Nypd Forms Cas 5A Printable 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.

QuestionAnswer
Form NameApd 5A Form
Form Length24 pages
Fillable?Yes
Fillable fields1118
Avg. time to fill out38 min 16 sec
Other namesnypd forms cas 5a, nypd telephone reference check, nypd cas 5 form, 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

1.

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.

2.

Sex: Male Female

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

4.Birth Certificate:

 

 

 

Certificate Number

City or Town

 

 

County

 

State

5.

 

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? ___________________________________________________________________________

6.

 

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

Yes

No

Expiration: __________________

 

 

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

 

 

Alien Registration No. __________________________________________________

 

 

7.

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Continued Employment Entries

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

Additional employment listed on pages 18 through 22?

Yes

No

16.If you listed any period(s) of unemployment, state how you were supported during that time: __________________

_______________________________________________________________________________________________

a.

Additional statements listed on pages 18 through 22?

Yes

No

17.

Are you currently employed by the New York City Police Department?

Yes

No

 

If yes, indicate current title: _______________________________________________________________________

 

Supervisor’s Name

Telephone Number

 

Command

 

 

 

 

 

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

Page 11

a.Have you ever applied for any position or taken any civil service examinations for a position with any City, Municipal, Village, Town, County, State, and/or Federal Authority? Yes No This includes if you have been interviewed without an examination. If “yes,” state name of agency concerned, position/title, year of exam, list position (if any), and current status:_________________________________________________________________

_______________________________________________________________________________________________

Additional applications listed on page 18 through 22 Yes No

b.Have you ever been employed by any City, Municipal, Village, Town, County, State, and/or Federal Authority?

Yes No If “yes” state name of agency concerned _______________________________________________

c.Are you employed by, or do you have an interest in an individual or organization that has business dealings with the City of New York? Yes No If “yes”, state name of company concerned: ___________________________

d.

Have you ever taken a polygraph examination? Yes No If “yes” list and explain______________________

 

_______________________________________________________________________________________________

 

What were the results? ___________________________________________________________________________

e.Have you ever been disqualified or barred from employment by any City, State, or Federal agency? Yes No If “yes”, explain: _________________________________________________________________________________

_______________________________________________________________________________________________

f. Have you ever been drug screened for employment? Yes No

If “yes”, when and for which employment: ____________________________________________________________

_______________________________________________________________________________________________

Describe circumstances and results_________________________________________________________________

18.Have you ever applied for, claimed, received or are now receiving any benefits under any law concerning unemploy- ment, social security, veteran’s administration, public assistance, welfare, or other social services assistance? This

includes housing, food stamps and Medicaid. Yes No If “yes” give details: _________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

19.List the names of any not-for-profit organization(s) to which you have made contributions of money or property, or otherwise supported, inside or outside the United States, within the last ten years: __________________________

_______________________________________________________________________________________________

a.Do any of these organizations have contact with any foreign government organizations or their representatives? Yes No

b.List any organization of which you are now or have ever been a member (or officer, if so, please state) foreign or domestic, that advocates violence. __________________________________________________________________

c.Income Tax Returns

No Have you filed a Federal and State income tax return for each of the past (5) years? Yes

If “no” explain ___________________________________________________________________________________

_______________________________________________________________________________________________

20.Do you now or have you ever had a business relationship (such as a real estate co-tenancy, partnership or significant stock ownership) with anyone? Please list associate information:

Name: _______________________________________ Address: ________________________________________

City, State ZIP: ________________________________________ Phone: _________________________________

Name/Address of Business ________________________________________________________________________

Type of Business ________________________________________________________________________________

a.Have you ever received support from or supported an individual in a foreign country Yes No

VIII. CONVICTION RECORD/PENDING CRIMINAL ACTIONS

21.List all incidents (including summonses which were returnable to a criminal court) which resulted in a CONVICTION, including YOUTHFUL OFFENDER ADJUDICATIONS. List all criminal actions that are still pending. You must also include any convictions which have been sealed pursuant to CPL §§160.55 and 160.59.

