Apd 5A Form – Fill Out and Use This PDF

The Apd 5A Form is a useful resource for police officers. It lists the local laws that pertain to police work, as well as some general information about being an officer.

If you wish to get this form PDF, our form editor is exactly what you need! By hitting the orange button below, you will access the page where you may fill out, download, and print your document. Enjoy the ease of navigation and user interface the tool presents.

Apd 5A Form PDF Details

If you are a public school employee, then it is possible that at some point during the year you will need to complete an Apd 5A form. This form can be used in many different situations, but most commonly it is used when your child needs to take medications on campus. The process for completing this document can vary depending on what type of medication your child has been prescribed and by whom. Below are some basic guidelines for filling out the Apd 5A Form. If you have any questions or concerns about how to fill out this document please feel free to contact us with details about your situation so we may better assist you with finding appropriate information related to your specific circumstance.

This information will aid you to comprehend better the details of the apd 5a form before starting filling it out.

Question	Answer
Form Name	Apd 5A Form
Form Length	24 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min
Other names	cas 67 form, nypd telephone reference check, nypd cas form, nypd cas 67

Form Preview Example

	POLICE DEPARTMENT				APD-5A
	CITY OF NEW YORK			CIVILIAN TITLES
Personal History of: _____________________
	Surname		First Name		M.I.
Applicant for appointment as:
Exam No. __________ List No. __________		Social Security No.:

The answers to questions in this questionnaire must be printed in BLACK INK BY THE APPLICANT. TWO (2) copies of this questionnaire are furnished, BOTH are to be completed, notarized in the space provided on page 18, and returned to your assigned investigator as directed. If the space is insufficient to complete your answer to any question, use pages eighteen through twenty-two (18-22) which have been provided for that purpose. Indicate the question number and continue your answer. If a question is not applicable, indicate such by entering “N/A” or “NONE”. Do not leave any question blank. Mistakes made should ONLY be corrected by drawing a single line through the mistake, placing your initials at the end. MISTAKES ARE NEVER TO BE CORRECTED WITH OPAQUE CORRECTION FLUID.

Applicants are cautioned to answer every question, truthfully, completely and without evasion. Both the N.Y. State Civil Service Law and the Personnel Rules of the City of New York, (which have the force and effect of the law) provide penalties for making a false statement of material fact in any application, or for practicing any fraud or deception in obtaining or attempting to obtain municipal employment. Such penalties include rejection for appointment, revocation of appointment, and prosecution.

Civil Service lists are valid for a period of up to four (4) years from the date of promulgation. Once the Civil Service list expires, appointment from that list is no longer possible. For this reason, all candidates are urged to submit all documents as expeditiously as possible. All candidates are cautioned that failing to appear for scheduled appointments could jeopardize chances for appointment.

THE NEW YORK CITY POLICE DEPARTMENT

IS AN EQUAL OPPORTUNITY EMPLOYER

Page 1

	Control No	Exam No.
	.
	________________________________	_________ List No.Soc
		. Sec. No.
APD-5A	Surname	__________________________________
	First Name	____________________
	Mid. Init	______
	.

PD 407-151A(Rev. 09-10)

I. PERSONAL DATA

Last Name	First Name	Mid. Init.	Social Security No.
a. Have you ever had a legal name change? If so,
From: ________________________	To: ____________________ Reason: ____________________________

Court: _________________________________________________ Index No.: ___________________________

If by marriage, date of marriage: _____________________________

b. List below, any other name, alias, nickname, by which you have been known, including maiden name if you are a married female, with the reason for such use:

c. Do you have any tattoos, brands, body piercings, or other body art? Yes  No 

If yes, include the location and complete description, including symbolized meaning and reason for getting same.

Sex: Male  Female 

3. Date of Birth: Month: __________ Day: _________ Year: ________

4.Birth Certificate:

Certificate Number

City or Town

County

State

Citizenship:

Citizen of the U.S.A.?

Yes 

No 

a. What country were you born in? __________________________________

b. If not born in U.S.A., date entered U.S.A. _______________________________

c. If you are a naturalized citizen of the U.S.A., list below,

Naturalization Certificate No.

Date

Court

City

State

d. Do you have dual citizenship with another country? Yes  No 

If yes, what country? ______________________________ When was it obtained? _________________________

How was it obtained? ___________________________________________________________________________

Do you have a U.S. Resident Alien Card?

