PSO Active Application

Information Request

First Name

Middle Initial

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Country

Cell Phone

Work Phone

Tax ID

Command

Location

Schedule

Number of Years with NYPD

Other PD

Education

Current Rank

Marital Status

Children

Are you presently enrolled in any educational pursuits? (Please describe):

Participation in community activities and/or groups including Military Reserve obligations. List How Many Hours per Month You Have Committed.

Membership in Police Fraternal and/or professional organizations (List names):

Are you licensed or certified in any specialty? (Please list)

List and describe any formal training that you have received in stress management, crisis interventions, post-traumatic stress disorders, counseling, 12-step programs, etc. List and describe any related workshops or conferences:

Why do you want to become a Peer Support Team Member?

Please list any additional comments or information that you think would aide us in the Peer Support selection process.

Are you presently on any promotional or special assignment list? (If yes, please describe)

Are you, or have you ever been on Chronic Sick List?

Yes

I do hereby certify that all statements made in this application are true and correct.

Date

Signature