GUYANA POLICE FORCE

PRE-EMPLOYMENT

APPLICATION QUESTIONNAIRE
……. /……/20

Tax Identification Number (TIN): ………………………………

Guyana National Insurance (NIS): ………………………………
Guyana National Identification: ………………………………
Guyana Passport: ………………………………
Bank Account Number: ………………………………

For Official Use ONLY

Processing on: ……………………………….
By: ……………………………….

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 HONESTY STATEMENT

PLEASE READ CAREFULLY: All questions must be answered, and all answer are subject to
Verification. You are required to provide truthful answers despite how personal the information seems.
The information provided will be treated with the highest level of confidentiality. Please be warned that
providing false or deceitful information could seriously hamper your chances of being considered as a
suitable candidate for employment with the Guyana Police Force.

Signature of Applicant: …………………………….

Date: ………………………….

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 POLYGRAPH TESTING AGREEMENT

PLEASE READ CAREFULLY

Based on the information you provide in this Application Questionnaire; a Polygraph Test would be
necessary in order to determine whether you have been completely truthful in the responses provided.
This procedure has become a necessary element of the recruitment procedure of the Guyana Police
Force, in order to determine the suitability of applicants.
You are therefore requested to indicate your willingness to be subjected to a Polygraph Test, by attaching
your name and signature to this agreement.

Name of Applicant (In BLOCK LETTERS): ………………………………………………

Signature of Applicant: ……………………………

Date: …………………………

During the course of the background investigation persons who know you will be asked to comment upon
your suitability for the position for the position you have applied for. Inquiries will be confined to job-
related matters.

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 PERSONAL HISTORY / GENERAL BACKGROUND INFORMATION

PLACE RECENT

PHOTOGRAPH

HERE
Full Legal Name:
……………………………………………………………………………………………
Last First Middle
1. Present Home Address: ……………………………………………………………….
……………………………………………………………………………………………...
How long have you been living at that address? Years………… Months ……………
Is the home being rented? Yes ( ) No ( )
If the answer is ‘Yes’ please state;
a) The amount of the rent …………………………………………………..
b) The name of the landlord ………………………………………………..
c) The address of the landlord ……………………………………………..
d) The telephone number of the landlord …………………………………
Have you ever lived at any other address previously? Yes ( ) No ( )

If the answer is ‘Yes’ please State:

a) The previous address …………………………………………………….
b) The amount of rent ……………………
c) The name of the Landlord ………………………………………………
d) The address of the Landlord ……………………………………………
e) The telephone number of the Landlord ………………………………..
f) The number of years……….. or Months …………….. you lived there
g) Your reason for leaving
(brief)………………………………………………………………………………………………
………………………………………………………….…………………………………………
………

2. Home Phone Business Phone Cellular Phone

………………… …………………. …………………..

E-mail: Address: ……………………………………………………

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3. Date of Birth Male Female NIS Number Race/Ethnic Background

……………….. ( ) ( ) ...……………… ………………………….

Are you a citizen of Guyana by Birth ( ) Naturalization ( )

Place of Birth …………………………………………………………………….
4. Have you ever used a different name? Yes ( ) No ( )
5. Have you ever legally changed your Name? Yes ( ) No ( )
Name Changed from……………………………………………
Name Changed to……………………………………………….
Date and place where change was done………………………………………………
Reason for Change……………………………………………………………………..
6. Have you ever used a different NIS Number? Yes ( ) No ( )
If yes, state the number……………………………
7. Have you ever used a different date of birth? Yes ( ) No ( )
If yes, state the reason…………………………………………………………………..
8. Do you have a National Identification Card? Yes ( ) No ( )
9. Have you ever used a National Identification Card Yes ( ) No ( )
10.Do you have a passport Number? Yes ( ) No ( )
If “Yes”, Passport Number……………………………………
11.For the purposes of identification, provide the following information:
Height………. Weight…………. Eye Color……………. Hair Color………………
12.Do you have any tattoo or other distinguishable mark (s) on your body? If yes, state exactly which part
of your body is this tattoo distinguishable marked?
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Would you consent to subject yourself to an Examination: YES NO
13.To which religious grouping do you belong? Christian ( ), Muslim ( ), Hindu ( ), None ( )
14.What sporting activities do you participate in and at what
level?..........................................................................................................................................................................
...................................................................................................................................................................................