Yes 

No 

Expiration: __________________

If yes, how was it obtained? (Lottery, etc.) ___________________________________________________________

Alien Registration No. __________________________________________________

Do you have a U.S. passport? Yes 

No 

If yes, passport no. ________________________ Date Issued ____________ Expiration Date ________________

a. Have you ever reported a passport lost or stolen?

Yes 

No  If yes, describe the circumstances of

the loss to include the date, location and police report number: __________________________________________

______________________________________________________________________________________________

b. Do you now have or have you ever had a foreign passport?

Yes  No  If yes, date issued ___________

Date of Surrender/Expiration ________________

Issuing Country____________________________________

c. Have you ever applied for a travel visa to travel to or from any country? If so, Date _______________________

Country ________________

Reason_______________________________________________________________

Has a visa ever been denied? ______________________________________________________________________

8.What countries outside of the U.S.A. have you traveled to? Include dates and how long you were in the country:

Country & Town, or City	Dates	Length of Stay	Purpose of Visit

Initial this page to indicate that you have provided complete and accurate information: __________

Page 2

9.Marital Status:

	Single  Married  Legally Separated  Divorced  Widowed  Registered Domestic Partner/Civil Union 

	Spouse/Registered Domestic Partner

	Name			Home Address (number/street/apt.)			City	State	ZIP


	D.O.B.			Occupation
N/A	D.O.B.			Occupation


	Home Phone			Work Address (number/street/apt.)			City	State	ZIP
	(	)

	Work Phone			Cell Phone		Email
	(	)		(	)

	Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?
	Yes 		No 

	Former Spouse/Registered Domestic Partner

	Name			Home Address (number/street/apt.)			City	State	ZIP


	D.O.B.			Occupation
N/A	D.O.B.			Occupation


	Home Phone			Work Address (number/street/apt.)			City	State	ZIP
	(	)

	Work Phone			Cell Phone		Email
	(	)		(	)

	Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?
	Yes 		No 

	Former Spouse/Registered Domestic Partner

	Name			Home Address (number/street/apt.)			City	State	ZIP


	D.O.B.			Occupation
N/A	D.O.B.			Occupation


	Home Phone			Work Address (number/street/apt.)			City	State	ZIP
	(	)

	Work Phone			Cell Phone		Email
	(	)		(	)

	Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?
	Yes 		No 

	Former Spouse/Registered Domestic Partner

	Name			Home Address (number/street/apt.)			City	State	ZIP


	D.O.B.			Occupation
N/A	D.O.B.			Occupation


	Home Phone			Work Address (number/street/apt.)			City	State	ZIP
	(	)

	Work Phone			Cell Phone		Email
	(	)		(	)

	Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?
	Yes 		No 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 3

II.RESIDENCE RECORD

10.Starting with your present address and working back, list each address (including temporary addresses) at which you have resided. Please include military and college (campus and/or off-campus) addresses. All foreign addresses must be included:

FROM	TO
Mo. Yr.	Mo.	Yr.

Street

Address

Apt.

No.

City or

Town

County of

Zip

State Code

PRESENT

a. Do you now or have you ever owned/co-owned any home/co-op/condo or other property? Yes  No . If yes, list

AddressCity/ TownStateZipCounty

b. With whom do you co-own? ____________________________________________________________________

c. All Residence telephone number(s): (Area Code) _____-_____-________

d. All Cell phone number(s): (Area Code) _____-_____-________

e. Email address(es): _____________________________________, _____________________________________

f. Do you now have or have you ever had an account on a social networking site, such as MySpace, Facebook or Twitter? Yes  No 

If yes, indicate address(es) ______________________, ______________________, ______________________

III.FAMILY RECORD

11.List below all of your living or deceased children, including natural, adopted, and/or foster care. Include any other children who have ever resided with you. Provide the name and contact information of the other parent or guardian.

Child’s Name (Last, First)			Sex	D.O.B.	Does Child Reside with You? Yes  No			 If No, Enter Full Address

Who has Custody of Child? Include Name and Relationship						Name of other Parent

Parent’s D.O.B.		Parent’s Home Address						Parent’s Contact Phone No.

