MILTON BOROUGH POLICE DEPARTMENT BOROUER E - = - XIXIXI - A B POLICE OFFICER APPLICATION Milton Borough Police Department - 1 Filbert Street, Milton, PA 17847 Page 1 of27 MILTON BOROUGH POLICE Chief Curt D. Zettlemoyer 1 Filbert Street, Milton, PA. 17847 Email: miltompdemitompdors Ph: 570-742-8757 Fax: 570-742-2325 Dear Police Applicant, May 30, 2025 Thank you for your interest in becoming a Police Officer with Milton Borough Police Department (MPD). Milton Police Department prides itself on the quality of its members. We hold our officers to a high standard of service and expect them to serve Milton Borough in a professional manner. Milton Borough Police Department offers a competitive salary, and an attractive benefits package. The testing process will include a written examination, physical agility test, and oral panel interview. Upon successful completion of these three phases, you will move forward in the eligibility process. Additional testing will take place prior to appointment. During the application process you will be asked to provide information about yourself that will be used in an investigation to evaluate your suitability for employment. Your cooperation will aid in the investigation and expedite the results. Please complete the application in its entirety. Failure to do sO will result in rejection of your application. It is to your advantage to respond openly and honestly. If you are untruthful, dishonest, knowingly omit, falsify, conceal, or obscure required information, or engage in similar misconduct or deception during any phase of the application and hiring process, you may be permanently disqualified. Please make certain the application is completed in full, and all information that is requested to be included with the application is attached prior to submission. Congratulations on your decision to pursue a career in policing and best of luck in your endeavor. Sincerely, Curt D. Zettlemoyer, Chief of Police Page 2 of 27 ON PE POLICE OFFICER APPLICANTI PROCESSING PROCEDURE The Police Officer applicant must fully complete the attached application in his/her own handwriting. The applicant must obtain proper notarization and original signatures on required forms, and return the application and requested information and document copies to the Milton Borough Police Department on or before: Monday, June 30th, 2025, by 2:00 p.m. GENERAL APPLICANT REQUIREMENTS 1. You must be a citizen of the United States of America. 2. All applicants must possess, at the minimum, a high school diploma or possess a graduate equivalency diploma. 3. You must be 21 years of age by the date of the written examination. 4. You must possess a valid motor vehicle operator's license prior to appointment and possess no suspension on said license for a period of ten (10) years prior to the date of application. 5. Must have or be eligible to obtain ACT 120 Certification prior to the date of appointment. 6. Be physically and mentally fit to perform the full duties of a police officer. 7. Successfully pass written and oral examinations, and physical agility test. Upon a vacancy, candidates on the eligibility list will need to pass a background and polygraph examinations along with medical and psychological examinations. AUTOMATICI DISQUALIFICATION An applicant may not apply and will be disqualified for any of the following criminal behavior: Criminal conviction of Misdemeanor-2 or higher. Criminal conviction of any section listed in the Uniform Firearms Act, Brady Law, Megan's Law or any other federal law or amendment prohibiting possession of a firearm. All convictions relating to drug use, drug possession and related criminal offenses. Any conflicts with the Municipal Police Officer's Education and Training Commission Certification Standards. ITEMSTO BE INCLUDED WITH THIS APPLICATION PACKET UPON SUBMISSION Photocopy of High School Diploma or G.E.D. Certificate Official certified college transcripts. All educational transcripts should be mailed directly to the police department in an officially sealed envelope from the school or attached to the application. Naturalization or Citizenship papers (if applicable) DD214 (if served in the military*). Name change documents. Copy of MPOETC certification card or Act 120. Academy certificate (if applicable) MPOETC transcripts (if applicable) Current PA Child Abuse History Clearance obtained from the Pa Dept. of Welfare (Form CY 113) Photocopy of a valid driver's license. *Qualifying veterans of military service will, upon successful completion of all portions of the hiring process, will receive additional points on their overall final score. In order to receive additional points, all veterans must attach a copy of their DD214 to their application. Page 3 of 27 APPLICATION FORTHE POSITION OF POLICE OFFICER (PRINT CLEARLY) FULL NAME: FIRST MIDDLE MAIDENI NAME LAST SUFFIX NICKNAME ADDRESS: COMPLETE. ADDRESS (NOI PO BOX) COUNTY STATE ZIP CODE GENERAL: RACE SEX AGE DATE OF BIRTH SOCIAL SECURITY NO. DR. LICENSE STATE & NO. CONTACT INFO: PRIMARY PHONE NO. PHONE NO.2 PHONE NO.3 EMAIL ADDRESS OTHER INFO; SELECTIVE: SERVICE NO. CITY/STATE/COUNTRY OF BIRTH NATURALIZATIONI NO. (IF APPLICABLE) Other names (alias, maiden names, and nicknames) by which you have been known. Please include the time period these names were used. Please explain in your own words why you wish to become a Milton Borough Police Officer and why you believe that you are suited for this position? Page 4 of27 ON PE POLICE WORKIN GENERAL The position of Police Officer involves shift work and varying days off. A Police Officer could be assigned any shift at any time. In addition, you may be required to work overtime and must be available for emergency call-in overtime, court appearances, trials, etc. You would work a high percentage of holidays and weekends and may not be able to get time off for personal events like anniversaries, birthdays, vacations, etc. Are you willing to work all hours of the day, all days of the week, holidays, special family occasions, and overtime when assigned? a Yes a No If the necessity arose in the course of your employment to use deadly force on a human being, could you do so? Yes - No If no, then explain: Do you belong to any organization or do you adhere to any belief(s) that in any way: Would limit or prohibit your use of weapons or firearms? Yes D No Would restrict or prohibit you from working on particular days or particular hours? Yes a No Would restrict you from conforming to and maintaining agency grooming standards? Yes D No If" "yes", please explain below in detail or on an attached page if necessary. Page 5 of2 27 UUG PE EDUCATION Please indicate appropriate high school status: Diploma GED List all high schoos/universites/coleges/rade schools you have attended, beginning with high school: From To School Address Phone Fax Mo/Yr Mo/Yr Have you ever been expelled from any high school, college, university, or any formal educational institution beyond high school? D Yes No If" "yes", please explain, including school(s) and date(s): Current Status of MPOETC Certification? Have you completed Act 120 Training L Yes No If"yes", please give date completed, name and address of academy, certification number, and current status (valid, inactive, lapsed, suspended, revoked, etc.): Has MPOETC Commission (or other similar authority) ever taken disciplinary action against your certification? - Yes No If" "yes", please provide dates and explanation for each situation: Page 6 of2 27 GA a MILITARY AND SELECTIVE SERVICE Ifyou are a male born after December 31,1959, provide the following information concerning your registration: Selective Service No. Date of Registration Ify you have not registered, explain why: Have you ever been denied entrance to any of the armed forces? Yes No Do you possess anything other than an Honorable Discharge from any armed forces? Yes No If "yes" to either question, please explain: List all periods of full or part-time U.S. military service performed: (Submit your original long-form DD214) From To Activel Branch Rank Service Serial # Type of Dischargel Mo/Yr Mo/Yr Reserve Separation or current status. Are you currently participating in any U.S. Military Reserve or National Guard Program? a Yes D No If' "yes", please indicate branch and organization name and your current status: Page 7 of2 27 LAW ENFORCEMENT/POLICE APPLICANT HISTORY Please list any and all other law enforcement agencies you have applied for or tested with in the past. Please provide year, agency and place an "X" in the block indicating which area of the process you completed and whether you were disqualified or hired, etc. Year Agency Written Physical Oral Background Poly Psych Medical Disqualfied Currently Hired Exam Agilily Inv. CVSA Exam Exam OrQuit OnList process If you were disqualified, please explain in each instance the reason why you were disqualified or decided to quit the process: Page 8 of27 0 CURRENT LAW ENFORCEMENT POSITION PLEASE DETAIL YOUR CURRENT OR MOST RECENT LAW ENFORCEMENT POSITION HELD: From (Mo/Yr) To (Mo/Yr) Agency Name Phone # Faxi # Agency Address Title Duties: Salary starting: Salary current/ending: Supervisor's Name Work Hours Address (f diferent/Phone E-mail Address Head of Agency Name Work Hours Address/Phone E-mail Address Reason for leaving OR attempting to leave current employer: Have you been the subject of any form of discipline during any period of law enforcement employment? Have you ever been released while on probation or resigned while on probation? If yes, please explain: Page 9 of 27 UG PE PAST 'LAW ENFORCEMENT POSITIONS HELD: From (Mo/Yr) To (Mo/Yr) Agency Name Phone # Fax# Agency Address Title Duties: Salary starting: Salary current/ending: Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Head of Agency Name Work Hours Address/Phone E-mail Address REASON FOR LEAVING: From (Mo/Yr) To (Mo/Yr) Agency Name