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If at club level, name the club(s)
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

RELATIVES, REFERENCES AND ACQUAINTANCES

1.PRESENT MARITAL STATUS

Single ( ) Married ( ) Separated ( ) Divorced ( ) Widowed ( )

2.MARRIAGE INFORMATION
Marriage Date: ………………………
Where Performed: ………………………………………………………………
Spouse’s Name/Wife’s Maiden Name: …………………………………………
Spouse’s D.O.B: …………………….

3. SPOUSES INFORMATION: (IF SEPARATED, DIVORCED OR IS IN A COMMON-LAW

RELATIONSHIP)
Name: …………………………………………. Telephone: …………………..
Address: ……………………………………………………………………………………….
Separated ( ) Marriage Annulled ( ) Divorced ( )
Date of: ………………………………………………………………………….
Order/Decree: …………………………………………………………………...
Granted by: ……………………………………………………………………...
Where issued: ……………………………………………………………………

4.CHILDREN
List all of your children, including step-children and adopted children. Give the following information.
(Attach additional pages if necessary)
Full Name Date of Birth
…………………………………………………………………………………………………
Address Phone
…………………………………………………………………………………………………
Full Name Date of Birth
…………………………………………………………………………………………………
Address Phone
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 ………………………………………………………………………………………………....

Full Name Date of Birth

…………………………………………………………………………………………………….
Address Phone
……………………………………………………………………………………………………

5.FAMILY MEMBERS
List the FULL NAME of your Father, Mother (maiden and current surname), Step-Father, Step-Mother
(including maiden name) ALL Brothers, Sisters, Step-Brothers, and Step-Sisters and any person(s) residing in
your home whether related to you or not.

Full Name Date of Birth Relationship

…………………………………………………………………………………………………….

Address Date of Birth Relationship

…………………………………………………………………………………………………….

Full Name Date of Birth Relationship

…………………………………………………………………………………………………….

Address Date of Birth Relationship

…………………………………………………………………………………………………….

Full Name Date of Birth Relationship

…………………………………………………………………………………………………….

Address Date of Birth Relationship

…………………………………………………………………………………………………….

Full Name Date of Birth Relationship

…………………………………………………………………………………………………….

Address Date of Birth Relationship

…………………………………………………………………………………………………….

Full Name Date of Birth Relationship

…………………………………………………………………………………………………….

Address Date of Birth Relationship

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 …………………………………………………………………………………………………….

EDUCATIONAL BACKGROUND
1.NAME OF PRIMARY SCHOOL ATTENDED ADDRESS
…………………………………………………………………………………………………………………….
Highest Grade/Class Completed Year
Left School
……………………………………………………………………………………………………………………
What is the name of your last class teacher?.........................................................................................................

2.NAME OF SECONDARY SCHOOL ATTENDED ADDRESS

……………………………………………………………………………………………………………………
Highest Grade/Class Completed Qualifications Received Year
Left School
……………………………………………………………………………………………………………………
What is the name of your last class teacher?.........................................................................................................

3.NAME OF TECHNICAL/VOCATIONAL COLLEGE ATTENDED ADDRESS

…………………………………………………………………………………………………………………….
Qualifications Received: Diploma ( ) Certificate ( ) Field of
Study: …………………………………………….. Year Graduated: ……………………………………

4.NAME OF UNIVERSITY ATTENDED ADDRESS

…………………………………………………………………………………………………………………….
Qualifications Received: Degree ( ) Diploma ( ) Certificate ( )
Field of Study: ……………………………………. Year Graduated: ……………………………

5.HAVE YOU EVER BEEN SUSPENDED OR EXPELLED FROM ANYONE OR THE ABOVE-
MENTIONED EDUCATIONAL INSTITUTIONS THAT YOU ATTENED?
Yes ( ) No ( )
If yes state reason:
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………

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 EXPERIENCE AND EMPLOYMENT
Beginning with your most current employment list all jobs FULL-TIME, PART-TIME, TEMPORARY
AND VOLUNTARY POSITIONS, you have held. If you had intervening periods of military service or
unemployment, list those periods in sequence in the spaces provided. (Attach additional pages if needed)

****ALL TIME MUST BE ACCOUNTED FOR****

1. Name of Employer: ……………………………………………………………………………...
Address: ………………………………………………………………………………………….
Telephone: …………………………………
Date of Employment: from………………… to ……………………….
Job Title: ………………………………………………….
Full-Time ( ) Part-Time ( ) Temporary ( ) Voluntary ( )
Name of Supervisor: …………………………………………………………………………….
Reason for Leaving: …………………………………………………………………………….
…………………………………………………………………………………………………..

