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#17-005911-0002
Supplemental Questionnaire

Last Name
First Name
1.

Are you between the age of 20 and 59?

Yes No
1a.

Please type your year of birth.

2.

If you have previously applied to MSP, then please provide when you applied and what was the reason you were not hired in the field below.

If you have not previously applied, then type "NA" in the field below.

3.

If you have a valid driver’s license, then please provide the State you have a valid driver’s license in.

If you do not have a valid driver's license, then type "NA" in the field below.

3b.

Please provide the amount of current points on your license.

0
1
2
3
4
5+
4.

Are you a certified paramedic who is seeking a position as a State Trooper / Flight Paramedic with the MSP Aviation Command?

Yes No
4b.

Are you currently a Nationally Registered Paramedic?

Yes No
4c.

Do you possess a valid state paramedic license / certification?

Yes No
 

If yes, in which state fo you have a valid paramedic license / certification?

4d.

How many years of experience do you have as an EMS Provider?

4e.

How many years of experience do you have as an ALS Provider?


4f.

What types of experience do you have? Check all that apply and provide the amount of years of experience for the type checked.


 

Paid Experience

 

Years

 

Volunteer Experience

 

Years

 

Scene/911 Response

 

Years

 

Inter-facility/Critical Care

 

Years

 

Aeromedical

 

Years


4g.

Which current / valid certifications do you possess? Check all that apply.


 

ITLS / PHTLS

 

ACLS

 

PALS / PEPP

 

CCEMTP / CCP-C

 

FP-C

 

Instructor (If Yes, please specify below)

 

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NOTE

IMPORTANT NOTICE FOR THE BELOW CRIMINAL HISTORY QUESTIONS:

The questions below pertaining to criminal history MUST contain the following details:

  • Date of arrest or court order (you must be specific MM/DD/YY)
  • Charge(s)
  • Police Agency involved
  • Location (City / State)
  • Disposition of Case
  • Specific details of the arrest / court order (include information regarding the cause of the arrest /court order)

For dates, we need at least a month and a year.

Initial applications that are received without this required information will be rejected.

I have read this notice and understand that I must complete the below questions with the instructed information.

Yes No
5.

Have you ever been arrested?

Yes No
5b.

If yes, provide the information for all arrests (include: Date of arrest, Charge(s), Police Agency Involved, City / State, Disposition of Case and Details).

6.

Have you ever been, or are you currently, under a court or exparte order relating to domestic violence?

Yes No
6b.

If yes, list information regarding the court order (s). (Include: Date be specific MM/DD/YY, Police Department Involved, Dispositon, Details)

NOTE

IMPORTANT NOTICE FOR THE BELOW ILLEGAL DRUG QUESTIONS:

The questions below pertaining to illegal drugs MUST contain the following details:

  • Name of Substance
  • Amount of times used during the requested age range
  • Date of last use

When completing the below questions regarding illegal drugs, use best estimates for dates and numbers.  DO NOT use amount ranges.  For example, if you estimate that you have smoked marijuana between 300 and 350 times, you should write the number 325.  You must use exact numbers and dates, but they can be estimated.  For dates, we need at least a month and a year.

Initial applications that are received without this required information will be rejected.

I have read this notice and understand that I must complete the below questions with the instructed information.

Yes No
7.

Have you ever used illegal drugs in your entire lifetime?

Yes No
7b.

Have you used any illegal drugs while UNDER 21 years of age?

Yes No
7c.

If yes, list information regarding usage UNDER the age of 21. (Include: Name of Substance, Total times used, Date of last use – be specific MM/DD/YY)

7d.

Have you ever used illegal drugs ON or AFTER 21 years of age?

Yes No
7e.

If yes, list information regarding usage ON or AFTER the age of 21. (Include: Name of Substance, Total times used, Date of last use – be specific MM/DD/YY)

NOTE

IMPORTANT NOTICE FOR THE BELOW PRESCRIPTION DRUG QUESTIONS:

The questions below pertaining to prescriptions prescribed to another MUST contain the following details:

  • Name of Substance
  • Amount of times used during the requested age range
  • Date of last use
  • Person and Relationship of the prescribed individual
  • Reason for use

When completing the below questions regarding prescriptions prescribed to another, use best estimates for dates and numbers.  DO NOT use amount ranges.  For example, if you estimate that you have used percocet between 300 and 350 times, you should write the number 325.  You must use exact numbers and dates, but they can be estimated.  For dates, we need at least a month and a year.

