PSI Screening Form | Panther Security and Investigations

Email

Social Security Number

###-##-####

Date of Birth required

Race/Ethnicity

Sex

Male

Female

Other

Additional Identifying Information

Citizenship acquired by:

Birth, Immigration, etc

Height

Weight

List of all other names you have gone by, including nicknames

If female, furnish maiden name

Have you ever legally changed your name?

Yes

No

Number of Dependents

Do you possess a valid driver's license issued from any other state other than Utah?

Yes

No

Parent Information

Father's First Name

Father's Last Name

Father's Address

Father's Date of Birth required

Is your father still living?

Yes

No

Mother's First Name

Mother's Last Name

Mother's Address

Mother's Date of Birth required

Is your mother still living?

Yes

No

Do you have any brothers?

Yes

No

Brother's Full Name

Brothers' Date of Birth

Brother's Address

Is your brother still living?

Yes

No

Do you have any sisters?

Yes

No

Sister's Full Name

Sister's Date of Birth

Sister's Address

Is your sister still living?

Yes

No

Are you currently married?

Yes

No

Spouse Name

Spouse Date of Birth

Spouse Address

Have you been previously married?

Yes

No

Former Spouse Name

Former Spouse Date of Birth

Former Spouse Address

Is (s)he still living?

Yes

No

Is there any other person not listed above with whom you currently reside with who is currently 16 years of age or older?

Yes

No

Current Address

Date began residing there

Do you rent or own?

Own

Rent

Landlord's Name

Landlord's Address

Landlord's Phone Number

Full Name of First Reference

Reference's Address

Reference Phone Number

Full Name of Second Reference

Address of Second Reference

Reference Phone Number

Have you previously submitted an application for employment to the agency to which you are applying today?

Yes

No

Education

Education beyond Highschool/GED

Law Enforcement Training

Academic, i.e. College

Police Academy

Institution/Agency

State

Date Completed required

Are you currently a certified law enforcement officer?

Yes

No

Employment History

When did you first decide to pursue a job in law enforcement, criminal justice, or public safety?

What is the date of your first application to any law enforcement, criminal justice, or public safety agency? required

Are you currently employed?

Yes

No

Have you ever been unemployed for more than 30 days?

Yes

No

Employer

Job Title

Duties

Is/was this position in law enforcement, criminal justice, or public safety?

Yes

No

Starting Salary/Wage/Commission

Ending Salary/Wage/Commission

Employer Number

Employer Address

Supervisor Name

Date Hired

Are you still employed?

Yes

No

Please list any incidents

Military History

Have you ever served in the military or active duty OR reserve duty?

Yes

No

Martial Status/Family Information

Current Marital Status

Date of Marriage

Number of Previous Marriages

With whom are you currently living?

Are you currently financially responsible for dependent children who do NOT live with you?

Yes

No

Legal

Traffic Violations

Accident(s) with property damage only

Number of Accidents

Date of Last Incident required

Describe and/or provide additional information regarding this/these violation(s)

Number of Times

Date of last civil court action?

Have you ever taken ANY money or property from an employer?

Yes

No

Have you ever taken, bought, sold, received, or held stolen property for someone else?

Yes

No

Have you ever been arrested, detained, pled guilty or no contest to a charge involving assault, domestic violence, or stalking?

Yes

No

Have you ever been incarcerated?

Yes

No

Have you ever been on probation or parole?

Yes

No

Have you ever been sentenced to community service?

Yes

No

Have you ever been ordered to make restitution?

Yes

No

Have you ever been mandated to counselling or education?

Yes

No

Do you smoke now?

Yes

No

Do you currently drink alcohol?

Yes

No

How many times have you consumed 6 or more drinks at one time?

How often have you driven after 4 or more drinks?

How many times have you driven with an open container?

What is the average number of drinks consumed per week?

How many times have you consumed alcohol on the job?

How many times have you been warned by an employer about drinking?

Have you ever used or experimented with marijuana?

Yes

No

Have you ever used or experimented with cocaine?

Yes

No

Have you ever used or experimented with amphetamines, dexedrine, "speed", "crank"?

Yes

No

Have you ever used or experimented with PCP (angel dust)?

Yes

No

Have you ever used or experimented with crack cocaine, opiates, morphine, heroin?

Yes

No

Have you ever used or experimented with any illegal drug not listed above?

Yes

No

Number of times you have smoked/used or experimented with marijuana in your entire life?

Number of times you have smoked/used or experimented with marijuana in the last 12 months?

Have you ever driven after smoking/using marijuana?

Yes

No

Have you ever provided marijuana in exchange for money or goods?

Yes

No

Have you ever grown, cultivated, or been involved in the manufacturing of marijuana?

Yes

No

Have you ever been refused employment or military service because of use of marijuana?

Yes

No

Have you ever been disciplined or discharged from employment or military service because of use of marijuana?

Yes

No

Age FIRST used or experimented with marijuana?

Have you used or experimented with any illegal drug not previously listed?

Yes

No

Number of times

Agency Name

Agency Address

Date Applied

Were you employed by this agency?

Yes

No

Screening Form