2. Name of Employer: ……………………………………………………………………………...

Address: ………………………………………………………………………………………….
Telephone: …………………………………
Date of Employment: from………………… to ……………………….
Job Title: ………………………………………………….
Full-Time ( ) Part-Time ( ) Temporary ( ) Voluntary ( )
Name of Supervisor: …………………………………………………………………………….
Reason for Leaving: ……………………………………………………………………………..
……………………………………………………………………………………………………

3. Name of Employer: ……………………………………………………………………………...

Address: ………………………………………………………………………………………….
Telephone: …………………………………
Date of Employment: from………………… to ……………………….
Job Title: ………………………………………………….
Full-Time ( ) Part-Time ( ) Temporary ( ) Voluntary ( )
Name of Supervisor: …………………………………………………………………………….
Reason for Leaving: …………………………………………………………………………….
…………………………………………………………………………………………………..

4. Name of Employer: ……………………………………………………………………………...

Address: ………………………………………………………………………………………….
Telephone: …………………………………
Date of Employment: from………………… to ……………………….
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 Job Title: ………………………………………………….
Full-Time ( ) Part-Time ( ) Temporary ( ) Voluntary ( )
Name of Supervisor: …………………………………………………………………………….
Reason for Leaving: …………………………………………………………………………….
…………………………………………………………………………………………………..

5.Name of Employer: ……………………………………………………………………………...

Address: ………………………………………………………………………………………….
Telephone: …………………………………
Date of Employment: from………………… to ……………………….
Job Title: ………………………………………………….
Full-Time ( ) Part-Time ( ) Temporary ( ) Voluntary ( )
Name of Supervisor: …………………………………………………………………………….
Reason for Leaving: …………………………………………………………………………….
…………………………………………………………………………………………………….
1. Have you ever been fired, asked to resign, or forced to leave a job? Yes ( ) No ( )
If yes, state briefly
…………………………………………………………………………………………………....
………………………………………………………………………………………………………
2. Have you ever resigned from a position to termination? Yes ( ) No ( )
If yes, state briefly
…………………………………………………………………………………………………....
………………………………………………………………………………………………………
3. Have you ever been the subject of an allegation charging you with
Racial or Ethnic bias or Sexual Harassment? Yes ( ) No ( )
If yes, state briefly
……………………………………………………………………………………………………....
………………………………………………………………………………………………………
4. Have you ever been disciplined (e.g. oral/written reprimand, docked
Pay, suspension demoted, etc.) for excessive absences, poor Judgment,
Unbecoming conduct, poor work performance or other work related
Reasons? Yes ( ) No ( )

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 If yes, state briefly
……………………………………………………………………………………………………....
………………………………………………………………………………………………………
5. Have you ever falsified or altered any official document? Yes ( ) No ( )
If yes, state briefly
……………………………………………………………………………………………………....
………………………………………………………………………………………………………

CREDIT INFORMATION
1. Have you ever been sued because of unpaid bills? Yes ( ) No ( )
2. Have you ever sued? Yes ( ) No ( )
3. Do you have any outstanding credit/loans with Banks,
Stores, other business or individuals? Yes ( ) No ( )

If yes, explain and provide amount: ………………………………………………………………….

4. Do you currently have any bills that are past due date that
you are not paying? Yes ( ) No ( )

If yes, explain: ………………………………………………………………………………………..

………………………………………………………………………………………………………...