Phone # Fax# Agency Address ( Title Duties: Salary starting: Salary currentending: Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Head of Agency Name Work Hours Address/Phone E-mail Address REASON FOR LEAVING: From (Mo/Yr) To (Mo/Yr) Agency Name Phone # Fax; # Agency Address Title Duties: Salary starting: Salary current/ending: Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Head of Agency Name Work Hours Address/Phone E-mail Address REASON FOR LEAVING: Page 10 of27 UUG CIVILIAN EMPLOYMENT HISTORY Beginning with your most recent employer, list all jobs, including part-time, temporary, or volunteer positions you have held since age 16 or over the last ten years, whichever is less. Ifyou had intervening periods of military service, unemployment, or school, list those periods in sequence in the place provided at the end of this section. If you were discharged from any employment or requested to resign, state this under "reason for leaving". May we contact your present employer? D Yes No (If "no" explain why we cannot contact) PRESENT OR MOST RECENT EMPLOYER: From (Mo/Yr) To (Mo/Yr) CompanylEmployer Name Phone # Fax# Company Address ( / Job Title Job Duties: Salary starting: Salary current/ending: Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Co-Worker's Name Work Hours Address/Phone E-mail Address Reason for leaving OR attempting to leave current employer: From (Mo/Yr) To (Mo/Yr) Company/Employer Name Phone # Fax# Company Address ( ) Job Title Job Duties Salary Reason for Leaving Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Co-Worker's Name Work Hours Address/Phone E-mail Address Page 11 of27 GA D PAST CIVILIAN EMPLOYMENT HISTORY CONTINUED From (Mo/Yr) To (Mo/Yr) CompanylEmployer Name Phone # Fax# Company Address - Job Title Job Duties Salary Reason for Leaving Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Co-Worker's Name Work Hours Address/Phone E-mail Address From (Mo/Yr) To (Mo/Yr) CompanylEmployer Name Phone # Fax# # Company Address - Job Title Job Duties Salary Reason for Leaving Supervisor's Name Work Hours Address if diferent/Phone E-mail Address Co-Worker's Name Work Hours Address/Phone E-mail Address From (Mo/Yr) To (Mo/Yr) CompanylEmployer Name Phone # Faxi # Company Address - Job Title Job Duties Salary Reason for Leaving Supervisor's Name Work Hours Address (if diferent/Phone E-mail Address Co-Worker's Name Work Hours Address/Phone E-mail Address List and explain all periods of unemployment: Reason From To Page 12 of27 PAST CIVILIAN EMPLOYMENT HISTORY CONTINUED Have you ever been subjected to verbal, written, or documented disciplinary or corrective action because of misconduct or unsatisfactory performance? a Yes No If "yes", please provide dates, company names, and explanations for each situation. Date Company Explanation Were you ever involuntarily terminated, asked to resign, or resigned a job to avoid disciplinary action or an investigation? a Yes No (Ifyes, please provide dates, company name, and explanations for each situation.) Date Company Explanation Additional explanation: Page 13 of27 UUB PE DRIVERS LICENSE HISTORY Do you possess a valid Pennsylvania driver's license? Yes No If"yes", list: License #: Class: Expiration: Please list other states where you have been licensed to operate a motor vehicle: State/DL Number Name under which license was issued Have you ever been refused a driver's license by any state? Yes No If "yes", 1 please explain when, where, and why: Has your driver's license ever been suspended, revoked, canceled, or denied? Yes No If' "yes", 1 provide when, where, and explanations for each situation: List all traffic summonses/ickets you have received. (not to include non-citation parking violations/tickets): Nature of Violation Location (City & State) Approximate Date Disposition/Actions Additional explanations: Page 14 of 27 UG 7 % RESIDENCE/FAMILY HISTORY List all for the past twenty (20) years, beginning with the present month/year: Date To & From Address With whom did you live & where are they now? List in the order given here, spouse(s), parents, guardians, step-parents, foster parents, brothers, sisters, step-brothers, and step-sisters. Include any other family members you have resided with: Relationship Name Address (if living) Phone Number Do you have any income from any source other than your principal occupation? If yes please explain: Page 15 of27 - PE ARREST/CONVICTION INFORMATION Have you ever been arrested and/or convicted of a Misdemeanor or Felony criminal violation? If yes please explain: Crime Jurisdiction Conviction Date Have you ever been arrested and/or convicted of a Summary violation? If yes please explain: Crime Jurisdiction Conviction Date Have you ever been listed as a defendant in a protection from abuse order or similar document? If yes please explain: Order Number Jurisdiction Outcome Past and present membership in organizations: Name of Organization Address Type (social, fraternal, Dates