CHARLOTTE-MECKLENBURG POLICE DEPARTMENT

SUPPLEMENTAL QUESTIONNAIRE

One of the core values of the Charlotte-Mecklenburg Police Department is INTEGRITY (being honest, doing what
you say you will do, and telling the truth). The answers you provide on the enclosed documents should be
truthful and complete, and will be verified through a polygraph examination as part of the application process.
Being untruthful during any phase of the application process will exclude you from further consideration. The
information provided in this supplement will be used as part of your background investigation.

INSTRUCTIONS

1. Read these instructions carefully before completing this questionnaire. Failure to follow
instructions and provide all the information requested may result in the rejection of your application
package.
2. Answer each question in the supplement. If a question does not apply to you, use “N/A.”
3. Be precise but brief when answering questions requiring an explanation. If you require additional
space when answering any of the questions, create a separate document using the format associated
with the question you are answering. Attach the document as an addendum when replying to CMPD.
4. After completing the CMPD Supplemental Questionnaire, save the document with your last name
and first initial. For example, “SmithJ”.
5. If you have questions regarding the CMPD Supplement Questionnaire please send an e-mail to:
CMPD_Recruitment@CMPD.Org
*PLEASE NOTE that only questions regarding the CMPD Supplemental Questionnaire form will be
discussed.
6. Send your completed CMPD Supplemental Questionnaire to: CMPD_Recruitment@CMPD.Org by
the required due date.

LAST NAME:
FIRST NAME:
MIDDLE NAME:
DOB:
DRIVERSLICENSE NUMBER:
DRIVERS LICENSE STATE:
LIST ALL DRIVER LICENSES PREVIOUSLY OR PRESENTLY OBTAINED (DRIVERS LICENSE STATE/ DRIVERS
LICENSE NUMBER):
HAVE YOU PREVIOUSLY APPLIED WITH CMPD? Yes No

DATE(S) PREVIOUSLY APPLIED:

Rev. 11/18/15

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SUPPLEMENTAL FORM for DRIVING HISTORY

Have you been issued a citation or charged with any type of driving offense (whether it remains on
your record or not) or involved in any motor vehicle accident?
Yes No

If yes, please explain each occurrence individually and completely in chronological order starting with
the most recent incident first.

1. Date of Offense or Accident:

Location of Offense or Accident:

Investigating Agency:

Original Charge:

Disposition (how the charge or incident was resolved; “paid fine,” “guilty,” “dismissed,”):

Explanation of the incident:

2. Date of Offense or Accident:

Location of Offense or Accident:

Investigating Agency:

Original Charge:

Disposition (how the charge or incident was resolved; “paid fine,” “guilty,” “dismissed,”):

Explanation of the incident:

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DRIVING HISTORY (continued)

3. Date of Offense or Accident:

Location of Offense or Accident:

Investigating Agency:

Original Charge:

Disposition (how the charge or incident was resolved; “paid fine,” “guilty,” “dismissed,”):

Explanation of the incident:

4. Date of Offense or Accident:

Location of Offense or Accident:

Investigating Agency:

Original Charge:

Disposition (how the charge or incident was resolved; “paid fine,” “guilty,” “dismissed,”):

Explanation of the incident:

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 DRIVING HISTORY (continued)

5. Date of Offense or Accident:

Location of Offense or Accident:

Investigating Agency:

Original Charge:

Disposition (how the charge or incident was resolved; “paid fine,” “guilty,” “dismissed,”):

Explanation of the incident:

6. Date of Offense or Accident:

Location of Offense or Accident:

Investigating Agency:

Original Charge:

Disposition (how the charge or incident was resolved; “paid fine,” “guilty,” “dismissed,”):

Explanation of the incident:

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 SUPPLEMENTAL FORM for APPLICANTS APPLYING TO OTHER AGENCIES

Have you applied to any other local, state, or federal law enforcement agency?
Yes No
If yes, document the status of each agency that you have sought employment with or are currently
seeking employment with. Include the status or results of your application. Provide a telephone
number and contact person for each agency that you have applied with. If you were rejected for
employment please explain the basis of your rejection (failed testing, driving record, criminal history,
drug usage, credit history, psychological testing, polygraph examination, oral board, other applicants
more qualified, etc.) If you were offered employment and did not accept, why did you decline?

