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0% found this document useful (0 votes)
793 views49 pagesCPO Adrian Calhoun Personnel File
Cleveland Police Officer Adrian Calhoun on the personnel file
Uploaded by
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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/ 49
Adrian Calhoun
Dept. of Human Resources
Personnel File ity of Cleveland Memorandum
rank kan Mor
Social Security Numbers andr Federal Identification Numbers have been redacted
Under State ex rel. Beacon Joumal Publishing Co. v. Akron (1970), 70 Ohio St.34 605.
“The employee's house number and street name have been redacted under State ox
‘al, Dispatch Printing Co. v. Johnson (2005), 106 Ohio St.3d 160.
“The employee's day and month of birth and personal telephone numbers have been
redacted because they are not records under O.R.C, 149.011(G) and 149.43
Personal information, including medical recorés, regarding safety personnel is exempt
from public records felease under Ohio Revised Code 149.43 and The STATE ex rel
PLAIN DEALER PUBLISHING COMPANY v. CITY OF CLEVELAND, 106 Ohio St.3d 70,
2005.
In defining what is a public record O.R.C. §149.43(A)(1(6) exempts Peace Orficer
familial information as Fallows:
(1) "Public record” means records kept by any public office, Including,
bat rot limited to, state, county, city, vilage, township, and schoo!
district units, and’ records pertaining to the dalvery of educational
services by an alternative schoo! in this state kept by the nonprofit or
for profit entity operating the alternative school pursuant to section
'3313.533 of the Revised Code. "Public record” does not mean any of
the following
(p) Peace officer, parole officer, prosecuting attorney, assistant
prosecuting attorney, corectional employee, youth services employes,
firefighter, or EMT residential and familial information;
O.R.C. $149.43 (AX7)(Q) further cares by stating that Peace Officer Includes
firefighter and EMT, and exempts from public records photographs of Peace Officers
Who are or may have undercover or plain clathes assignments as determined by the
appointing authority. That section reads as follows:
(7) "Peace officer, parole officer, prosecuting attorney, assistant
prosecuting attorney, correctional employee, youth services employee,
Frefighter, or EMT residential and familial Information” means any
information that discloses any of the folowing about peace officer,
parole officer, prosecuting attomey, assistant prosecuting attorney,
correctional employee, youth services employee, firefighter, or EMT:
*(@) A photograph of a peace officer who holds @ position or has an
assignment that may include undercover or plain dothes postions or
assignments as determined by the peace offce’s appointing
author.”
Ege Opertaiy Epon ‘hy of Cleveland
Department of Human Resources
Orientation checklist
Employee Orientation
Human Resources Department (21664-2499
Name of
employes ATI ne Coivorn Dept Quel segs Date WDSN>_
This hackles tobe campleted bythe new erpayee a New Hie Orentation Teg. €2ch tem we
‘suse dtaltnoneraton bythe Human Resources Falitatr. When the cess capeted each ne
Employee an Human Resources actatristo sgn an the frm wl Be qlaedin te employee's permanent
‘New Hire Orientation Binder Includes:
> Nien Hire Packet
> Medes Benes Summary ude
> Rouble Suing Account Fors
> Manor Tanne Courer
> ‘donal Employ Forms
Welcome!
Trang objective
‘ur cy/Our ayo
‘ky of leva Mision Statement
Performance and Expectations (Ou Core Vales)
Mandatory Tangs
1 Wurman Resources Poly and Procedures Manval Overview
1 Secon A Holy, Vacation and Sek Poi
Secon & Probation Prod
1 Seon € Artendance oly, Erland intr, Personal lecranc Deis, Progressive
Dine Sensal Horasment Poly, WorgaceOess Code
Onin nvliment
Medial Choses
Elie nsrance
Fel Sein Account forms IN. ChSenvces Commision
1 What eCullserices
Testing
1G Serves Rules ad Regul
V._OPERS and Deere Comp overaw
2 OFKS
Deferred compensation
VL Mandatory Taning courses
12 Org fre Wrkpace
12 Violence inthe Workace
= Dversty
iL Adtinal Employee normaton
1 Employer Asian Programs
1 RTAAdvantage Progam
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Personnel information Document
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Cleveland Alt PERSONNEL ACTION JUSTIFICATION
Date: _ November 11,2013 Department: —_ Publ Safety
Division: —_
Name: __131% Clevelnd Police Academy Classifiation: __Patoloffcer
PRe 10588 natin 7 Patna sina
re Gay nator
‘tion: statu
New ire: eo eget, _<
Promation: Temporary Appointee (TA:
acssifeation: Unease
Union: _O%
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Cll Service Review:
Personnel/HR Reviews
‘Reason/ Justification for this action: —_To full the requirements of Personne! Requisition 10399,
Applicant Flow Chart:
__Souren of tetera Dispasiton
Past Employers Contactod? Ye te
Personal References Contacted? Yer YN.