professional) Page 16 of27 - 0G E SUBVERSIVE ORGANIZATIONS Yes/No Are you now, or have you ever been, a member of any organization, association, movement, group or combination of persons which advocated the overthrow of our constitutional form of government, or which has adopted the policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States or which seeks to alter the form of government of the United States by any unconstitutional means? Are you, or have you ever been, affiliated or associated with any organization of the type described above, as an agent, official or employee? Are you now associating with, or have you associated with, any individuals, including relatives, who you know or have reason to believe are or have been members of any of the organizations identified above? Have you ever been engaged in any of the following activities with any organization of the type described above: contribution(s) to, attendance at or participation in any organizational, social, or other activities of said organizations or of any projects sponsored by them; the sale, gift, or distribution of any written, printed, or other matter, prepared, reproduced, or published, by them or any of their agents or instrumentalities? If you answered yes to any of the questions above, please provide an explanation. Attach additional sheets for a fully detailed statement. If associated with any of these organizations, specify the nature and extent of association with each, including office or position held. Also include dates, places, and credentials now or formerly held. If associations have been with individuals who are members of these organizations, then list the individuals and the organization with which they were or are affiliated. Page 17 of27 SPECIAL QUALIFICATONS AND SKILLS List any special license, such as pilot, radio operator, etc., showing licensing authority, where the license was first issued, and date current license expires. List any special skills you possess with machines and equipment (i.e.: computer programmer, polygraph operator, vehicle inspection mechanic, scientific or professional devices, etc.). Foreign Language: Language Reading Speaking Understanding Writing Hobbies and Sports: Name Length of Participation Level of Proficiency Page 18 of27 CHARACTER REBERENCES List five (5) character references that have knowledge of your qualifications for the position of police officer. (Do not list relatives, former employers, or individuals living outside the United States.) Name Address Phone Years Known Misc. CHARACTER REFRENCE/ CO-WORKER List co-worker character references that have experience concerning your work ethic and work performance. (Can include Teachers/ Professors/ Coaches) Date To & Name Address Relationship to Applicant From Page 19 of27 ES AFFIDAVIT I certify that the answers given by me to the questions and statements in this application are true and correct without consequential omissions of any kind. I - authorize the companies, schools, or persons named above to give any information regarding my employment, character, and qualifications. I I authorize the members of the Milton Borough Police Department to conduct a thorough background investigation pertaining to my suitability for employment which may include a criminal history or other checks. I hereby release said companies, schools, or persons from all liability for any damage for issuing this information. I understand and agree that any misleading or incorrect statements or omissions may render this application void, and if employed could be cause for termination and this employer shall not be liable in any respect for such action or termination. I understand that any false statement in this document or willful misrepresentation will result in disqualification from the application process. Omission of information may be considered a disqualifying factor as well. If the misrepresentation is discovered after hiring, I may be subject to an inquiry and appropriate administrative or disciplinary actions, up to and including termination. As an applicant for employment, I understand that, if hired, I may be required to comply with the Employee Drug and Alcohol Policy. Additionally, I agree to submit to any physical exam, pre-employment drug screening test, a polygraph test, and other tests as required by the Milton Borough Police Department. Applicant Signature Date Witness Signature Date Page 20 of27 u PHYSCIAL PERFORMANCE TEST BATTERY The Physical Performance Test Battery consists of four exercise test events, immediately preceded by a warm-up session with intermittent rest periods to ensure the safety of the applicants. The Physical Performance Test Battery is designed to measure the cumulative effect on each Candidate. Therefore, a failure on any one of the test events constitutes a failure of the entire Test Battery. The Physical Performance Test Battery and Standards are detailed below along with