Employment history, including without limitation all disciplinary records, performance evaluations, attendance records and any other matters contained in my personnel file 2. Scholastic records 3. financial records and credit information 4. Records maintained by any law enforcement agency, including but not limited to records of arrest and/or conviction, juvenile records, or those relating to traffic violations This information is to be used to assist the Skokomish Tribal Police Department in determining my qualifications and fitness for the position I am seeking with the Department. Please provide the Skokomish Tribal Police Department and/or any representative thereof any information falling within the categories listed above, including any information which otherwise would be considered confidential or privileged, and permit the Skokomish Tribal Police Department and/or any representative thereof to make copies of that information if they so desire. I hereby release, and hold harmless, on behalf of me, my heirs, assigns and successors interest forever, both you and/or your employer or educational facility/ organization from any liability or damage whatsoever which may result because of your responses to this request for information. Further, I covenant not to sue you or your employer or educational facility/ organization for any information which is released in response to this request. In making these statements, I understand that information which you give may result in my not being employed. A photocopy reproduction of this request shall be for all intents and purposes as valid as the original. This release remains effective until you receive signed written instructions to the contrary. You may retain this form in your files. Date \ \ Signature Print Name Date of Birth \\ Social Security Number Skokomish Tribal Police Department Employment Application (SDPS33-01) 01/2005 Skokomish Tribal Police Department North 861 Reservation Road - Shelton, Washington 98584 Emergency Dial 911 - Office (360) 426-4740 - Fax (360) 877-6672 Pre-Employment Investigation Discovery Waiver As an applicant to the Skokomish Department of Public Safety for the position of , | understand that an employing law enforcement agency has a legal as well as a moral obligation to take every reasonable effort to ensure that persons employed by them as peace officers or in other positions conform to the very highest standards. Therefore, I release and hold harmless the Skokomish Department of Public Safety and their officers, agents or assigns, now and in the future, from any claim or damages in law of inequity on behalf of myself, my heirs and assigns, for their refusal to make available any and all of the information contained in this pre-employment investigation, including, but not limited to, the identity(ies) of any person(s) and/or organization(s) which may have supplied information in the course of this investigation, as well as the substance of any information supplied I hereby waive my right, now and in the future, to examine, review, ot otherwise discover the contents of this investigation and all related documents thereto. Applicant Signature _ /_/ Signature of Applicant Date __Notary Public Subsctibed and Sworn to before me the day of , 20 Notary Public in and for said County of , State of Notary Public Skokomish Tribal Police Department Pre-Employment Investigation Discovery Waiver (SDPS36-01) 10/2005 Skokomish Tribal Police Department North 861 Reservation Road ~ Shelton, Washington 98584 Emergency Dial 911 - Office (360) 426-4740 - Fax (360) 877-6672 Child Support Affidavit Please mark the appropriate response. Failure to mark one of the three will result in the denial of your application. O I am not subject to a court order for the support of a child O I am subject to a court order for the support of one or more children and I am in compliance with the order, or I am in compliance with a plan approved by the District Attorney (or other public agency), enforcing the order for the repayment of the amount owed, pursuant to the order. O I am subject to a court order for the support of one or more children and I am NOT in compliance with the order or a plan approved by the District Attorney (or other public agency), enforcing the order for the repayment of the amount owed, pursuant to the order. Applicant’s Social Security Number: - - Signature /_/ Signature Date _Notary Public Subscribed and Sworn to before me the day of ,20__. Notary Public in and for said County of , State of Notary Public Skokomish Tribal Police Department Child Support Affidavit (SDPS38-01) 10/2005 Skokomish Tribal Police Department North 861 Reservation Road - Shelton, Washington 98584 Emergency Dial 911 - Office (360) 426-4740 ~ Fax (360) 877-6672 Certification and Penalty I hereby declare that all statements and information provided to the Skokomish Tribal Police Department in this Personal History