duction Godentals Verified? = Yor” No
Comments:
Background Checks (hires, rehires, recalls only):
Felony Conviction(sy: Yes No Comments:
‘ator Vehicle Racord heck Valld_~ “Suspended i teense
Personnel Administrator: ao
‘Commissioner:
Director: a cate ay, 2013
er ate,
Depwenet oat ey, niente Fon ec avon ‘
contre
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hia tea st have Ohio Saace Ceticat Training headeny (0.P-0.2-A.1
age 2 of 2 ‘PERSONNEL REQUEST EVALUATION FORM.
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City of Cleveland
Department of Human Resources and Civil Service Commission Application
602 Lakeside Avenue.
Cleveland, Ohio 44i14
http://wocty.cleveland.oh.us 3ob Hotne: (246) 664-2420
[Rise sey othe Gy af Geta oe eal oppor henplrae and SBarczroa sa RIMES HENTES WiO |
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"TO BE CONSIDERED FOR EMPLOYMENT:
1 Fl outapoation completly and aver ever question fly 2) Do not ptf to recur 3) Be sure to ln anddate |
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ANTIOISCRIMINATION NOTICE! sepals ducal spre! vert-adrsed vale Englyers CANNOT pany ih
Sr) ot got erie, cams Re oamertaon sees hae
[Section 1. Employee information and Attestation Enloyosmual comple and abn Solan 1 of Fam [Ore er
nan ne etsy of ensloymant ba Ble csplng 8a oer)
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tenets her ere pie nest capi an sp actor? bes oa beng empayon You
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Toon 9 aw N Pues City of Cleveland Employee Consent Form for Internet/Intranet and E-mail
Usage
1, Pdtien coduese have read the Cit’ Policy on Employee Use
of E-Mail and Intemet/Intranet (“Net”) and agree to comply with all of its terms and
conditions. I understand and agree that all computer and electronic activity, including,
but not limited to, electronic mall and Net network activity, being conducted with City
resources is the property of the Cty.
1 acknowledge and consent to the City's right to monitor, lg, access,
and review all such activity, with or without notice. I therefore understand and agree
that Ihave no expectation of privacy in the use ofthese resources. understand that
such Cty monitoring may Include printing and reading all electronic mail, websites, and
data entered, left, backed up, or stored on the City’s computing equipment, whether or
not I have Intended its deletion.
Finally, T understand that olation ofthis Policy may subject me to disciplinary
acon, upto and including, termination of employment.
Employee Name Date .
Adan Cader VEVSXD
Employee Signature Division
Que
ecived By
(Supervisor or Appointing Authority) Date
Distribution of Copies; One Copy - Attention: Department of Human
Resources One Copy = Employee Department File One Copy - Division of
Information Technology and Services One Copy - Employee
cet STATE OF OHIO WHISTLEBLOWER PROTECTION POLICY
1 Adela, Cealboun confirm that I have received a copy of the 3 pages of the
Ohio Whistleblower Proteetion Policy.
OL PAK + 3-S-13,
Name Date
- __ go
Social Security Number Date of Birth Acknowledgement of receipt of Auditor of State Fraud-reporting system
f
ink
Pursuant of Ohio Revised Code 117.103(B)(), a public office shall provide
information about the Ohio fraud-roporting system and the means of reporting
fraud to each now employoe upon employment with the public office.
Each new employee has thirty days after beginning employment to confirm receipt
of this information.