5. Have you ever filed for Bankruptcy? Yes ( ) No ( )

If yes, explain: ……………………………………………………………………………………….
………………………………………………………………………………………………………..
6. Have you ever had a house, a vehicle, or other item repossessed? Yes ( ) No ( )
If yes, explain:
………………………………………………………………………………………………………
………………………………………………………………………………………………………..
7. Are you currently behind in your payment of any bills to
any creditor? Yes ( ) No ( )
If yes, explain and provide amount: ………………………………………………………………….
………………………………………………………………………………………………………...

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8. Have you ever failed to provide financial support to someone to
whom you are obligated? Yes ( ) No ( )
9. Are you currently experiencing financial problems? Yes ( ) No ( )
If yes, explain: ………………………………………………………………………………………..
………………………………………………………………………………………………………..

LEGAL/CRIMINAL ACTIVITIES
1. Have you ever been arrested or convicted of any crime? Yes ( ) No ( )
If yes, explain the nature of the offence: …………………………………………………………
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
2. Have you ever committed or participated in any criminal
activity or activities? Yes ( ) No ( )
If yes, explain the activity: ………………………………………………………………………
……………………………………………………………………………………………………
3. Have you ever been investigated for any criminal offence? Yes ( ) No ( )
If yes, explain: …………………………………………………………………………………...
……………………………………………………………………………………………………
4. Have you ever been accused of stealing from any previous place
of Employment? Yes ( ) No ( )
5. Were you ever required to appears before a juvenile court for
any act that would be considered a crime? Yes ( ) No ( )
If yes, explain the nature of the crime: ………………………………………………………….
…………………………………………………………………………………………………...
6. Has your spouse (husband, wife, companion) ever been arrested
or convicted of any crime? Yes ( ) No ( )
If yes, explain the nature of the crime: ………………………………………………………….
…………………………………………………………………………………………………...
7. Have you ever been involved in any physical assault? Yes ( ) No ( )
If yes, explain: …………………………………………………………………………………..
……………………………………………………………………………………………………
8. Have you ever had a restraining order or any other type of protection

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 order taken out against you? Yes ( ) No ( )
If yes, explain: …………………………………………………………………………………...
……………………………………………………………………………………………………
9. Have you ever had cause to take out a restraining order against anyone Yes ( ) No ( )
If yes, explain: …………………………………………………………………………………..
10. Have you ever committed, or been convicted of any act of domestic
violence (physical assault or verbal threats) Yes ( ) No ( )
11. Have you ever purposely or negligently caused the death of another
human being? Yes ( ) No ( )
12. Have you ever harmed, or attempted to cause harm to someone
with a weapon Yes ( ) No ( )
13. Have you ever been involved in or accused of any act of disturbing
the peace? (fighting in public, cursing in public, threating another
Person in public) Yes ( ) No ( )
14. Have you ever taken something from someone through the use of
force or intimidation? Yes ( ) No ( )
15. Have you ever deliberately damaged or destroyed someone else’s
property? Yes ( ) No ( )
16. Have you ever broken into someone else’s home, vehicle or any
other property to steal something? Yes ( ) No ( )
17. Have you ever illegally used someone else’s bank card to access
their bank account or make a purchase? Yes ( ) No ( )
18. Have you ever taken anything from a shop or store without paying
for it (shoplifting)? Yes ( ) No ( )
19. Have you ever had in your possession or do you possess an illegal
weapon? Yes ( ) No ( )
20. Are you a member of, or have you ever been a member of any gang? Yes ( ) No ( )
21. Do you currently live, reside, or associate with anyone involved in
any criminal activity? Yes ( ) No ( )
22. Have you ever live, reside, or associate with anyone involved in
any criminal activity? Yes ( ) No ( )

