EMPLOYMENT INFORMATION

Please complete the following information.  This information will remain CONFIDENTIAL.

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* 1. First Name

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* 2. Last Name

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* 3. Title/Rank

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* 4. Unit/Division

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* 5. Agency

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* 6. Agency Street Address

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* 7. Agency City

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* 8. Agency State

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* 9. Agency Zip Code

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* 10. Agency Phone Number

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* 11. Preferred Email Address

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* 12. Preferred Phone

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* 13. Years of Employment in Law Enforcement

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* 14. Employment Status

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* 15. What Shift Do You Usually Work?

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