a general explanation of each test event protocol: Vertical Jump 15.5 inches Sit-ups 30 repetitions, no time limit 300 Meter Run 66 Seconds Push-ups 25 repetitions, no time limit 1.5 Mile Run 15 Minutes, 54 seconds 1. Vertical Jump: This is a measure of lower body explosive strength. This is an important part of any physical exertion scenario. Example: Vaulting or jumping during a foot pursuit. The Candidate stands directly under the horizontally aligned, half inch graduated blades of the Vertex Vertical Jump Tester. With their feet together, they begin by reaching up with one hand as high as possible keeping their heels flat on the ground. This established the applicant's base line reach height mark. From this mark, a measurement is made to fix the height of the standard mark. The vertical jump may be performed in one of two ways. The Candidate may take a position with both feet squarely beneath them, bending down, and jumping straight up. The other method allows one-foot stationary, with the opposite foot, step back or to the side, then stepping back to a square position, and jumping straight up. With either method, the applicant must reach up with one hand and touch the machines graduated blade set to the standard mark. The Officer has three valid attempts to reach the standard mark. 2. Sit-ups: This is a test of the muscular endurance of the trunk including the abdominal muscles and hip flexors. This is an important factor in a use of force scenario and minimizing lower back problems. Example: Gaining control of a suspect. The Candidate starts by lying on their back, knees bent at approximately 90 degrees, feet flat on the ground, and their hands behind the head with their fingers interlaced. Their feet will be firmly held in place. For a repetition to be counted, the candidate must touch their knees with their elbows and then return to the lying position SO that the shoulder blades touch the ground. During the exercise, the Candidate may not raise their hips or "kip" and they may only rest in the "up" position. The required number of repetitions must be completed with no time limit. 3. 300 Meter Run: This is a measure of anaerobic power. This is an important factor in exerting short bursts of energy. Example: A Foot pursuit. The Candidate must complete a 300-meter course in the required time. On a standard 440-yard track, this is approximately % of the way around the track. 4. Push-ups: This is a measure of dynamic upper body strength. This is an important part of any dynamic physical exertion scenario. Example: Gaining physical control of a suspect or breaching a doorway. Page 21 of27 The Candidate starts in a kneeling position in order to set their hands, palms down on the ground, approximately shoulder width apart. The legs are then extended straight back with the feet together or up to six inches apart. The Candidate flexes their arms at the elbow until the upper part of the arm becomes parallel to the ground. This is approximately three inches off of the ground. The Candidate then returns to the up position with a straight or "soft lock" of the elbows. The Candidate must remain in the straight plank position from their head to their heels. The Candidate may only rest in the up position. There is a no time limit on this event. No other part of the Candidate's body may touch the ground during the test event, or they fail. 5. 1.5 Mile Run: This is a measure of aerobic power or VO2 max. This is the foundation for almost all physical tasks. Example: Use of force incident or administering one-person CPR. The Candidate must complete the 1.5-mile course in or under the required time. On a measured 1.5-mile course or a standard 440-yard track, six laps must be completed. The Candidate may not leave the running surface prior to successfully completing the course. Page 22 of 27 R UUB PHYSICALI FITNESS TEST - PHYSICIAN FORM (To be completed and signed by the personal physician of the applicant.) Listed below are the requirements as established by the Municipal Police Officers' Education and Training Commission (MPOETC) for the physical fitness test, which are part of the application process. Will the applicant be able to take part in the following requirements? YES or NO (circle) YES NO (CHECK THE FOLLOWING) #1 300 Meter Run. This test is a measurement of aerobic power. This sprint simulates the police officer's job in quick/fast pursuits, use of force incidents that are under 2 minutes, and all types of lifting and carrying. Score is based on age, gender and time. #2 1 Minute Push-ups. This test is a measurement of upper body muscular endurance, forcing a muscle group (primary: pectorals, deltoids and triceps) to exeit force over a short period of time. This simulates a police officer's job in a use of force incident and in pushing/lifting something or someone. Score is based on age, gender, and number of repetitions. #3 1 Minute Sit-ups. This test is a measurement of abdominal