Parent’s Occupation	Parent’s Work Address						Candidate’s Current Relationship with other Parent


Child’s Name (Last, First)			Sex	D.O.B.	Does Child Reside with You? Yes  No			 If No, Enter Full Address

Who has Custody of Child? Include Name and Relationship						Name of other Parent

Parent’s D.O.B.		Parent’s Home Address						Parent’s Contact Phone No.

Parent’s Occupation	Parent’s Work Address						Candidate’s Current Relationship with other Parent

Initial this page to indicate that you have provided complete and accurate information: __________

Page 4

	Child’s Name (Last, First)			Sex	D.O.B.	Does Child Reside with You? Yes  No				 If No, Enter Full Address

	Who has Custody of Child? Include Name and Relationship						Name of other Parent

	Parent’s D.O.B.		Parent’s Home Address							Parent’s Contact Phone No.

	Parent’s Occupation	Parent’s Work Address						Candidate’s Current Relationship with other Parent


	Child’s Name (Last, First)			Sex	D.O.B.	Does Child Reside with You? Yes  No				 If No, Enter Full Address

	Who has Custody of Child? Include Name and Relationship						Name of other Parent

	Parent’s D.O.B.		Parent’s Home Address							Parent’s Contact Phone No.

	Parent’s Occupation	Parent’s Work Address						Candidate’s Current Relationship with other Parent


	Child’s Name (Last, First)			Sex	D.O.B.	Does Child Reside with You? Yes  No				 If No, Enter Full Address

	Who has Custody of Child? Include Name and Relationship						Name of other Parent

	Parent’s D.O.B.		Parent’s Home Address							Parent’s Contact Phone No.

	Parent’s Occupation	Parent’s Work Address						Candidate’s Current Relationship with other Parent

a. Additional children listed on pages 18-22?						Yes  No 
b. What provisions have you made for the support of the children listed above?									________________________________

_______________________________________________________________________________________________

c. Do any of your children receive child support or other supportive income? (Social Security, disability) Yes  No  If yes, explain: __________________________________________________________________________________

_______________________________________________________________________________________________

IV. FAMILY RECORD AND REFERENCES

12.List the full names of biological mother and father; stepmothers/stepfathers; grandfathers; grandmothers; father-in-law; mother-in-law, living or deceased. The complete address for each must be listed (include city and state).

	Father’s Name	Home Address (number/street/apt.)					City	State ZIP

	Work Address (number/street/apt.)		City	State	ZIP		Occupation

	Home Phone		Work Phone			Cell Phone

	D.O.B.			Email

	Place of Birth (Village or Town, City, State, Country)

Initial this page to indicate that you have provided complete and accurate information: __________

Page 5

Mother’s Name	Home Address (number/street/apt.)					City	State ZIP

Work Address (number/street/apt.)		City	State	ZIP		Occupation

Home Phone		Work Phone			Cell Phone

D.O.B.			Email

Place of Birth (Village or Town, City, State, Country)

N/A

Stepfather’s Name	Home Address (number/street/apt.)					City	State ZIP

Work Address (number/street/apt.)		City	State	ZIP		Occupation

Home Phone		Work Phone			Cell Phone

D.O.B.			Email

Place of Birth (Village or Town, City, State, Country)

N/A

Stepmother’s	Name	Home Address (number/street/apt.)					City	State ZIP

Work Address (number/street/apt.)			City	State	ZIP		Occupation

Home Phone			Work Phone			Cell Phone

D.O.B.				Email

Place of Birth (Village or Town, City, State, Country)

N/A

	Father-in-law’s Name	Home Address (number/street/apt.)					City	State	ZIP

	Work Address (number/street/apt.)		City	State	ZIP		Occupation

	Home Phone		Work Phone			Cell Phone

	D.O.B.			Email

	Place of Birth (Village or Town, City, State, Country)


	N/A

	Mother-in-law’s Name	Home Address (number/street/apt.)					City	State	ZIP

	Work Address (number/street/apt.)		City	State	ZIP		Occupation

	Home Phone		Work Phone			Cell Phone

	D.O.B.			Email

	Place of Birth (Village or Town, City, State, Country)

Initial this page to indicate that you have provided complete and accurate information: __________

Page 6

N/A

Grandmother’s Name	Home Address (number/street/apt.)					City	State ZIP

Work Address (number/street/apt.)		City	State	ZIP		Occupation

Home Phone		Work Phone			Cell Phone

D.O.B.			Email

Place of Birth (Village or Town, City, State, Country)

N/A

Grandfather’s Name	Home Address (number/street/apt.)					City	State ZIP

Work Address (number/street/apt.)		City	State	ZIP		Occupation

Home Phone		Work Phone			Cell Phone

D.O.B.			Email

Place of Birth (Village or Town, City, State, Country)

a.List the full names of all biological brothers and sisters; half-brothers/half-sisters; stepbrothers/stepsisters; uncle; aunt; great aunt; great uncle; first cousin; nephew; niece; fiancé or fiancée, living or deceased (include females’ maiden names). The complete address for each must be listed (must include city and state).

