1

Name

 *

Name

2

Contact Information

Contact Information

Mailing address

Email address

Phoneext.

3

Email address

Email address

4

Personal Information

Place of Birth

5

Date of Birth

Date of Birth

6

Driver's License Number

Driver's License Number

7

Occupation Information

Occupation Information

Occupation

Work Phoneext.

8

Please list your skills and knowledge that would be relevant to this advisory committee

Please list your skills and knowledge that would be relevant to this advisory committee

9

CAC members are charged with developing public safety recommendations – this may challenge your personal perspective - describe how you would handle such challenges if they were to arise

CAC members are charged with developing public safety recommendations – this may challenge your personal perspective - describe how you would handle such challenges if they were to arise

10

Describe how your presence on this committee would represent a substantial segment of the community

Describe how your presence on this committee would represent a substantial segment of the community

11

Describe how you have shown the ability to think and discuss public safety topics objectively

Describe how you have shown the ability to think and discuss public safety topics objectively

12

Why do you want to serve on the Chief’s Advisory Committee

Why do you want to serve on the Chief’s Advisory Committee

Please list two references that are knowledgeable about your skills and perspectives related to serving on the Chief’s Advisory Committee

13

Reference #1

Reference #1

Name

Phoneext.

Email

14

Reference #2

Reference #2

Name

Phoneext.

Email

15

Have you ever had any contact with the SCPD? 

Have you ever had any contact with the SCPD?

No

Yes

If so, was your experience positive or negative? Please describe.

16

Have you ever applied to work for the City of Santa Clara?

Have you ever applied to work for the City of Santa Clara?

No

Yes

If so, in what capacity?

17

Are you at least 18 years of age?

Are you at least 18 years of age?

Yes

No

18

Are you currently on probation?

Are you currently on probation?

Yes

No

19

Are you currently on parole?

Are you currently on parole?

Yes

No

20

Certification and Authorization 

Certification and Authorization

I certify that the statements made by me in this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that falsification, misrepresentation or omission of facts called for by the application could result in immediate dismissal in this program.

I authorize the City of Santa Clara the right to contact and obtain information from all references, employers, educational institutions, and law enforcement agencies, and otherwise verify the accuracy of the information contained in the application. I hereby release from liability the City of Santa Clara and its representative from seeking, gathering and using such information and all other person, corporation or organization from furnishing and disclosing information.

I agree to report all contact(s) (e.g. speeding ticket, arrest, etc.) with any law enforcement agency during the course of the Chief's Advisory Committee to the Management Analyst or Lieutenant immediately.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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