Date

Location

Original Charge(s)

Final Charge(s)

Disposition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Page 12

22.List ALL summonses served upon you by a law enforcement officer, court or other authority in any jurisdiction which were returnable to a Transit Adjudication Bureau, Environmental Control Board, etc. (For example, turnstile jumping, drinking alcohol in public, Disorderly Conduct, etc.) If you have never received this type of summons, enter NONE.

Date

Location

Original Charge(s)

Final Charge(s)

Disposition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.Has any member of your immediate family (spouse, parent, brother, sister) or any person with whom you have ever resided with you, although not related to you, ever been convicted or incarcerated? Include any person listed in

questions 9, 11, 12a and 12b. Yes No If “yes”, explain on pages 18 through 22.

24.Have any individuals with whom you have a child in common ever been convicted of a crime or incarcerated?

Yes No If “yes” explain: _____________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

25.Have you ever been involved in any domestic incidents? Yes No

If “yes” explain: __________________________________________________________________________________

________________________________________________________________________________________________

a.Has an order of protection ever been issued against you? Yes No

Date(s) Issued ___________________________ Date(s) Expired ___________________________

26.List any case or instance in which you were: 1) a plaintiff, defendant, or witness in any civil court proceeding, 2) a petitioner or respondent in a Family Court Proceeding, 3) a complainant or witness in a criminal court or grand jury proceeding, 4) the subject, complainant, or witness of any investigation by any city, state, or federal agency, 5) a subject, complainant or witness in any administrative hearing. Do not include any court appearances made in your official capacity as a law enforcement officer, peace officer, or security guard.

Date

City/Town & State

Court or Agency

Purpose of the Hearing, and Your Involvement in Case

a.Were you ever the subject/witness or have you ever been questioned during a police investigation in which you were not charged with a crime? Yes No If “yes”, explain: ___________________________________________

_______________________________________________________________________________________________

IX. LICENSE RECORD

27.Do you possess, or have you ever possessed a valid NY State Driver’s License? Yes No

a.If“yes”complete:Class_____LicenseNo.___________________Dateissued_______________Expires_______________

b.Has your NYS Driver’s License ever been suspended or revoked? Yes No If “yes” explain:

Date

Reason

 

 

 

 

 

 

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

Page 13

c.Are there any restrictions on your license? Yes No If “yes”, list here: ________________________________

_______________________________________________________________________________________________

d.Have you ever been issued a Driver’s License by a state other than NY? Yes No

If “yes”, issuing state(s) ______________________________________________

License No. ___________________________ Date issued __________________ Expires____________________

e.Has any driver’s license issued to you by a state other than NY ever been suspended or revoked? Yes No If “yes”, explain: issuing state(s): _______________________________________

When: _________________________________________ Why: __________________________________________

f.Do you possess, or have you ever possessed a valid U.S. Military License? If “yes” what branch of service? __________

License No. ___________________________ Date issued __________________ Expires____________________

Ever suspended or revoked? Yes No If “yes” to suspended or revoked, explain

When: _________________________________________ Why: __________________________________________

g.Do you now possess, or have you ever possessed, a foreign driver license? If “yes”, issuing

government(s) _____________________________ License No. ___________________ Date Issued ___________

28.List ALL summonses or citations you have ever received violations of any traffic laws or regulations, in any jurisdictions.

Date of Violation

City/Town & State & Country

Violation or Charges

Court Disposition & Date

29.List below all motor vehicles ever owned by you or registered to you. Include all motor vehicles a) owned by you and registered to you, b) owned by you but registered to someone else, c) registered to you but owned by someone else.:

Year of Vehicle

Make of Vehicle

Type of Vehicle

Period Owned

From

To

 

 

Reg. Plate No.

State

Licensing

30.

Do you have any outstanding, unpaid parking summonses? Yes No If “yes”, how many? ___________

31.Were you ever in a motor vehicle accident in which YOU WERE THE DRIVER OF THE VEHICLE? Yes No If “yes” list all accidents below.

Date

Vehicle Owner

Accident Location

Any Injuries?

To Whom?

Police Pct./Accident No.

Claims Pending?

By Whom?