N/A	Name		Relationship
N/A

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email


N/A	Name		Relationship

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email


N/A	Name		Relationship
N/A

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email

Initial this page to indicate that you have provided complete and accurate information: __________

Page 7

N/A	Name		Relationship

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email


N/A	Name		Relationship

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email


N/A	Name		Relationship
N/A

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email

b.List any person(s) who has ever resided with you, whether related to you or not (include females’ maiden names). The complete address for each must be listed (must include city and state).

N/A	Name		Relationship

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email


N/A	Name		Relationship
N/A

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email


N/A	Name		Relationship

Home Address (number/street/apt.)			City	State	ZIP	D.O.B.

Work Address (number/street/apt.)			City	State	ZIP	Occupation

Home Phone		Work Phone		Cell Phone			Email

Initial this page to indicate that you have provided complete and accurate information: __________

Page 8

c.List 5-6 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.

Name		How do you know this person?
		(for example: friend, teacher,
		family friend, co-worker)
Home Address (number/street/apt.)		City	State	ZIP	D.O.B.

Work Address (number/street/apt.)		City	State	ZIP	Occupation

Home Phone	Work Phone		Cell Phone			Email


Name		How do you know this person?
		(for example: friend, teacher,
		family friend, co-worker)
Home Address (number/street/apt.)		City	State	ZIP	D.O.B.

Work Address (number/street/apt.)		City	State	ZIP	Occupation

Home Phone	Work Phone		Cell Phone			Email


Name		How do you know this person?
		(for example: friend, teacher,
		family friend, co-worker)
Home Address (number/street/apt.)		City	State	ZIP	D.O.B.

Work Address (number/street/apt.)		City	State	ZIP	Occupation

Home Phone	Work Phone		Cell Phone			Email


Name		How do you know this person?
		(for example: friend, teacher,
		family friend, co-worker)
Home Address (number/street/apt.)		City	State	ZIP	D.O.B.

Work Address (number/street/apt.)		City	State	ZIP	Occupation

Home Phone	Work Phone		Cell Phone			Email


Name		How do you know this person?
		(for example: friend, teacher,
		family friend, co-worker)
Home Address (number/street/apt.)		City	State	ZIP	D.O.B.

Work Address (number/street/apt.)		City	State	ZIP	Occupation

Home Phone	Work Phone		Cell Phone			Email


Name		How do you know this person?
		(for example: friend, teacher,
		family friend, co-worker)
Home Address (number/street/apt.)		City	State	ZIP	D.O.B.

Work Address (number/street/apt.)		City	State	ZIP	Occupation

Home Phone	Work Phone		Cell Phone			Email

Initial this page to indicate that you have provided complete and accurate information: __________

Page 9

V.FOREIGN CONTACTS (OR LANGUAGE)

13a. Do you speak, read, write, or understand a foreign language? Yes  No . If Yes, list language(s) and educational level of proficiency: ____________________________________________________________________

b.How often is each language(s) used? ________________________________________________________________

c.With whom is each language used? ____________________________ How often?__________________________

d.Is this person inside or outside of the United States? Inside  Outside 

If outside, list country ____________________________________________________________________________

VI. EDUCATION RECORD

14. List all schools you have attended beginning with the 9th grade:

School Name,

City, State and Zip Code

Month and Year

Attended

From To

Number of Credit Hours

Completed

Semester Quarter

Type of Degree

(e.g. H.S. Diploma,

B.A., M.A.)

Month and Year

of Graduation,

Degree

a.List any other schools attended, including but not limited to, trade, vocation, business, professional and occupational licenses, training courses, internships, certificate programs, etc. List the dates of attendance.