By signing below you are acknowledging the City of Cleveland provided you
‘information about the fraud-reporting system as described by Section 117.108 (A) of
the Revised Code, and that you reed and understand the information provided. You
are also acknowledging you have received and read the information regarding
Section 124.341 of the Revised Code and the protections you are provided as @
classified of unclassified employee if you use the before-mentioned fraud-reporting,
system.
[Raster Cavan, have rad information provided by my omployer
regarding the Baud reporting oyotom operated bythe Ohio Auditor State's office. I
arhor stato hat tho undoroignod signature acknowledges receipt of this
information
Qsan tmiase Quid caters
Print Name, Title, and Department
Modan nn Nea
Please Sign Name Date CITY OF CLEVELAND
Mayr Frank. jackson
CITY OF CLEVELAND ETHICS POLICY
T_fadclon Centeaun confirm that I have received a
copy of the 8 pagos of the City of Cleveland Bthies Policy.
AAgeA _cen\no, VAS,
Date
Name
— . . oO
Social Security Number Date of Birth, €
at pera En CITY OF CLEVELAND
Mayor Frank G. Jackson
OHIO ETHICS LAW AND RELATED STATUTES
1_Advton Cond confirm that I have received a copy of
the 24 pages of the Ohio Ethics Law and Related Statutes as required
under the Revised Code 102.09(D).
‘Social Security Number Date of Birth City of Cleveland
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Frank G. Jackson, Mayor
Employee Name Ana Cotaciin Social Security?
‘Your eamings from this job are not covered under Social Security, When you rei, oF if you
become disabled, you may receive @ pension based on earnings from this job. Ifyou do, and you
are also entitled to a benefit fom Social Security based on etter your own work or the work of
Yyour husband or wife, or former husband or wife, your pension may affect the amount of the
Socal Securty beneft you receive. Your Medicare benefits, however, wil not be affected. Under
the Socal Security lav, there are two ways your Sodal Security benefit amount may be affected,
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Secu retirement or csabiity benefits
figured using @ modified formula when you are ago entitled to @ pension from a Job where you
id not pay Socal Secury tax, Asa result, you will receive a lower Sociel Secuty benefit than it
you were not enttied to a pension from tis job. For example, if you are age 62 in 2005, the
maximum monthly reduction In your Socal Security benefit as a result ofthis provision is $313.50,
‘This amount is updated annually, This provision reduces, but doesnt totally eliminate, your
Social Security benef. For addtional information, please refer to Socil Security Pubication,
"Windfall Elimination Provision.”
Government Pension Ortset Provision
Under the Government Pension Offset Provision, any Socal Security spouse or widow (er) benefit
to which you become entitled wil be offset if you aso receive a Federal, State or local
‘government pension based on wrk where you did not pay Social Secuty tax. The ofset reduces
{he amount of your Sodal Securty spouse or widow(er) beneft by two-thirds of the amount of
your pension.
For example, ifyou get a monthly pension of $600 based on earnings that are not covered under
Social Security, two-thirds of that amount, $400, is used to offset your Socal Securty spouse or
widow) benefit. IF you are eligible fora $500 widow(er) benefit, you wil receive $200 per
‘month from Sodal Securty ($500 - $400=$100). Even If your pension is high enough to totally
Offset your spouse oF widow(er) Socal Securty benef, you are sil eigible for Medicare at age
655, For addtional Information, please refer to Socal Securty Publeaton, "Government Pension
offset.”
For More Information
‘Socal Security publications and addtional information, Including information about exceptions to
‘each provision, are avaliable at wwn.sacalsecurty.gov. You may aso cal tol free 1-800-772-
1213, of for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your
local Social Securty offic.
{eertiy that I have received Form SSA-1945 that contains Information about the possible
effects of the Windfall Elimination Provision and the Government Pension Offset Provision on
‘my potential future Social Security benefits.
