Address___________________________
First Middle Last __________________________________
Date of Birth-MONTH____ DAY____ YEAR______
Place of Birth___________________
City/County/State_______________________________________
State__________________________________________
Sos. Sec. # _____________________
Drivers License #_______________________
Sex _______
Race __________
Phone #: Day _____________
Eve. ______________
Have you had any convictions of Criminal Offenses ? ________
Any Pending ? _______
Have you had any convictions for a D.U.I. ? ________
Any Pending ? _______
If you answered yes to any of last four, state charges and year. _______________
List Three References.
Name Occupation Address Phone
1._________________ _________________ __________________ ______________
2._________________ _________________ __________________ ______________
3._________________ _________________ __________________ ______________
Signature,____________________________________ Date ___________________
Allow two-three weeks for initial checks.
You may return this form to the Town Hall, or mail to
Swayzee Police Department
P.O. Box 247
Swayzee, IN 46986