_______________________________________________________________________________________________

b.	High school diploma from an accredited U.S. Institution? Yes  No 	G.E.D.	Yes  No 
	If “Yes”, G.E.D.-Issuing State _____________________ Date Issued ___________		Other ___________________

c.Were you ever the subject of any disciplinary action at any educational institution which you attended?

Yes  No  If “yes” give details on pages 18 through 22. (School name, disposition date, etc.)

VII. EMPLOYMENT RECORD

15.Have you ever been fired or suspended from any job, or has any form of disciplinary action been taken against you by any employer? Yes  No . If Yes, explain below.

______________________________________________________________________________________________

List below, starting with your current employment-or unemployment - and working back, each period of employ- ment and period of unemployment you have had. Include within the sequence any period of active military ser- vice. If you were discharged from any employment, or requested to resign, so state under “Reason for leaving employment”. DO NOT LEAVE ANY TIME PERIODS UNACCOUNTED FOR.

From		To		 Full Time	Name of Supervisor:
Mo.:	Yr.:		PRESENT	 Part Time

Company Name (it unemployed, so state)					Type of work you performed:

Street Address of Company

Employer’s Telephone Number:

City, State and Zip Code

Reason for leaving employment:

From		To		 Full Time	Name of Supervisor:
Mo.:	Yr.:	Mo.:	Yr.:	 Part Time

Company Name (if unemployed, so state)					Type of work you performed:

Street Address of Company

Employer’s Telephone Number:

City, State and Zip Code

Reason for leaving employment:

Continue employment entries on Page 11

Initial this page to indicate that you have provided complete and accurate information: __________

Page 10

How to Edit Apd 5A Form Online for Free

Filling out nypd telephone reference check is a snap. Our team designed our software to really make it convenient and assist you to fill in any form online. Below are some steps you'll want to follow:

Step 1: Step one is to click on the orange "Get Form Now" button.

Step 2: Now it's easy to edit the nypd telephone reference check. The multifunctional toolbar can help you include, eliminate, modify, and highlight text or carry out several other commands.

These particular areas are going to make up your PDF document:

In the part I PERSONAL DATA, Last Name, First Name, Mid Init, Social Security No, a Have you ever had a legal name, From To Reason, Court Index No, If by marriage date of marriage, b List below any other name alias, c Do you have any tattoos brands, Sex Male Female, and Date of Birth Month Day Year note the particulars that the application requires you to do.

Be sure to highlight the relevant information from the Citizenship, Citizen of the USA Yes, a What country were you born in, b If not born in USA date entered, c If you are a naturalized citizen, Naturalization Certificate No d Do, Court, State, Date, C i t y, How was it obtained, Do you have a US Resident Alien, No Expiration, If yes how was it obtained Lottery, and Alien Registration No box.

nypd cas 5 form Citizenship, Citizen of the USA Yes, a What country were you born in, b If not born in USA date entered, c If you are a naturalized citizen, Naturalization Certificate No d Do, Court, State, Date, C i t y, How was it obtained, Do you have a US Resident Alien, No Expiration, If yes how was it obtained Lottery, and Alien Registration No blanks to fill out

In the section Country Reason, Has a visa ever been denied, What countries outside of the USA, Country Town or City, Dates, Length of Stay, Purpose of Visit, Initial this page to indicate that, and Page, list the rights and responsibilities of the sides.

Fill out the form by reading the following areas: SpouseRegistered Domestic Partner, Home Address numberstreetapt, City, State, ZIP, DOB, Occupation, Home Phone, Work Phone, Work Address numberstreetapt, City, State, ZIP, Cell Phone, and Email.

Step 3: Choose the Done button to make sure that your finished form may be exported to any electronic device you select or delivered to an email you specify.

Step 4: You can also make duplicates of the document tokeep away from any future troubles. Don't get worried, we do not reveal or monitor your data.

Apd 5A Form – Fill Out and Use This PDF

Apd 5A Form PDF Details

Form Preview Example

How to Edit Apd 5A Form Online for Free

Watch Apd 5A Form Video Instruction

Apd 5A Form isn’t the one you’re looking for?

Please rate Apd 5A Form

Apd 5A Form – Fill Out and Use This PDF

Apd 5A Form PDF Details

Form Preview Example

How to Edit Apd 5A Form Online for Free

Watch Apd 5A Form Video Instruction

Apd 5A Form isn’t the one you’re looking for?

Related Documents

Please rate Apd 5A Form

Related Resources