Signature of employee 4 Xp A pate W2xS A
Fam SSA-1985 (15-2004) (Ceres nur, 2009) CITY OF CLEVELAND
DEPARTMENT OF HUMAN RESOURCES
EQUAL EMPLOYMENT OPPORTUNITY
[AS an equal employment opporturity employer, the Cly of Cleveland adheres to all federal, state and local
laws, rules and reguations as they pertain to equal employment opportunity and affirmative action. The
Information requested below wil assist us in analyzing our affirmative action efforis, We ask that you complete
the information below on a VOLUNTARY basis. Any inclusions or exclusions will NOT affect any application or
‘employment decision, The data secured willbe used for statistical purposes only and wil be maintained In 2
separate confident il
(PLEASE PRINT) DATE _1\ 5 wis
NAME
ADDRESS C\evelond, Ola
POSITION APPLYING FOR _Qo\ice OS8icec
HOW DID YOU LEARN OF THIS OPENING? _A\evecsice
CHECK ONE:
Female
CHECK THE BOX OF THE RACIALIETHNIC CATEGORY TO WHICH YOU IDENTIFY:
caWnite American Indian/Alaskan Native ([oAfriean American
CiAsianPacific islander Hispanic Other
CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:
(Vietnam Era Veteran CaDisabled Veteran [DDisabled individual
BIRTH DATE __
— BA CIVIL SERVICE TESTING
This notice is to inform all prospective City of Cleveland employees of the Civil Service
testing requirement
CIVIL SERVICE TESTING
Ifyou have been hired by the City of Cleveland from a Civil Service list, your position
status is "regular." If not, your status is “temporary” and you are subject to testing
through the Civil Service Commission. The Commission conducts examinations to
determine your qualifications for the position for which you have been hired. If you do
not pass the test or score sufficiently high enough to be appointed “regular,” your
‘employment with the City of Cleveland may be terminated.
By signing below, | acknowledge the implications Civil Service testing may have on my
future employment with the City of Cleveland.
Dire Is R
Applicant's Signature Date AuTHON IN
‘AND WAIVER OF PRIVACY RIGHTS
Pease read the flowing before soir:
1
< hereby authorize the iy of Cleveland and its agents or employees to
‘hae rerpojer meses ens)
cond» background deck on me and author the release of pertinent information angering me ram any source,
Including, Duk no ted 8, past erpayers.
“The undersigned appar, in granting this appeation, hereby specifically WAIVES ay right to PERSONAL PRIVACY he or
she might have inthe above lfermation and RELEASES the Cty of Cleveland and any person er agency fort ANY
LABILITY WHATSOEVER rsuting fom the rlese of uch Ifermaton
NOTE: Pubic Law 91-508 requires that we advise you that 3 routine nquy may be made which vat
provide appicabe formation concering characte, general reputation, and personal charactrstcs
ROUTINE INQUIRIES MAY INCLUDE PERSONAL INTERVIEWS WITH FRIENDS, NEIGHBORS, REFERENCES
AND PAST EMPLOYERS. Upon wen request, adonal information ast te nature and Scope of 3
resulag report fone s made, wl be provides,
My signature below cris that my responses o the Application for Employment Sere Test Arpcaion are true
and complete to thebestof my knowledge. T understand that employment is based on competion ofl pre-engloyment
requirements and procedures which ay Weld!
Interviews
Urine drug screen and pre-employment physical
Dron of eenty ant empnymen sie Far work nthe LS
Edyeation and reference checking
“esting (i applable to the postion for whlch you are applying)
Cina and motor veil recor check
‘Consumer report check
{In addition, f understand that any offer of employment will be contingent upon the results of @ physical
‘examination by authorized medical personnel of or forthe Cly of Cleveland,
Compliance withthe Gity of Cleveland's Drug Testing Policy Isa condition of employment: Therefore, a
Job offers are made withthe understanding that prospective employees pass adr screening tet prict to
being hired.
{understand and agree that any falsification or omission, either on this form or in response to questions
‘asked during my interview or examination processor on employment forms 1 subsequently complete,
Including 1-8 forms, shall be grounds for immediate termination, no matter when the falsification or
comission is discovered.