Statement, as well as any other statements and information provided for my pre-employment background investigation or any other phase of my pre-employment screening, are true and complete to the best of my knowledge and belief. I understand that any mis-statement of material fact, willful omission or material fact, or willful deception, will be cause for disqualification and rejection as a candidate for employment, without appeal. I further understand that these aforementioned mis-statements, omissions, or deceptions are also grounds for termination after employment, without notice and without any right or appeal. Applicant Signatute /_/ Signature of Applicant Date ___ Notary Public Subscribed and Sworn to before me the day of 20 Notary Public in and for said County of , State of Notary Public Skokomish Tribal Police Department Certification and Penalty Form (SDPS37-01) 10/2005 Bureau of Indian Affairs — Office of Justice Services (BIA-OJS) NOTICE OF CRIMINAL HISTORY CHECK OF FBI RECORDS AND NOTICE OF APPLICANT’S RIGHT TO CHALLENGE ACCURACY OF CRIMINAL HISTORY RECORD As an applicant for employment and/or volunteer service with BIA-OJS, you are being provided with a copy of this form to serve as a formal notice that your fingerprints will be used to check the criminal history record files that are kept by the FBI Criminal Justice Information Services (CJIS) for any criminal history records attributable to you. The results of this check are known as an Identity History Summary (IdHS). BIA-OJS is required to retain the original copy of this signed NOTICE OF CRIMINAL HISTORY CHECK OF FBI RECORDS AND NOTICE OF APPLICANT’S RIGHT TO CHALLENGE ACCURACY OF CRIMINAL HISTORY RECORD and to provide a copy of this notice to you. Once the criminal history check is complete, you may obtain a copy of your IdHS by contacting: BIA-OJS, Internal Affairs Division, Background Unit, 1001 Indian School Road, Suite 251, Albuquerque, NM 87104 (505) 563-3244. In the event that you believe the results of your IdHS are incomplete or inaccurate, you have an opportunity to challenge the accuracy of that information. Applicants may request updates and/or corrections to information in their IdHS by either: a. Contacting the Tribal, state or Federal agency (or agencies) that provided the challenged information to the FBI; or b. Sending a written challenge request to the FBI’s Criminal Justice Information Services (CJIS) Division: FBI CJIS Division, Attention: SCU, Mod. D-2, 1000 Custer Hollow Road Clarksburg, WV 26306 Your written request should be addressed to the FBI, as listed above, and should clearly identify the information that you feel is inaccurate and/or incomplete. It is advisable to include copies of any available proof or documents that support your claim. For example, if information about what happened to a criminal charge against you is incorrect or missing, you may submit documentation from the court or the office that prosecuted the offense. Please be aware that the FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and Federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based record checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including criminal justice, non-criminal justice, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. Routine Uses: During the processing of this application, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine Uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, Tribal or Federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. More information about your rights can be found in the Privacy Act (5 USC 552a) and in 28 C.F.R.§ 16.34. NOTICE OF CRIMINAL HISTORY CHECK OF FBI RECORDS AND NOTICE OF APPLICANT’S RIGHT TO CHALLENGE ACCURACY OF CRIMINAL HISTORY RECORD Acknowledgement | have been advised that | may request my IdHS when the final results are received. | further understand that | have the right to challenge information contained in my IdHS and have been provided a copy of this notice with instructions regarding the process for making a request for the correction and/or update of information contained in my IdHS. Applicant Agency Point of Contact (Signature) (Signature) (Print Name) (Print Name) (Date) (Date) NOTICE OF CRIMINAL HISTORY CHECK OF FBI RECORDS AND NOTICE OF APPLICANT’S RIGHT TO CHALLENGE ACCURACY OF CRIMINAL HISTORY RECORD Information contained in this questionnaire is for official use only. Investigative Questionnaire for Law Enforcement Position Notice to Applicant: The Crime Control Act of 1990, Public Law 101-647 (codified in 42 United States Code § 13041), requires that employment applications for law enforcement positions have a national criminal and financial record check and will be conducted as a condition of employment. 