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2. Date of Application
4. Name
5. Date of Birth
7. Address
9. City
10. State
11. Zip Code
13. E-mail Address
15. Phone Number
16. Work Number
18. Social Security Number
19. Driver's License Number
21. Employer
22. Occupation
24. Employer's Address
26. Home Church
28. Why do you wish to be an Odessa Police Department Chaplain?
30. How did you hear about the Odessa Police Department Chaplaincy?
32. Have you ever been arrested or convicted of a crime? If so, please describe what for, when and where.
34. Give the name, address and phone number of two (2) character references:
36. Reference 1
38. Reference 2
40. Person to be contacted in case of emergency during your attendance as a Chaplain:
42. Name
44. Address
46. Relationship
47. Phone Number
51. ODESSA POLICE DEPARTMENT CHAPLAINCY APPLICANT ADVISORY AND WAIVER

    Due to the sensitive nature of some subjects being presented in the Odessa Police Department, a criminal history background check will be conducted on all individuals applying for the position of Police Chaplain. 

    Odessa Police Department facilities are in compliance with ADA rules. 

    The Odessa Police Department reserves the right to deny attendance to any person for any reason deemed to cause concern to the Chief of Police, Michael Gerke regarding the safety, legality, or advisability of the person’s attendance. In addition, any person with a criminal conviction could be denied admittance into the Odessa Police Department’s Chaplaincy. 

53. I authorize the Odessa Police Department and its agents to conduct a background investigation. I authorize the release of all records requested, both public and private. I agree to hold harmless from criminal or civil prosecution any entity which releases records as a result of this request, the Odessa Police Department and their agents. 

    I hereby grant OPD permission to use my likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration. 

    I further agree that if I should be accepted into the Odessa Police Department’s Chaplaincy, I will abide by the instructions of Odessa Police staff during all activities related to the Odessa Police Department. 

55. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
57. Electronic Signature
58. Date
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60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit Submit and Print

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