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

Page 14

X.LICENSE AND FIREARM RECORD

32.Do you now own or possess, or have you ever owned or possessed a pistol, rifle, or firearm? Yes No If “yes”, give details below.

Type of Weapon

Manufacturer

Model Calibre

Serial Number

Dates Owned

How Obtained?

Where Obtained?

a.For each weapon listed above, give details below.

Weapon

License/ Certification No.

Issuing Agency

Date Issued

Date Expired

Suspended / Revoked?

33.Have you ever been issued a license by any city, state, or federal agency, for any purpose, including, but not

limited to: attorney, teacher, real-estate broker, doctor, taxi driver, security guard, notary public, locksmith, or for

any premises licensed by the State Liquor Authority? Yes No

If “yes”, explain below.

Kind of License

License Number

Issuing Agency

Issue Date

Expire Date

Ever Suspended

Or Revoked

XI. MILITARY SERVICE RECORD

34.List below military service performed on either Active Duty or on Reserve or National Guard Status. Include any foreign military service.

From To

Active or Reserve

Branch Service

Rank

Service Ser. No.

Type of Discharge or Separation

35.Have you ever been disciplined while in military service, including, but not limited to, Court Martial and/or action(s) under Article 15, Code of Military Justice.

Date

Charges Against You (SPECIFIC)

Reason

Type of

Action

Disposition of Charges

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

Page 15

XII.

SELECTIVE SERVICE RECORD

36.

Does Selective Service apply to you? Yes No

 

All males born after December 31, 1959 are required to register with the Selective Service System. If you are a male, have

 

you registered? Yes No If “yes”, Selective Service No.: ________________ Date of registration: ______________

 

If “no”, explain: __________________________________________________________________________________

XIII. DEBTS - FINANCIAL STATUS

37.List below all persons or entities to whom you presently owe money (including student loans not yet due for repayment) such as banks, credit cards, mortgages, personal loans, tax liens, revolving or store credit, etc.

Name and address of person or entity to whom debt is owed

Original Amount

Present Balance

Monthly or

Periodic Payment

Purpose of Debt

Date Made

 

Total amount of debt $ __________

Student Loan(s)

$ __________

Mortgage $ __________

 

Total annual income $ __________

Credit Card(s)

$ __________

Other

$ __________

a.

Have you ever filed for bankruptcy?

Yes No

If “yes” explain below: _____________________________

_______________________________________________________________________________________________

b.Have you ever been in default, or had any garnishment, wage assignment, or judgement filed against you for failure

to pay a debt? Yes No If “yes” explain: ________________________________________________

_______________________________________________________________________________________________

XIV. CONTROLLED SUBSTANCE / ALCOHOL USE

38.Answer either “Yes” or “No” after each question below. An answer of “Yes” to any question requires an explanation on pages 18 through 22, including dates, frequency, treatment, cure, etc. The phrase “ever used” in this context includes everything from one (1) time usage or occasional usage to frequent or regular usage.

a.Do you now or have you ever used marijuana? _______________

b.Do you now or ever have you ever used crack and/or cocaine? _______________

c.Do you now or have you ever used any opiate (heroin, morphine, opium, etc.)? _______________

d.Do you now or have you ever used any hallucinogenic drug (LSD, PCP, etc.)? _______________

e.Do you now or have you ever used any other non-prescribed controlled substance? _______________

f.Doyounoworhaveyoueverusedanynon-prescribedamphetamines,barbiturates,orothertranquilizers? _______________

g.Do you now or have ever used steroids? _______________________

h.Have you ever used any other type of illegal drugs, including, but not limited to, ecstasy, crystal methamphetamine, “club drugs”, etc.? ___________________________________

i.Do you now or have you ever used any other prescription medicine for which you did not have a prescription?