1. Full Name 2. Date of Birth Last Name First Name Middle Name Jr., Il, ete. Month 00 Day 00 Year 0000 3. Other Names Used — Maiden name, from a former 4. Driver’s License No. 5. Social Security Number marriage, alias(s), or nickname(s). Name No.: State: 6. Your Telephone No. 7. Place of Birth Home Cell City County State (_) (_) 8. Other Identifying Information Height (feet and inches) Weight (pounds) Hair Color Eye Color Sex (Mark one box) Female oO Male oO 9. Citizenship lama U.S. citizen or national by birth in the U.S. or U.S. territory/possession. country in the space provided below. lama U.S. citizen, but |! was NOT born in the U.S. If you have checked this box, provide information about your proof of citizenship in the space provided below. oO Cl jam a U.S. citizen, and | have dual citizenship with another country. If you have checked this box, provide the name of that O Oo lam not a U.S. citizen. If you have checked this box, provide when you entered the U.S., your Alien Registration Number, and Country of Citizenship. Use this space to provide citizenship information. 10. Residence — List where you have lived, beginning with the most recent and working back 10 years. All periods in the last 10 years must be accounted for in your list. Month/Year Month/Year Street Address City State Zip code 1) To Present Month/Year Month/Year Street Address City State Zip code 2) To Month/Year Month/Year Street Address City State Zip code 3) To Month/Year Month/Year Street Address City State Zip code 5) To Month/Year Month/Year Street Address City State Zip code 6) To 11. Residence/Employment on an Indian Reservation - List any Indian Reservation, Village, Community, Rancheria or Pueblo in which you have lived or worked in the last 10 years. Information contained in this questionnaire is for official use only. Full Name Date of Birth Last Name First Name Middle Name Jr. Il, ete. Month 00 Day 00 Year 0000 12. Education — List the schools you have attended beyond high school, beginning with the most recent and working back 10 years. You MUST list College or University degrees and the dates they were received. Month/Year Month/Year Name of School Choose one: If degree received, [Degree Attendance Only | Month/Year Awarded O Diploma 1 Other 1) To Street Address and City of School State Zip Code Month/Year Month/Year Name of School Choose one: If degree received, O1 Degree 1 Attendance Only | Month/Year Awarded ODiploma TC Other 2) To Street Address and City of School State Zip Code 13. Employment History - List your employment activities, beginning with the present and working back 10 years. The 10 year period must be accounted for without breaks. For periods of unemployment, list dates and “unemployed” or “attending school.” Month/Year Month/Year Employer Name Position Title 1) To Employer Street Address City State Zip Code Supervisor's Name Telephone number Other Employer Reference Telephone Number (_) (__) For this employment, in the last ten (10) years have you/did you receive a written warning, been officially reprimanded, suspended or disciplined for misconduct in the workplace, such as a violation of policy? LINo [1 Yes If Yes, Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) If no longer employed, specific reason you left: Month/Year Month/Year Employer Name Position Title 2) To Employer Street Address City State Zip Code Supervisor's Name Telephone number Other Employer Reference Telephone Number ( For this employment, in the last ten (10) years have you/did you receive a written warning, been officially reprimanded, suspended or disciplined for misconduct in the workplace, such as a violation of policy? LINo 1 Yes If Yes, Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Reason you left Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial | Jr., Il, etc. | Social Security Number Month/Year Month/Year Employer Name Position Title |_3) To Employer Street Address City State Zip Code Supervisor's Name Telephone number Other Employer Reference Telephone Number (_) ( For this employment, in the last ten (10) years have you/did you receive a written warning, been officially reprimanded, suspended or disciplined for misconduct in the workplace, such as a violation of policy? LINo C1 Yes If Yes, Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Reason you left Month/Year Month/Year Employer Name Position Title 4 To Employer Street Address City State Zip Code Supervisor's Name Telephone number Other Employer Reference Telephone Number ( LI No O Yes For this employment, in the last ten (10) years have you/did you receive a written warning, been officially reprimanded, suspended or disciplined for misconduct in the workplace, such as a violation of policy? If Yes, Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Reason you left Month/Year Month/Year Employer Name Position Title 5) To Employer Street Address City State Zip Code Supervisor's Name Telephone number Other Employer Reference Telephone Number (__) Date: (Month/Year) For this employment, in the last ten (10) years have you/did you receive a written warning, been officially reprimanded, suspended or disciplined for misconduct in the workplace, such as a violation of policy? [No Yes If Yes, Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Reason you left Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr., Il, etc. | Social Security Number Employment Record 14. In the last 10 years, have you been: Fired from any job for any reason? Did you quit after being told that you | YES would be fired? Did you leave any job by mutual agreement because of allegations of misconduct? ol NO If you answered “Yes”, begin with the most recent occurrence and go backward, providing date fired, quit, or left, and other information requested below. Month/Year Month/Year Specify Reason Employer's Name and Address 1) To Month/Year Month/Year Specify Reason Employer's Name and Address 2 To 15. Personal References — List 3 people who know you well. They should be good friends, peers, roommates, etc., and who have known you for at least the last 10 years. Do not list relatives or anyone who is listed elsewhere else on this form. 1) Name Dates Known Telephone Number Month/Year Month/Year O Day To O Night (__) Home or Work Address City State Zip Code 2) Name Dates Known Telephone Number Month/Year Month/Year O Day To O Night( _) Home or Work Address City State Zip Code 3) Name Dates Known Telephone Number Month/Year Month/Y ear O Day To O Night( _) Home or Work Address City State Zip Code 16. Your Spouse Mark one box to show your current marital status and provide information about your spouse(s) in items a and/or b below. 11 Never married. O Separated O1 Divorced 1 Married O1 Legally Separated O Widowed A | Current Spouse — Complete the following about your current spouse only. Full Name Date of Birth Place of Birth Social Security No. Other Names Used (Specify maiden names, names by other marriages, etc., and show dates used for each name) Country of Citizenship Date Married Place Married State If Separated, Date of Separation If Legally Separated, Where is the Record Located? City State Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr, Il etc. Social Security Number B | Former Spouse(s) - Complete the following about your former spouse(s). Use blank sheets if needed. Full Name Date of Birth Place of Birth Country of Citizenship Date Married Place Married State Check one, then give date. | Month/Year lf Divorced, where is the Record Located? City State O1 Divorced O Widowed 17. Citizenship of Your Relatives and Associates A | [If your mother, father, sibling, child, spouse or person with whom you have a spouse-like relationship is a U.S. citizen by OTHER than birth, or if they are an alien residing in the U.S., provide nature of the individual's association to you (ie., spouse, mother, etc.), and the individual's name and date of birth below. 1) Association Name Date of Birth 2) Association Name Date of Birth B | Provide the individual's naturalization certificate information or alien registration number below. 1) Certificate/Registration No.: 2) Certificate/Registration No.: Military History 18. Have you served in the United States military? YES NO 19. Have you ever received other than an honorable discharge from the military? If “Yes”, provide the date of YES NO discharge and type of discharge below. cl Cl Month/Y ear Type of Discharge 20. List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service and work backward. If you had a break in service, each separate period should be listed. e Available Codes: 1- Air Force 2-Army 3-Navy 4-Marine Corps 5-Coast Guard 6-Merchant Marine 7-National Guard ® Mark appropriate block for either Officer or Enlisted. ® Status-Mark the appropriate block for the status of your service during the time that you served. Month/Year Month/Year Code Officer | Enlisted Status Country Active Active Reserve Inactive Reserve | National Guard (state) 1) To Selective Service Record 21. Are you a male born after December 31, 1959? YES | NO If you answered “Yes” to the question above, have you registered with the Selective Service System? If “Yes”, YES NO provide your registration number. If “No”, provide the reason for your legal exemption. ol Cl Registration Number Legal Exemption Explanation Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr. Il, etc. | Social Security Number Medical Record 22. In the last 10 years, have you consulted with a mental health professional (psychiatrist, psychologist, YES NO counselor, etc.) or have you consulted with another health care provider about a mental health related condition? ol oO If you answered “Yes”, provide the dates of treatment and the name and address of the therapist or doctor below, UNLESS the consultations(s) involved ONLY marital, family or grief counseling, not related to violence by you. MonthYear Month/Year Name/Address of Therapist or Doctor State Zip code 1) To Month/Year Month/Year Name/Address of Therapist or Doctor State Zip Code 2 To Your Foreign Activities 23. Do you have any foreign property, business connections, or financial interests? YES 24. Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm, or YES agency? Ol 25. Have you ever had a contract with a foreign government, its establishments (embassies or consultants), orits | YES representatives, whether inside or outside the U.S., other than on official US. Government business? (Does not oO include routine visa applications and border crossing contacts). 26. In the last 10 years, have you had an active passport that was issued by a foreign government? YES Osaosaosaa lf you answered “Yes”, to any of the questions in this section, explain in the space below the dates, names of firms and/or governments involved, and an explanation of your involvement. Month/Year Month/Year Firm and/or Government Explanation 1) To Month/Year Month/Year Firm and/or Government Explanation 2) To 27. Foreign Countries You Have Visited- List foreign countries you have visited, except on travel under official Government orders, beginning with the most current and working back 10 years. ° Available Codes: 1-Business 2-Pleasure 3-Education 4-Other @ Include short trips to Canada and Mexico. If you have lived near a border and have many short (one day or less) trips to the neighboring country, you do not need to list each trip. Instead, provide the time period, the code, the country, and a note (‘Many short trips”) MonthYear Month/Year Code Country Month/Year Month/Year Code Country 1) To 3) To Month/Year Month/Year Code Country Month/Year Month/Year Code Country 2) To 4) To Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr., Il, etc. | Social Security Number Association Record 28. Have you ever been an officer or a member or made a contribution to an organization dedicated to the violent overthrow of the U.S. Government and which engages in illegal activities to that end, knowing that the organization | engages in such activities with the specific intent to further such activities? 29. Have you ever knowingly engaged in any acts or activities designed to overthrow the U.S. Government by force? DOsaio4 If you answered “Yes”, explain your answer in the space below. Police Record-For this section, report information regardless of whether you believe the record in your case has been “sealed” or otherwise stricken from the court record. The single exception to this requirement is for certain convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. 30. Have you ever been charged with or convicted of any felony offense? YES NO 31. Have you ever been charged with or convicted of a firearms or explosives offense? OO 32. Have you ever been charged with or convicted of any offense(s) related to alcohol or drugs? YES O70 probation, or been on parole for any offense(s) not listed in the responses above? Include all offenses where 33. In the last 10 years, have you been convicted by a military court-martial or other disciplinary proceedings NO under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast, etc.) oO 34. Have you ever been arrested for or charged with a crime involving a child? YES NO 35, Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to, any YES NO felonious offense, or any of two or more misdemeanor offenses under Federal, State, or tribal law involving | Cl crimes of violence; sexual assault, molestation, exploitation, contact or prostitution; crimes against persons; or offenses committed against children? 36. In the last 10 years, have you been arrested for, charged with, or convicted of, been imprisoned, been on YES NO you have been found guilty, pled guilty or nolo contendere (no contest). (Include traffic fines and accidents where you were the driver.) 37. Have you ever been a subject of a restraining order or an order of protection? < Os (ep) Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr. Il, etc. | Social Security Number 38. Have you ever been a subject of a grand jury investigation? YES NO O |O 39. Are you now under charges for any violation of law or are there currently any charges pending against YES NO you for any criminal offense? oO oO 40. Have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement YES NO officer? O |O If you have answered “Yes”, for any of the above questions in this section, explain your answer(s) below. Question #_| Month/Year Offense Action Taken Arresting Law Enforcement /Military Agency State Illegal Drugs and Drug Activity-You are required to answer the questions fully and truthfully, and your failure to you responses will be used as evidence against you in any subsequent criminal proceeding. do so could be ground for an adverse employment decision or action against you, but neither your truthful responses nor information derived from 41. Since the age of 16 or in the last 10 years, whichever is shorter, have you illegally used any controlled YES NO substance, for example, marijuana, cocaine, crack cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), amphetamines, depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenic (LSD, C CO PCP, etc.), or illegally used prescription drugs? 