—AN-\SAS A
Date ‘Signature of Employee or Prospective Employee
2 BA —
Bate of birth ‘Social Security Number
‘current Brivo" Lidénse Number ‘Commercial Driver's License Type & Number ( REFERENCES
REFERENCES oof ens mec seins commntson (Do tt lav)
Tae es eeporeWonber
Kae buenas De H10- eH
NYRG 535-8750
[iene — a ie
____ Toy 901-3885,
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{ain a ne arn ert! den nel ry be conser safer cus fer Sc enon OT
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soy ete ato ed tdean toy event a ery coed thik ey SSE Sc) ONES
ifomazon wich ty Ete Pe Fey oan coset Yo te eas of my pl Es NCE
Stamuetco f ome. een cy of Sevan, ana wate aye > personal pricy Tight Rave
“a apping tr ele whey of Cevean, tundra tf evade to oft erase of yf
ear ee eT habe scooter conan wich he Cy of Ceeand may aR
vt wander x, te stakeents mae by ns pplcaton ee ne, aoe an coe 10S as ee
sma on te sap nab stn case termination rom employment wth he Ch, exe
emany sonata remo oy ame fon SOs tae by fe evans i Serve Comms
sonanure otapoicant: \A3.. pate LS-Vy Adrian Calhoun
Personnel File — Div. of Police
Dept. of Public Safety i CLEVELAND DIVISION OF POLICE
DIVISIONAL INFORMATION
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PHONE: neawisrosruce Af samannane:_/V (A
EMERGENCY CONTACT: ___ RELATIONSIUP,_sraynee PHONE: /
MansratsraTus: (v1 YEARSOFCOLLEGE:_Q) HIGHEST DEGREE OBTAINED:_A/ID\
NaMEOF DEGREE: fy 2 ae
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sce jo wast C1087) ae
HAVE YOUEVERBEEN: — LAOFF: DISMISSED-TERMINATED:, EstGNED:
eIviLIANs ONLY
PERSONNEL INIT USEONTY
access om O m O woes City of Cleveland
Fran son pe
Depserereo pbc Stay
eter
Seeing oupanteirs
ieepesise tac Ne o64754
Sows
‘November 11, 2013
Adsian Calhown
Cleveland, Obio
Deer Adrian Calhoun,
Ik is my pleasure to inform you of your appointment to the position of Patrol Officer in the
Cleveland Division of Police, Depariment of Public Safety, effective, Monday, November 25,
2013.
You are to report to the Cleveland Police Academy, 1300 Ontario Street, Room 731 at 0800
hours ou Moadsy, November 25, 2013. Enclosed are insieutions regarding dreas cede and other
information you will need when you report.
‘You are advised that you ae subject to a final revord check reganding traffic violations, criminal
convietions, and traffic accidents prier 1o your appointment date. Signifiant changes in your
background or medieal situs may be grounds for reseission ofthis appointment.
‘You are required to contact the Division of Police Personne! Unit at 216-623-5136 to report any
changes in your status,
Sinestely, Sincerely,
Marin L. Flask, Difector
Department of Public Safery
4 Ey Opry Empoe Eligibility List \_-nber - 69
Personal History Statement
TG
&
DEPARTMENT OF PUBLIC SAFETY
DIVISION OF POLICE Eligit'“y List Number_ YP
CLEVELAND DIVISION OF POLICE
PERSONAL HISTORY STATEMENT
‘This Personal History Statement is intended forthe ust of the Clevelend Police Department. Failure to
provide complete and truth informaion will result in rejection for eppointment parsuant to City of
Cleveland Civil Service Commission rules, andlor discharge after appointment. All information is
subject to independent verification. All documents filed withthe City of Cleveland ae public records,
‘The answers to questions contained in this Personal History Statement must be legibly printed in your
own hand. Each individual question must be answered; there can be no blanks. Ifa question does not
apply to your particular circumstance, inser “DNA” (does not apply) in that blank/section. . Whe
answering questions that require dates, insert the full date; partial month/year responses are
uunacoeptable. You must provide complete address information, including 2ip code, when requested.
Partial address information is not acceptable, Additional space for explanation or clarifiction
regarding your responses can be found in Section 11, page 14.
‘Applicants are cautioned to answer every question trthfully and without evasion. The Ohio Revised
(Code provides penalties for msking false statement of a material fact, or for perpetmting any fraud or
deception in obtzining, or attempting to obtain municipal employment. Penalties include rejection for
‘appointment, discharge after appointment, andlor prosecution under Ohio Revised Code Section
2921.13.