39.Answer either “Yes” or “No” after each question below. An answer of “Yes” to any question requires an explanation on pages 18 through 22, including frequency of use, treatment, etc. In this context, “alcohol” refers to any and all alcoholic beverages, including beer, wine, wine coolers, scotch, etc.

a.Do you use alcohol? _______________

b.Is alcohol a part of your social life? _______________

c.Does a relative or friend worry or complain about your drinking? _______________

d.Do you miss days from work because of drinking? _______________

e.Have you awakened the morning after drinking and could not remember part of the previous evening? ____________

f.Has drinking created medical, financial, relationship, or work-related problems for you?

g.Do you get into arguments or fights when you are drinking? ____________

h.Have you ever used more alcohol than you intended? _______________

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

Page 16

XV. MISCELLANEOUS

40.Are you now, have you ever been, or have you ever applied for a position as an auxiliary police officer?

 

Yes No

If “yes”, list dates of application/service, precinct or location of service, and name of

 

 

supervisor and/or coordinator.

 

 

 

 

 

 

_______________________________________________________________________________________________

 

_______________________________________________________________________________________________

41.

Are you now, have you ever been, or have you ever applied to become a volunteer firefighter?

Yes

No

 

If “yes”, list dates of application/service, location of service, and name of supervisor.

 

 

 

_______________________________________________________________________________________________

 

_______________________________________________________________________________________________

42.

Were you a member of the NYPD Explorer Program?

 

 

Yes

No

 

If “yes”, list dates of service, location of service, and name of supervisor.

 

 

 

_______________________________________________________________________________________________

43.

Have you ever visited any persons incarcerated in any Correctional Facilities?

Yes

No

 

If “yes”, list the identity of the person(s): relationship, purpose of visit, name of facility, and date of visit.

 

 

 

Last Name

First Name

Relationship

Purpose of Visit Name of Facility

Date of Visit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

44.

Have you ever been involved with any street gangs or organized crime organizations?

Yes

No

 

If “yes”, list all groups, reason, and dates of involvement.

 

 

 

 

Group Name

Nature of Involvement

Dates of Involvement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

45.Do you have any knowledge or information, in addition to that specifically called for in the preceding questions, which may be relevant to an investigation into your eligibility for appointment to the position for which you have applied? Yes No If “yes”, explain: _________________________________________________________

_______________________________________________________________________________________________

I am aware that if appointed to the New York City Police Department, I must adhere to Patrol Guide procedure 203-10 “Public Contact/Prohibited Conduct.” It is prohibited to have contact with any person/organization reasonably believed to be engaged in, likely to engage in or to have engaged in criminal activities.

___________________________________________________

Signature

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

Page 17

State of:

 

City of:

S.S.

County of:

 

I, ____________________________________________________________, being duly sworn, do hereby depose and

say that I am the above named person and that I have completed the foregoing questionnaire, including the additions thereto which appear on pages 18 through 22 following, and that I understand the contents. I further state that the answers contained herein are complete and correct in every respect. I also understand that any material misrepresentation of fact may be cause for rejection before appointment or disqualification and prosecution after appointment.

Signature of Candidate in Presence of Notary Public

Sworn to before me this _________________ day of _____________________________________ 20

Notary Public or Commissioner of Deeds

(or Commissioned Officer for Military Personnel on Active Duty)

DO NOT SIGN BELOW UNTIL DIRECTED BY YOUR INVESTIGATING OFFICER:

Signature of Applicant at Interview

Date

Rank/Signature of Investigator

The following space is provided for detailed answers to preceding questions. Indicate the question number to which the answers apply.

Question Number

Answer

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

Page 18

The following space is provided for detailed answers to preceding questions. Indicate the question number to which the answers apply.

Question Number

Answer

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

Page 19

The following space is provided for detailed answers to preceding questions. Indicate the question number to which the answers apply.

Question Number

Answer

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

Page 20

The following space is provided for detailed answers to preceding questions. Indicate the question number to which the answers apply.

Question Number

Answer

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

Page 21

The following space is provided for detailed answers to preceding questions. Indicate the question number to which the answers apply.

Question Number

Answer

(If additional space is required, use 81/2” x 11” bond paper and attach to this questionnaire)

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

Page 22

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

How to Edit Apd 5A Form

Filling out nypd forms cas 5a 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 forms cas 5a. 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:

part 1 to filling in  nypd forms cas 5a printable

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.

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .