Official SealHuman Resource Services Department


#17-6049-08
Supplemental Questionnaire

Last Name
First Name
 

IMPORTANT:  Applicants for this position are required to submit responses to the following supplemental questions. 

By selecting yes below, you certify your understanding that all applicants must meet minimum qualifications in order to move forward in the process.  Do you understand the above statement?

Yes No
1.

Please indicate if you have ever been convicted of murder.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

2.

Please indicate if you have ever been convicted of unlawful sexual intercourse.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

3.

Please indicate if you have ever been convicted of rape.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

4.

Please indicate if you have ever been convicted of spousal battery.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

5.

Please indicate if you have ever been convicted of robbery.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

6.

Please indicate if you have ever been convicted of burglary.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

7.

Please indicate if you have ever been convicted of arson.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

8.

Please indicate if you have ever been convicted of grand theft.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

9.

Please indicate if you have ever been convicted of forgery.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

10.

Please indicate if you have ever been convicted of kidnapping.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

11.

Please indicate if you have ever been convicted of embezzlement.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

12.

Please indicate if you have ever been convicted of any sexual activity with a child.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

13.

Please indicate if you have ever been convicted of other forcible sex acts?

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

14.

Please indicate if you have ever been convicted of possession of a controlled substance.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

15.

Please indicate if you have ever been convicted of child abuse.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

16.

Please indicate if you have ever been convicted of possession for sale or sale of controlled substances.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

17.

Please indicate if you have ever been convicted of aggravated assault.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

18.

Please indicate if you have ever been convicted of a hit and run with injury.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

19.

Please indicate if you have ever been convicted of domestic violence.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

20.

Please indicate if you have ever been convicted of auto theft.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

21.

Please indicate if you have ever been convicted of the manufacturing/cultivating of a controlled substance.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

22.

Please indicate if you have ever been convicted of driving under the influence of alcohol or drugs.

Yes No
 

If you answered yes, please give the date (mm/dd/yyyy).

23.

Have you ever been detained for investigation or arrested for a violation of any criminal act?  If so, when?

24.

Have you used any controlled substances, including marijuana and/or prescription drugs (not prescribed to you), in the last five (5) years?  (If so, what controlled substances and when?)

25.

Have you ever been placed on probation?  If so, when and where?

26.

How many vehicle citation convictions and vehicle accidents do you have combined in the last three (3) years?

27.

Have you ever failed to appear for court?  If so, when?

28.

Has your California Driver's License ever been suspended, revoked, or restricted?  If so, when?

29.

Have you ever declared bankruptcy?  If so, when?

30.

Do you currently have any outstanding warrants or active restraining orders against you?

31.

I hereby certify that all statements made in this pre-investigative questionnaire are true and complete.  I understand that any misstatement or omission of material facts may disqualify me from the hiring process and/or be grounds for the termination of my employment?

Yes No