Applicants are required to provide originals of the following documents atthe time of the Personal
History Statement Review: (1) Birth Certgcate (2) ligh School Diploma or GED Certifieate (3)
‘Valid Drivers License (4) Secial Security Card (5) DD214 ~ Long form (for Miltary service) (6)
‘Marriage Cerificate (7) Divorce Decree (8) Naturalization Papers. These documents will be copied
by investigators of the Cleveland Division of Police Personnel Unit st the time of the interview. Any
‘additional degrees/cenificates that you have acquired may be included with your Personal History
Statement
If you are presently self-employed, or have been selfemployed, you must submit copies of the prior
three (3) years Federal, State, and Local Income Tax returns (both personal and business tax returns)
In addition, you must submit the names, addresses, and telephone numbers of five (S) business clients.
Failure to fully complete the Personal History Statement or to submit the required documents will
Gelay investigation of your suitability for employment and may jeopardize your appointment to the
(Cleveland Police Department.
‘You must notify the Division of Police Personnel Unit, (216) 623-5135, in writing of any changes
relating to your residential eddress, criminal or arest history, traffic offense history, driver's license
‘status, marital stars, and any changes in employment stats or employers, This information may be
faxed to the Cleveland Division of Police Personne] Unit at (216) 623-5820. Failure to do s0 will be
rounds for further review of your qualifications for the position of Patrol Officer with the City of
Cleveland.
PLEASE NOTE: This document MUST be notetized before your Personal History Statement
review appointment; please see page 15 for Notary statement,
1 Eligit"“ty List Number @O4
eee Saar
ame: _CO\WOIA FirstName: Ahoy ML
Maiden Name/Nick Names/aliss: [nt Pk
Social Seourty Number: DeteofBink: —_/__—/ 989
Place of Bit: _Clave\oun Oh
Gy —Canclagae. — Sa
Age 32 Height_(p'Y Weight 334 __ Hair Color: Ble Bye Color: HOt
List any tatios, scars, or unusual birthmarks youhave: (no babioo Qiasea on tht
ces Srosins persue 2 tg
Obie Drivers License Number: __ Typ:
Expiration: aaa
Outer Sute Operators License Nunber Tove Sue: DA Expiration: OMA
‘Are you an American Citizen? (__) Yes (DAA) No
‘Are you a permanent residentalien? (V0) Yes (DN Be) No
[Ifyou are a naturalized citizen ofthe United States, ls the information below:
Dyk _Dva__ Dvr
Caries Naber oes
a sean ars ete An ea tae
Name of Curent Spouse: __ (Yn Dateof Mariage: _ NN
Spouse's SSN: Qn - Dhak - Typ Spouse's Date of Binh: DA 7 Daya / DAP
4G) Areyou supporting all dependents you ae required suppor? (Dus) Yes (ast ) No
+ @) Areyoupaying cit suppor orstmony? (Que) Yes (_W~_) No
feo, amount peid pet month: $ CAUB —_Collesing Agency: ONL
¢ @)__Have you ever been sued for als. y payments child support, nonpayment of deb, or fraud as
it pertains to State of Ohio Child Support Laws?
(oma) Ys (oY _) No
2 iigibiy List Number_WM
tion: lence Information
Stating with your present address and working back, list each address at which you have resi
since age 18, Include addresses while at school and in the military as well as family owmed fevilities.
For college on-campus residences, give the dorm name, address, city, and state. If residence in the
military cannot be shown a @ steet addzess, indicste the complete military unit designation and
location by city, state, and country. If renting or leasing, include the landlord, agent or management
‘company to whom you paid ent.
