Membership Application — Middletown Township Police Auxiliary

Note: This is the first of two short applications. Everything you enter here carries over automatically into the second.

Please complete every section. If a question does not apply to you, enter N/A. Fields marked * are required. You can complete this entirely online — no printing or mailing needed.

Social Security number. Upon further consideration of your application, you will be required to furnish your Social Security number to the Middletown Township Police Auxiliary for the purpose of conducting a background investigation. This information is not collected through this website. Never send your Social Security number by email or text message.

Your privacy matters. This application requests personal information used solely to process your membership and conduct the required background investigation. Your answers are saved in this browser only until you finish Step 2, then cleared.

Applicant Information

Last Name *

First Name *

Middle Initial

Recent Photograph * — head-and-shoulders headshot taken within the last 6 months (JPG or PNG)

Street Address *

Apartment / Unit #

City *

State *

ZIP Code *

Previous addresses for the past ten (10) years * — enter each on a new line, or N/A if you've lived at your current address for 10+ years

Home Phone

Business Phone

Cell Phone *

E-mail *

Birth Date *

Place of Birth *

Race

Caucasian African-American Asian/Pacific Islander Hispanic/Non-White Native American Other

Height (ft) *

Height (in) *

Weight (lbs) *

Age *

Gender *

Eye Color *

Hair Color *

Marital Status *

Scars, Marks, Tattoos, Piercings, etc.

Education

High School

School Name

Address

From

Did you graduate?

Yes No

Diploma

College

School Name

Address

From

Did you graduate?

Yes No

Credits

Major

Trade School

School Name

Address

From

Did you graduate?

Yes No

Credits

Military Service Enter N/A if you have not served.

Branch

From

Rank at Discharge

Type of Discharge

If other than honorable, please explain

Criminal & Motor Vehicle History

Have you ever been arrested? (include expungements) *

Yes No

Have you ever been convicted of a crime? *

Yes No

If you answered Yes to either of the above, list the jurisdiction, charge, and disposition

Driver's license? *

Yes No

Driver's License Number

State Issued

Have you ever received a Motor Vehicle Summons? *

Yes No

If yes, list each below.

Date	Violation	Disposition	Court

Have you ever been involved in a Motor Vehicle Accident? *

Yes No

If yes, list each below.

Date	Location of Accident	Jurisdiction

Vehicles you own — leave blank any rows that don't apply

	Make	Model	Color	License Plate #	State
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4

Additional Information

NJ Firearms ID Card? *

Yes No

Firearms ID Card #

Place Issued

Date Issued

Firearms you own or possess — leave blank any rows that don't apply

	Make	Model	Caliber	Serial #
Weapon 1
Weapon 2
Weapon 3
Weapon 4

Employment History

Present Occupation

Occupation *

Phone

Address

Supervisor

Responsibilities

From

May we contact your current supervisor for a reference?

Yes No

List your employers for the past 5 years. Add each prior employer below; use the "additional employment" box if you need more space.

Previous Employer

Company

Phone

Address

Supervisor

Job Title

Salary

Responsibilities

From

Reason for Leaving

May we contact this previous supervisor for a reference?

Yes No

Additional employment (past 5 years)

Skills & Community Involvement

Special qualifications you have

Civic involvement, hobbies, etc.

References List three people who have known you for at least three (3) years. Do not list relatives.

Reference 1

Full Name *

Relationship *

Occupation

Years Known *

Address *

Phone *

Reference 2

Full Name *

Relationship *

Occupation

Years Known *

Address *

Phone *

Reference 3

Full Name *

Relationship *

Occupation

Years Known *

Address *

Phone *

Disclaimer & Signature

I swear (or affirm) that all of the information provided with this application is true, complete, and accurate to the best of my knowledge and belief. I understand that any false statements will result in denial of this application and possible prosecution for the violation of NJS 2C:28-3 and/or 2C:28-4. *

Electronic Signature * — type your full legal name

Date *

Step 2 is the Office of Emergency Management volunteer application. Your details will carry over automatically.

Application for Membership

High School

College

Trade School

Present Occupation

Previous Employer

Reference 1

Reference 2

Reference 3