muscular endurance and of the core body region. Muscular endurance of the core body is needed in use of force incidents, lifting/carrying, and dragging/pullng something or someone. the applicant will be required to perform as many sit-ups as possible in 1 minute. Score is based on age, gender, and number of repetitions. #4 1-1/2 Mile Run. This test is a measurement of aerobic power (cardiovascular endurance) and simulates a police officer's job in sustained pursuits and a use of force incident that is greater than 2 minutes. The applicant will be required to run non-stop for one and one-half miles. Score is based on age, gender and time. Does the applicant have any pre-existing medical condition requiring continued or long-term medical treatment, or follow-up? YES NO Ify yes, please explain: Are you aware of any medical condition that the applicant may have that could be aggravated by the above listed requirements? YES NO If yes, please explain: Please list all currently prescribed medications: DATE OF EXAM: PHYSICIAN (SIGNATURE): PHYSICIAN (PRINTED): PRACTICE AND ADDRESS: PRACTICE PHONE NO: Page 23 of27 UG MEMORANDUM OF UNDERSTANDING I understand that I am applying fori the position of Police Officer with the Milton Borough Police Department. I understand that there are certain requirements - - must meet before I can be accepted into this position. I understand that I must participate in and cooperate with all aspects of the hiring process as conducted by the Milton Borough Police and/or Milton Borough Civil Service Commission. I understand that I must cooperate and submit to an extensive background investigation, which consists of the following areas of concern at a minimum: Review of my completed Personal History Statement Thorough criminal background check Thorough examination of prior employment Examination of my driving record Examination of my personal credit/financial report I understand that as part of this process I will be asked to participate in an Oral Interview Board, which will evaluate my potential suitability for employment. This, in turn, may be followed by my completion of any or all of the following tests: Drug screening test Standard medical examination Physical agility tests Hearing test Psychological evaluation The aforementioned tests will be administered in a manner selected by the Milton Borough Police Department and the Milton Borough Civil Service Commission. I understand that the results of the tests are the property of Milton Borough Police and that I will not receive copies of the reports nor any information contained in them, except as it may relate to a serious condition discovered by the examining physician. A final decision as to my suitability for employment will be made by the Milton Borough Police Administration and/or Milton Borough Civil Service Commission after all tests, in light of the requirements of the job, along with the previous information have been reviewed. I agree to assist in the expedient conclusion of these reviews, tests, and examinations. I understand that successful completion of this process does not guarantee employment, only that I may be considered for a position(s) as they become available, pursuant to established rules and regulations of the agency and the Civil Service Commission. have read and understand the content and purpose of this Memorandum of Understanding. I agree to abide by these requirements as a condition of employment while participating in the Milton Borough Police examination process. Signature of Applicant Date Page 24 of27 UG NOTIFICATION PROCEDURE In the processing procedure required for applicants, it may become necessary to contact the applicant in the event the applicant is being given further consideration for the position of Police Officer with the Milton Borough Police Department. If conventional methods fail in attempting to contact the applicant, a certified registered letter will be sent to the address listed on the application. Should the registered letter be returned indicating that it was unclaimed or undeliverable, the applicant will be eliminated from further processing and consideration. It is the applicant's responsibility to notify the Milton Borough Police Department, in writing, of any address change. By signing this form, the applicant acknowledges reading and understanding this notification procedure. Date: Signature: Page 25 of 27 1UG WAIVER AND RELEASE FOR BACKGROUND INVESTIGATION 1, am presently applying for employment as a police officer with the Milton Borough Police Department, which I acknowledge and understand, must thoroughly investigate my employment background, criminal history, personal oackground, education and references in order to evaluate my qualifications for a position as a police officer. I understand that it is in the public's interest that all relevant information in this regard, including my personal and employment history with my current and