Lease —DateFrom / To Street Address/ Ant. if SitwSsiate Zip
‘Own
“beese Deka. to Present _ = Saar,
EER Soca eta — Litdinadicha
ase Mosk to Spay, etna bo '
ins NOVAdG to egy ee -Llavielncdth
esc Clem t Ahaha, —— Hievdand On _
fatets Suyamio to Sot ior - Geveleadon 44
Qe Qe © Dea rp tt
Swnwk_ » Due tan A
Mua Qua © yup ——huh —__Qub__
SNe Due w Dyg > Oye pe
awh Sua © De —_Dwa ___ __Ov A _
Sos Duk © Data Dope __s_pwa _
REREPES
Curent Residence Telephone Number: (
wo Sahin Sone oF st
(Current Employment Telephone Number: (2 ), __ a sanye Cintsite/ Hatse shoe
Phone Number for Messages: (Dok De
Poger Number: (Dah DQ
4 Have you ever been evicted or takeu t0 court for non-payment of rent or for damage done to any
leased dwelling? (SYQ\K) Yes (_¥__) No
3 Blighty List Namber_W™
High School:
Name of High Shoot: Yymes & QModes
Fall Address of High School: Sion iasiois aut, Cltueiand De utis
Graduated: (__y~_) Yes ( OMVAL) No Yearand Month of Graduation: \ya-o8
you di not graduate from High School, what was the highest grade completed? _ CVV
General Educational Development Test (GED):
Do youhavea high school euivalencydiplome? (Due ) Ye ( Owa ) No
Issuing Site: _Q)0V Cerin amber. _ DN Date: QE
‘Test Date: ok ‘Testing Agency: DAA
Coneges 5
Name of College: snihueten
FAM OO NOt ChE jsf ei omy 4ans
Years Attended: From (QQ to OB _DegreeReecived: _picn
Wisi REgleRe ake Minor: _ (NA GPA. Ou
Ifyou did not greduste, approximate number ofcredithours takes: SS ANA
‘Technical and Trade Schools:
Name ofSchool: American Cedcsass
Full Address of School: ow x
‘Years Attended: From poy 3anth Signe Norm AreaofSmudy: _qyts
‘Year of Graduation: ovo, Degree Reveived: STINE Cec light" List Number_ (ef
‘Section 4 — Military History
‘Have you ever served on active duty in the Armed Forces of the United States?
(Dale ) Yes (_ VW) No
Brenchof Service: _ DNS
vnc _ aia
‘Military Active Duty Dates (do not include short reserve tours of 90 days or less):
‘From: Dora To: vf
‘Highest Military Rank or Rate Held: _|YNY Py
TypeotDiscimee: _ 1) NB
Military Reserve Sus: ( (\MR _) Active © QA) Inactive
{you sil stend drills the name and location ofthe attending military bate:
BERET ford se Ue e000 00ue0000 0000000000 50eesee8n00008
‘¢ (1) Have you ever requested or received deferment from military service?
(Qa) Yes (_V_) No
+ @) Were you ever cour mantisled, ied on charges, or the subject of a summary court manial
captain's mas, or Article 15, while inthe Armed Services?
Ca) Yes (_Y_) No
© G) Have you ever requested or received an upgrade of the 1ype of separation you curently hold
fom any branch of the Armed Forces of the United States?
CR) ves (VY ve
‘+ ifyouranswer to #3 is yes, indicate the date and original type of discharge _ {VI
Qs Eligh"y List Number_@ML
Scetion §~Emplovment History
Begin with your current job and list your complete work history in revere chronological order, ic
most recent o least recent. include inthis sequence all parttime jobs, periods of unemployment, and
‘military service. All address information must be complete: number, street, apartment or suite, city,
‘Rate, and zip code. For military service, subttte for the name of your immediste supervisor, the
‘name and rani of th last conumissioned officer who was your immediate commissioned superios. For
peviods of unemployment, indicate the dates in the spaces provided. In the space designated
“Employer” write in "unemployed In the space designated “Reason for Leaving” indicate from what
source you received income diring that peiod of unemployment. Your entire work history must be
‘sccounted for, Do not slp any te periods.
