ATLANTA POLICE DEPARTMENT

2011/2012 Employee Data Form

Complete all fields. Place N/A if not applicable.	Report type:	Initial or Update

Part I General Information.

Employee/Unique ID #:
SSN:
Name:
First
MI
Last	SR., Jr., II, III
Job Classification:
Division
Section:
Unit:

Part II Personal Information. The information collected is confidential and is For Official Use Only. Release of this
information is restricted.

Home Address:
Apt #:
City
State
Zip Code
Home Phone #:
Alternate phone #:
Race:	Native American	Latino	Asian	Black	White	Sex:	Male	Female
Civilian or Sworn Employee:	Civilian	Sworn	Date of Birth:
Part III Personnel Information.
Original Sworn Date:
Re-sworn Date (if applicable):
P.O. Badge #:
City Cell #:	City Pager #:	Off Duty Radio #:
Hire Date:	Rehire Date (if applicable):	Civilian Supervisor:	Yes	No
SGT Promotion Date:	LT Promotion Date:	Capt Promotion Date:
Major Appointment Date:	Deputy Chief Appointment Date:
Assistant Chief Appointment Date:	Chief of Police Appointment Date:
Part IV Emergency Contact Information.
Name:
Last
First
Middle Initial
Relationship:	Address:	same as above or
City
County
State
Zip Code
Phone #:

Part V Education and Special Skills.

Education and Training Completed
Educational Institution Name or Class Title	Date Completed

2011/2012 Employee Data Form (page 2)

Language Skills: List any language(s) other than English that you are fluent in (include sign language).
Language(s)
Language(s)
Part VI Authentication.
This report requires the signature of both the employee and his or her supervisor. The Personnel Service Unit will not accept data forms that do not include these signatures.
(Print or Type) Employee’s name	First
Middle Initial
Last

Date:
Employee’s Signature

Date:
Supervisor’s Signature

Keep a copy in the unit personnel file. Forward the completed original form to the Personnel Services Unit.

Form APD 200 1/26/11

ATLANTA POLICE DEPARTMENT

vlivsey

2011-01-26

APD