42. Have you ever illegally used a controlled substance while employed as a law enforcement officer, YES NO prosecutor, or courtroom official; while possessing a security clearance; or while in a position directly and immediately affecting the public safety? CO CI 43. In the last 10 years, have you been involved in the illegal purchase, manufacture, trafficking, production, YES NO transfer, shipping, receiving, or sale of any narcotic, depressant, stimulant, hallucinogen, or cannabis, for your own intended profit or that of another? CO Ol If you answered “Yes”, provide the date(s) and explanation of your use below. Question # | Month/Year Month/Year Controlled Substance/Prescription Drug Used Number of Times Used 1) To Question # | Month/Year Month/Year Controlled Substance/Prescription Drug Used Number of Times Used 2) To Use of Alcohol 44. In the last 10 years, has your use of alcoholic beverages (such as liquor, beer, wine) resulted in any alcoholrelated treatment or counseling (such as for alcohol abuse or alcoholism)? YES NO OO If you answered “Yes”, provide the date(s) of treatment/counseling and additional information below. Month/Year Month/Year Name/Address of Counselor or Doctor State Zip code 1) To Month/Year Month/Year Name/Address of Counselor or Doctor State Zip code 2) To Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr., Il, etc. | Social Security Number Public Record Civil Court Actions 45. In the last 10 years, have you been a party to any public record civil court actions not listed elsewhere on this form? YES Ci If you answered “Yes”, for any of the above questions in this section, provide the information requested below. Incurred Nature of Action Result of Action Name of Parties Involved Court Month/Year Financial Records 46. In the last 10 years, have you, or a company over which you exercised some control, filed under any chapter of the bankruptcy code or been declared Bankrupt? < m™m (ep) 47. In the last 10 years, have you had your wages garnished or had any property repossessed for any reason? YES NO O |o 48. In the last 10 years, have you had a lien placed against your property for failing to pay taxes or other debts? YES NO O |o 49. In the last 10 years, have you had any judgments against you that have not been paid? YES NO O |a 50. In the last 10 years, have you defaulted on any type of loan? YES NO O |do 51. In the last 10 years, have you had bills or debts turned over to a collection agency? YES NO O a 52. Have you EVER experienced financial problems due to gambling? YES NO O | oO 53. Have you ever been under investigation for embezzlement? YES NO If you answered “Yes”, for any of the above questions in this section, provide the information requested below. Question # Month/Year Type of Amount Name Action Name/Address of Creditor or Obligee and/or Action Occurred Under Name of Court or Agency Handling Case Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr, Il, ete. Social Security Number Use of Information Technology Systems 54. In the last 10 years, have you illegally or without proper authorization entered into information technology system? YES NO 55. In the last 10 years, have you illegally or without proper authorization modified, destroyed, manipulated or denied others access to information residing an information technology system? 56. In the last 10 years, have you introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rule, procedures, guidelines or regulations? O YES O YES O oOso2zo If you answered “Yes”, for any of the above questions in this section, provide the information requested below. Question # Nature of Incident/Offense Location of Incident Action Taken Use this space or a separate sheet to provide additional explanations or information to any questions you may have answered, "Yes" on this form. Ensure full name and social security number is on any attachments to this form. 10 Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr., ll, etc. | Social Security Number Certification that my Answers are True My statements on this application, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. | understand that a false or fraudulent answer to any question or item on any part of this application or its attachments may be grounds for not hiring me, or firing me after | begin work, and may be punishable by fine or imprisonment. Applicant's initials Date | certify that my responses to the above questions are made under penalty of perjury, which is punishable by fine or imprisonment, and that | have received notice that a national criminal history records check will be conducted and is a condition of employment. | understand my right to obtain a copy of any national criminal history report