From: precy \aryoxe To: Present Job Tite:
BERS colomto ‘Ave,
Employer: Qc laa of Address: “ays, Onin wuoil” __
0
Immediate Supervisor: Goctasta Soa Business Phone: ve, GL 0S)
Description of Your ues: peot/idtan neile cate SecVLeG athe goa oF Hatt bones
‘Reason for Leaving: _ OYA
Disciplinary Actions: _ AEE Work HoursShift ope 383 anor
Ta
From pySceb— Te: gonens JobTie: Coane comma C68
Employer: Sar /orsesine Crimes AMES oo Pinte square Cel Oe MANS
Immediate Supervisor: Jaaye Ctantiee! Kat Business Phone: Qu p88 Nar wa
Description of YourDutes: Colicc+ ad pincass tustnt
Reason for Leaving: {Yai
Disciplinary Actions: TD) Ni fy ‘Work Hours/Shift yop? 8°" yea Blgit “ty List Namber_WM_
‘Section § = Emplovment History (cont)
From [pig-t) — To: Zycra eb Title: _Seeyersy OFeicec
Employer: Ceosas anti Hatseciee Che. AMES ion puniic Squnte 61K nyt
Immediate Supervisor ov Seawes Benstan — Business Phone: Quay yett-S\
Deseition of Your Duies: Gra) Bing, S2Ciutny tol Sossiy ts tae Pusaic
Reason for Leaving: f. Wuacesnea®
Disciplinary Actions: ) 0) fA Work Hous/Shift 49 / yer
Immediate Supervisor _T)N\ 0 Business Phone: _() tN
Deseription of Your Duties: _ YA} 0
Reason for Leaving: _\nomngio4 ment Compensation
Dnt hs woikHouwsnit Day
Disciplinary Actions:
J poe: spite. Tahaan. WE Sites ,
TR Arid eater os
raisin meer _ yal is Se Wich
Description of Your Duties: _ trai Au see
Reason for Leaving: Jobeoah "
Disciplinary Actions: tention det bo sugiteh ch cetticats Wark Hours/Shift Yo/ wae.
eS light ty List Number U4
Section § Employment History (cont)
From poo hont Te Secknona OTHE Disc supgase gees
Eaplye: swag soosdasion scat. MARS {1 emosgent tanaeh
Inmet Superior: _ DAN ind Pane iS Wet
Desipionof YourDutes:_gaselion snag eeeatel
‘Reason for Leaving: yy guy ke Sibi ‘ i
Disipinny Ati _ DAG WorkHousttin 28
ee
From: S.x4 nee Te: Sola gang JobTite: foie
Employer: _ynger passe Adéress: ache
Immediate Supervisor: _g\vi 0 Business Phone: [Yap
Description of Your Duties: QS by
Reason for Leaving: AL) ore \asusi@ Can Saree
Diseiplinary Actions: Ty ii ‘Work HouShift at
pa erences sea
From: Smeaone Te! sascreng bTille: Tyas A
Employer: zoeveiank netin ques eon AMMeSS! Beh 24 WAALS enh Siniagh MA,
Inmediate Superior: _ Oats ‘Business Phone: gai
Description of Your Duties a ;
Retson for Leaving: od rei ee Qoeaesctve tor faGatst amis
Duh ‘Work Hours/Shift sheng od
—_—_——————
Disciplinary Actio
additional room is needed, attach a separate sheet of paper. Blight “ty List Number_(@M4
‘Section 5 Employment History (cont)
+ (1) Have youtaken a polygraph exam forany reason? (Tye) Yes (_W7_) No
Dawe: Diy __Loeation: _ ve. Reason: Sv
¢ (2) Have youever been rejected for bonding? (Oi ) Yes (Ly) No
4 () Within the pat seven (7) years, have you taken a Civil Service Entrance Examination for the
‘position of Patrol Officer with any lw enforcement or other governmental agency (including
the Cleveland Police Department)?
(Dw) ve (_v_) Ne
Date of Test
a
Ni
‘Section 6~Traic ond Driving Resord
“List all moving citations served upon you by & aw enforcement officer, coun, or other authority in any
slate ot country for violation(s) of traffic laws or regulations. Parking tickets do not apply.
Date Offense Tgeaey Disposition
e 5 te cu
= x
ai
Lis all traffic avidents you have been involved in ss the driver of ax automobile,
Date [. Location geney Was you ced? | Injury Involved Eligh “Uty List Number TOY
+ 0). Doymemeatytuve miomebioiosmme? — (_y-“_) Yer (fiir) No
foitearno,
Jnsrance Company: Sage Ayyha Agent Phone eop- Baa
+ @)_ Has yourDiivers License ever been evoked/suspended? (Paid _) Yes (_V_) No
‘Year of Suspension Tae of Suspension ‘Reason for Suspension
fy A Pe NR
NE Dye NR
Si
© (1) List ALL arrests, incloding any resulting in youthful offender treatment, arrests which were