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 SEXUAL MISCONDUCT
1.Have you ever engaged in or ever been accused of engaging in any
illegal sexual act? (buggery, sex with animals) Yes ( ) No ( )
2.Have you ever committed or ever been accused of committing any act
of sexual assault against any adult or child (intercourse, oral sex, anal sex,
fondling)? Yes ( ) No ( )
3.Have you ever forced anyone, either by word or action, to have sexual
contact with you against his/her will (including spouse)? Yes ( ) No ( )
4.Have you ever engaged in any acts of prostitution or received payment
for someone else’s act or sexual performance Yes ( ) No ( )
5.Have you ever engaged in any acts of prostitution, such as either paying
someone or being paid to perform a sexual act? Yes ( ) No ( )
6.Have you ever engaged in any form of sexual act or ever had sexual
relations with anyone while at work? Yes ( ) No ( )
7.Have you ever engaged in any form of sexual act with a minor? Yes ( ) No ( )
8.Have you ever been involved in or been accused of being involved in the
sale or production of pornographic materials (books, video, CD’s) Yes ( ) No ( )
9.Have you ever been involved in or been accused of being involved in any
act of indecent exposure? (deliberate exposure of your genitals to the public) Yes ( ) No ( )
10.Have you ever participated in any window peeping for lewd purposes? Yes ( ) No ( )
11.Have you ever engaged in or have been accused of engaging in making
lewd, obscene or harassing phone calls? Yes ( ) No ( )
12.Have you ever had or been accused of having sexual relations or contact with
anyone not able to give consent? (mentally incompetent, drunk, drugged,
unconscious) Yes ( ) No ( )
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If yes, explain: ……………………………………………………………………………………………
………………………………………………………………………………………………………………
13.Have you ever knowingly had sexual relations or contact with a relative? Yes ( ) No ( )

ILLEGAL DRUGS
1.Have you ever been involved in or been accused of being involved
in the sale or delivery of illegal drugs? Yes ( ) No ( )
2.Have you ever participated in or been accused of participating in the
manufacture of illegal drugs? Yes ( ) No ( )
3.Have you ever been involved or been accused of being involved in
cultivating or growing of illegal drugs? Yes ( ) No ( )
4.Have you ever bought or been accused of buying illegal drugs for your
own use or for another person? Yes ( ) No ( )
5.Have you ever been associated with or accused of associating with persons
who use illegal drugs? Yes ( ) No ( )
6.Have you ever driven a vehicle or been accused of driving a vehicle under
the influence of any form of narcotic? Yes ( ) No ( )
7. Do you currently use any form of illegal drugs? Yes ( ) No ( )
If yes, explain: ………………………………………………………………………………………………
ALCOHLIC USE
1.Do you usually consume alcohol? Yes ( ) No ( )
If yes, explain how often: ……………………………………………………………………………………
2.How often do you become intoxicated?
Explain: ………………………………………………………………………………………………………
3.Have you ever driven a vehicle or been accused of driving a vehicle while being
intoxicated or under the influence of alcohol? Yes ( ) No ( )
4.Have you ever been involved in an accident due to the use of alcohol? Yes ( ) No ( )
5.Have you ever been charged for driving under the influence of alcohol? Yes ( ) No ( )
6.Have you ever missed work because of alcohol consumption? Yes ( ) No ( )
7. Have you ever consumed or been accused of consuming alcohol during your
working hours? Yes ( ) No ( )

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 TRAFFIC AND DRIVING RECORD
1. Have you ever been accused of or charged for any traffic offence? Yes ( ) No ( )
2.Have you ever driven a vehicle without a driver’s license? Yes ( ) No ( )
3.Are you in possession of a valid driver’s license? Yes ( ) No ( )
4.Have you ever driven a vehicle that was not registered or insured? Yes ( ) No ( )
5.Have you ever been involved in a motor vehicle accident that you failed to
report to the police or where you left the scene without identifying yourself?
(Hit and run) Yes ( ) No ( )

DECLARATION
A. I hereby declare that while being an applicant for the Guyana Police Force, I am willing
to subject myself to be examined for tattoo(s) and tested for the use of narcotic drugs.
Should I be successful at both examinations and become a member of the Guyana Police Force,
I am committed not to alter my physical status with any tattoo(s) or the use of narcotic
Drugs.

……………………………………..
Signature of Applicant

Date: ……………………………….

B. I hereby further declare that now being a member of the Guyana Police Force, I am willing
to subject myself to be physically examined and tested at any time to confirm that I have not
altered my physical status with any tattoo(s) or the use of narcotic drugs. Should I be found in
breach of my acceptable physical status as it relates to tattooing and the use of narcotic drugs,
Whilst being a serving member of the Guyana Police Force, I accept that my service will be
immediately terminated.

………………………………………..
Signature and Number of Rank

Date: ………………………………….

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