Agency Name:

Contact Name:

Contact Number:

Date of Application:

Status of Application:

Explanation:

Agency Name:

Contact Name:

Contact Number:

Date of Application:

Status of Application:

Explanation:

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SUPPLEMENTAL FORM for DRUG USAGE

Have you ever, even one time, tasted, sniffed, smoked, ingested in any way or experimented with
illegal drugs or other substances (glues, aerosols etc.), marijuana, cocaine, crack cocaine, P.C.P.,
L.S.D., amphetamines, steroids, heroin, mushrooms, barbiturates, GHB, Ice, Ecstasy, Opium, M.D.A.,
Rohypnol, methamphetamines, or any other illegal drug?
Yes No
If yes, please list each drug and explain your usage in detail including the last time you used
each drug.

Marijuana: Yes No
If yes, last time used: Month: Year:

Estimated total number of times used:

Explanation:

Other Illegal Drugs: Yes No

If yes, last time used: Month: Year:

Estimated total number of times used:

Explanation:

Prescription drugs other than prescribed by a doctor: Yes No

If yes, last time used: Month: Year:

Estimated total number of times used:

Explanation:

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SUPPLEMENTAL FORM for EMPLOYMENTHISTORY

Have you ever been written-up, counseled, reprimanded, disciplined, suspended, released, asked to
resign, terminated, or you quit before being terminated from any job or other position for any reason?
Yes No
If yes, please write a detailed explanation of each occurrence in chronological order starting with the
most recent job first. (ONLY employments where you have had negative incidents need to be listed)

Employer:

Supervisor:

Contact Number:

Address:

Dates Employed:

Position:

Reason for Leaving:

Explanation:

Employer:

Supervisor:

Contact Number:

Address:

Dates Employed:

Position:

Reason for Leaving:

Explanation:

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SUPPLEMENTAL FORM for INTERNET USAGE

Do you presently or have you in the past, hosted, administered, or subscribed to any internet website
or any other forum that promotes hate or discrimination based on race, sex, creed, religion, or sexual
orientation?
Yes No
If yes, provide a detailed explanation:

Have you ever been involved in, investigated for, or arrested for any type of illegal activity on your
personal computer or any other computer? This includes, but is not limited to: cyber stalking,
fraud, downloading child pornography, communicating or soliciting in a sexual manner with anyone
you knew or thought to be a juvenile under the age of 16?
Yes No
If yes, provide a detailed explanation:

Do you have any personal web page or social media accounts such as Facebook, Myspace, X-Peeps,
Twitter, Flickr, Instagram, etc., or any other website?
Yes No
If yes, list addresses.
Explanation:

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SUPPMENTAL FORM for CREDIT HISTORY and/or CHILD SUPPORT

Have you ever had charged- off accounts, collection accounts, filed for bankruptcy, judgments,
liens, or any other negative incidents pertaining to your credit history?
Yes No
Please explain in detail the status and circumstances of each:

Do you currently have, or have you ever had child support obligations.
Yes No
Please provide names and contact numbers of the person that your child resides with:

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 SUPPMENTAL FORM for CRIMINAL HISTORY

Have you ever been charged with a criminal offense (whether it remains on your record or not, to
include charges that were expunged or dismissed), issued a summons for a criminal offense, issued a
citation for a criminal offense, placed on probation or parole, sentenced to community service, or
incarcerated, etc.? This would include incidents of Domestic Violence.
Yes No
If yes, please explain each occurrence in chronological order starting with the most recent incident
first.

Date of Offense:

Location of offense:

Charge:

Law Enforcement Agency:

Disposition:

Explanation:

Date of Offense:

Location of offense:

Charge:

Law Enforcement Agency:

Disposition:

Explanation:

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 SUPPMENTAL FORM for MILITARY HISTORY

Have you ever received any type of formal military discipline including, but not limited to,
written reprimand, NJP (Non-Judicial Punishment), UCMJ (Uniform Code of Military Justice),
Article 15’s, Court-martial, positive drug test, negative entries in file, or reduction in rank, etc.
Yes No
If yes, please explain each incident:

Date of Incident:

Location of Incident:

Supervisor:

Military Unit:

Punishment/Disposition:
Explanation:

Have you ever been charged, involved with or questioned about any incident you were involved in on
or off base regarding violations of criminal or motor vehicle laws, violations of military law, use of
alcoholic beverages, drug use, fighting, etc. while you were a member of the United Stated Military?
Yes No
If yes, please explain each incident:

Date of Incident:

Location of Incident:

Supervisor:

Military Unit:

Punishment/Disposition:
Explanation:

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I certify that the statements made on this questionnaire are
true and complete to the best of my knowledge. I understand
that false or incomplete information are grounds for denial of
employment or dismissal.

I certify the above information is true.

I do not certify that the above information is true.

Print Name:

Date:

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