made available to the Skokomish Indian Tribe and my rights to challenge the accuracy and completeness of any information contained in the report. Applicant’s Signature Printed Name Date 11 Information contained in this questionnaire is for official use only. Application continuation Last Name First Name Middle Initial Jr. ll, etc. | Social Security Number Release to Obtain a Credit Report Fair Credit Reporting Act of 1970, as amended. One or more consumer credit reports may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, as amended, 15 U.S.C. § 1681, et seq. Should a decision to take any adverse action against you be made based either in whole or in part on the consumer credit report, the consumer reporting agency that provided the report played no role in the Skokomish Indian Tribe ’s decision to take such adverse action. Information provided by you on the form will be furnished to the consumer reporting agency in order to obtain information in connection with an investigation to determine your (1) fitness for employment, (2) clearance to perform contractual services, and/or (3) security clearance or access. The information obtained may be re-disclosed to other agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law. Your Social Security number is needed to keep records accurate, because other people may have the same name. | hereby authorize the Skokomish Indian Tribe, to obtain such report(s) from any consumer/credit reporting agency for employment purposes. Applicant's Signature Printed Name Date 12 Information contained in this questionnaire is for official use only. Authorization for Release of Information | authorize any investigator, or other duly accredited representative of the agency conducting my background investigation, to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and national criminal history record information. | further authorize any investigator, or other duly accredited representative of the Skokomish Indian Tribe, who is conducting my background investigation, to request national criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in a position working with children. | understand that | may request a copy of such records as may be available to me under the law. | authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, or other duly accredited representative authorized above regardless of any previous agreement to the contrary. | understand that the information released by records custodians and sources of information is for official use by the Skokomish Indian Tribe only for the purpose of determining my suitability for employment with the Skokomish Indian Tribe. Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for five (5) years from the date signed or upon the termination of my affiliation with the Skokomish Indian Tribe, whichever is sooner. Signature (sign in black ink) Printed Name Date Signed Position for Which you are being Investigated. Primary Contact Number Current Address State Zip Code Secondary Contact Number (__) 13 Information contained in this questionnaire is for official use only. Authorization for Release of Medical Information This is a release for the investigator to ask you health practitioner(s) the three questions below concerning your mental health consultations. Our signature will allow the practitioner(s) to answer only these questions. | am seeking assignment to or retention in a position with the Skokomish Indian Tribe which may require access to Classified national security information. As part of the clearance process, | hereby authorize the investigator, special agent, or duly accredited representative of the Skokomish Indian Tribe conducting my background investigation, to obtain the following information relating to my mental health consultations: Does the person under investigation have a condition or treatment that could impair his/her judgment or reliability, particularly in the context of safeguarding classified national security information? If so, please describe the nature of the condition and the extent and duration of the impairment or treatment. What is the prognosis? | understand that the information released pursuant to this release is for official use by the Skokomish Indian Tribe only for the purpose of determining my suitability for employment in a law enforcement position with the Skokomish Indian Tribe. Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for one (1) years from the date signed or upon the termination of my affiliation with the Skokomish Indian Tribe whichever is sooner. Signature (sign in black ink) Printed Name Date Signed Position for Which you are being Investigated. Primary Contact Number Current Address State Zip Code Secondary Contact Number (_) 14 [OCR skipped on page(s) 31-35] [Read from a scan; the first 30 pages.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Askokomish%3Aadb29bd860b14a48. Public record. Not legal advice.