former employers, be disclosed to the Milton Borough Police Department. By this release, I hereby authorize any representative of all of my former employers, which have been fully disclosed and identified in my employment application, to divulge any information in its files pertaining to my employment records and history, and I further authorize the release of such information upon request to any representative of the Milton Borough Police Department. I also authorize all former employers identified in my employment application to permit a review and full disclosure of all records, or any part thereof, concerning myself and my employment with those former employers, by and to any duly authorized agent of the Milton Borough Police Department, whether said records are of public, private, or confidential nature. The intent of this authorization is to permit all former employers identified in my employment application to provide, and for the Milton Borough Police Department to obtain, full and free access to the background and history of my personal life and my employment history and performance, for the specific purpose of permitting the Milton Borough Police Department to conduct a thorough background investigation regarding me that will provide pertinent data for consideration by the Milton Borough Police Department in determining my suitability for employment as a police officer. It is my specific intent to provide the Milton Borough Police Department with access to personnel information, however personal or confidential it may appear to be. I authorize all former employers, financial institutions and educational facilities which have been fully disclosed and identified in my employment application, to release any and all public and private information that it may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including my arrest record(s) and records compiled during or as the result of a criminal investigation(s) of me, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had, an interest, attendance records, polygraph examinations; and any internal affairs investigations and discipline, including any files which are deemed to be confidential and/or sealed. hereby release all former employers, financial institutions and educational facilities identified in my employment application, and, if applicable, their elected and appointed officials, employees and agents and all others from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. hereby release all former employers, financial institutions and educational facilities identified in my employment application, and, if applicable, its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct all former employers, financial institutions and educational facilities identified in my employment application to release such information upon request of the duly accredited representative of the Milton Borough Police Department, regardless of any agreement, written or oral, may have made with the former employer, financial institution and educational facility to the contrary. Page 26 of27 In addition, also give the Milton Borough Police Department the right to thoroughly investigate my background, previous employment, education and references in order to ascertain my suitability for service as a Milton Borough Police Department employee, I release and hold harmless the Milton Borough Police Department, its elected and appointed officials, agents and employees from and against any and all liability which might result from conducting such an investigation, including any damages of whatever kind which may at any time result to me, my heirs, family or associates because of such investigation. - recognize and understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and disclosure of records, and - waive those rights with the understanding that information furnished by any former employer will be used by the Milton Borough Police Department in conjunction with employment procedures. I understand that if a former employer refused to cooperate with this investigation by failing to provide full disclosure of any and all relevant information about me, then the Milton Borough Police Department may disqualify me from further consideration for employment as a police officer. A photocopy or facsimile of this release form will be valid as an original thereof, even though the said photocopy or facsimile does not contain an original writing of my signature. This waiver is valid for a period of one year from the date of my signature. Should there be any questions as to the validity of this release, you may contact me at the address listed on my employment application. I agree to indemnify and hold harmless the person, to whom this request is presented, as well as his agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request. Date Signature of applicant Sworn and Subscribed Before Me This Day of 20 NOTARY PUBLIC MY COMMISSION EXPIRES: Page 27 of27