Initial applications that are received without this required information will be rejected.

I have read this notice and understand that I must complete the below questions with the instructed information.

Yes No
8.

Have you ever used prescriptions prescribed to another person?

Yes No
8b.

Have you ever used prescriptions prescribed to another person while UNDER 21 years of age?

Yes No
8c.

If yes, list information regarding usage UNDER the age of 21. (Include: Name of Prescription, Total times used, Reason for Use, Who the prescription was prescribed to, Date of last use – be specific MM/DD/YY)

8d.

Have you ever used prescriptions prescribed to another person ON or AFTER 21 years of age?

Yes No
8e.

If yes, list information regarding usage ON or AFTER the age of 21. (Include: Name of Prescription, Total times used, Reason for Use, Who the prescription was prescribed to, Date of last use – be specific MM/DD/YY)

9.

Have you ever directly sold any illegal drug or prescription drugs? (Obtained through sale: money, merchandise, property, services or favors)

Yes No
9b.

If yes, list information regarding the sale. (Include: Date of last activity, Name of substance or prescription, Indicate what was received through the sale - i.e. money, merchandise, property, services, and/or favors, and Additional Details)

10.

Are you related to a current or former member of the Maryland State Police?

Yes No
10b.

If Yes, please list the former/current Maryland State Police employee''s name, rank, and their relationship to you.

 

SUBJECT:       Truthfulness

One of the most critically important issues that defines the effectiveness of any organization is the perception that it is a credible organization.  Central to that image is the integrity and truthfulness of the department’s employees, from the newest entrant through the top-level managers. 

The need for honest, impartial and accurate representation of facts is nowhere more vital than within a law enforcement agency where success or failure rests with the degree of public support it receives.  Public support can quickly erode where there is a lack of credibility in existence within an organization.

The very basis of an individual’s integrity, as perceived by the public, friends and fellow workers is at stake whenever the truth is not told.  The loss of integrity by an individual or group of individuals can quickly spread throughout the department.

As Superintendent, it is my responsibility to maintain the effectiveness of the Department of State Police as a viable law enforcement agency.  This document serves notice that I will not tolerate lying of any kind by any member of this department, including applicants.  You are therefore advised that all information disclosed or gleaned during the application process may be verified by means of a polygraph examination.

Any statements or omissions, either written or verbal, that are given by any applicant with the intent to deceive will result in rejection from further consideration for employment with the Department of State Police.  There is no substitute for the truth.

William M. Pallozzi

Superintendent

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I have read and considered the preceding statement and agree that all information that I supply during the course of my processing, either written or verbal, will be answered honestly and truthfully. I will not intentionally omit any information with the intent to deceive.

 

Yes No
 

I HAVE READ AND COMPLETED ALL QUESTIONS ON THIS PAGE THAT CONSTITUTE MY INITIAL APPLICATION PART A. I UNDERSTAND THAT FAILURE TO COMPLETE A QUESTION WITHOUT ALL REQUIRED INFORMATION WILL RESULT IN MY INITIAL APPLICATION BEING REJECTED.

Yes No
 

Please enter today's date (format of MM/DD/YYYY)

 

State where you reside:

 

I HAVE COMPLETED THIS PAGE, THE INITIAL APPLICATION (PART A) AND AM SUBMITTING IT TO MARYLAND STATE POLICE RECRUITMENT AND SELECTION UNIT FOR REVIEW.

PLEASE NOTE, BY CLICKING THIS CHECKBOX YOU ARE SUBMITTING YOUR APPLICATION PART A FOR REVIEW.

NO FURTHER STEPS MUST BE TAKEN AT THIS TIME. YOU WILL RECEIVE FURTHER NOTIFICATION WITHIN 3-5 BUSINESS DAYS.


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