Fill - Free fillable 8666 Supplemental Personal History Statement (City of Everett) PDF form

Name:

ENTRY LEVEL POLICE OFFICER

BACKGROUND INVESTIGATION

SUPPLEMENTAL PERSONAL HISTORY STATEMENT

Dear Applicant,

You have received a Background Investigation Supplemental Personal History Packet for the City of Everett

Police Department. All Entry Level Police Officer candidates are required to complete the

Background Investigation Supplemental Personal History Statement. The Background Investigation

Supplemental Personal History Statement may be either delivered or mailed to the City of Everett Human

Resources Department located at: 2930 Wetmore Avenue, Suite 5A, Everett, WA 98201. Please refer to the

deadline instructions listed in the e-mail in which this form was attached.

Please carefully read the instructions on each page and have the Waiver and Authorization to Release

Information notarized when completed (each of the last two pages). Applicants can take their Waiver and

Authorization to Release Information to a Notary Public of their choosing. Notary services are also available at

the City of Everett Clerk’s office. The City of Everett Clerk’s office is located on the first floor at 2930

Wetmore Avenue, Everett, WA 98201. It i

s recommended that all applicants make a copy of their Background

Investigation Supplemental Personal History Statement for future reference. Applicants who have

questions regarding the Background Investigation Personal History Statement should contact the

Everett Police Department’s Office of Professional Standards at (425) 257-8425, Monday – Friday, from

8:00 a.m. – 3:00 p.m.

Everett Police Department

3002 Wetmore Ave

Everett, WA 98201

425-257-8400

PERSONAL HISTORY STATEMENT SUPPLEMENT

Instructions to the Applicant

•

The information you provide in this Personal History Statement Supplement will be used as part of the

background investigation to assist in determining your suitability for the position of Everett Police

Officer.

•

Type or neatly print, in ink, responses to all items and questions. If a question does not apply to you,

write “N/A” (not applicable) in the space provided for your response. If you cannot obtain or

remember certain information, indicate so in your response.

•

If you need more space for any response, attach additional pages and identify the additional

information by the question number.

Disqualification

Deliberate misstatements or omissions can and often will result in your application being rejected,

regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason

individuals “fail” background investigations is because they deliberately withhold or misrepresent job-

relevant information from their prospective employer.

BOTTOM LINE: Be as complete, honest and specific as possible in your responses.

Disclosure of Medically-Related Information

In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring process

applicants are not expected or required to reveal any medical or other disability-related

information about themselves in response to questions on this form, or to any other inquiry

made prior to receiving a conditional offer of employment.

Page 1 of 3 Initial this page to indicate that you have read the instructions:

Everett Police Department

3002 Wetmore Ave

Everett, WA 98201

425-257-8400

PERSONAL HISTORY STATEMENT SUPPLEMENT

Partner/Significant Other

NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

HOME PHONE

( )

WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

WORK PHONE

( )

YEARS OF DATING

CELL PHONE

( )

Is there, or has there been, a restraining or stay-away order in effect for this individual? YES NO

Supplemental questions

1) Do you participate in social media? YES NO

If so, list:

2) Have you ever committed a crime as a juvenile or adult that went undetected? YES NO

IF SO, EXPLAIN:

3) Have you ever received or accepted property you know or thought may have been stolen? YES NO

IF SO, EXPLAIN:

4) Have you ever taken anything belonging to an employer without permission? YES NO

IF SO, EXPLAIN:

5) Have you ever allowed or helped anyone steal from an employer? YES NO

IF SO, EXPLAIN:

6) Have you ever cheated on an expense account? YES NO

IF SO, EXPLAIN:

7) Have you ever given away employers property? YES NO

IF SO, EXPLAIN:

8) Have you ever falsified an official government document (DSHS,L&I claims, etc) or lied in an official hearing (court testimony, employment hearing, etc.)?

YES NO

IF SO, EXPLAIN:

9) Have you or anyone in your family ever been a member of, or attended meetings for, any extremist or subversive group(s)? YES NO

IF SO, EXPLAIN:

10) Have you ever participated in any illegal sexual activity? YES NO

IF SO, EXPLAIN:

11) Have you ever had any sexual contact with a child under the age of 16? YES NO

IF SO, EXPLAIN:

12) Have you ever been arrested or detained on a morals or decency charge? YES NO

IF SO, EXPLAIN:

13) Have you ever engaged in nude modeling, dancing or participated in any form of sex related entertainment to include attending strip clubs?

YES NO

IF SO, EXPLAIN:

For strip clubs list date of last visit and location of strip club.

14) Have you ever viewed someone in a private place without their knowledge? YES NO

IF SO, EXPLAIN:

Page 2 of 3 Initial this page to indicate that you have read the instructions:

Everett Police Department

3002 Wetmore Ave

Everett, WA 98201

425-257-8400

PERSONAL HISTORY STATEMENT SUPPLEMENT

15)

Have you ever photographed or filmed anyone without their knowledge or permission?

☐

YES

☐

SO, EXPLAIN:

16)

Have you ever participated in a sexual act with an animal? ☐YES ☐NO

SO, EXPLAIN:

17)

Have you ever been involved in a pursuit in which you evaded or attempted to evade the police? ☐YES ☐NO

SO, EXPLAIN:

18)

Have you ever used physical force against anyone or been in a fight at any point in your lifetime?

☐

YES

☐

SO, EXPLAIN:

19)

Have you ever damaged property during an argument with a spouse, significant other, roommate or anyone else? ☐YES ☐NO

SO, EXPLAIN:

20 )

Have you ever used physical force against your spouse/partner/significant other/roommate?

☐

YES

☐

SO, EXPLAIN:

21)

Have you ever been arrested for domestic violence? ☐YES ☐NO

SO, EXPLAIN:

22)

Are you now or have you ever been employed in law enforcement? ☐YES ☐NO

If so, please answer the following:

Have you ever accepted a gratuity? ☐YES ☐NO

Have you ever accepted anything for overlooking a violation? ☐YES ☐NO

Have you ever used your official position for personal gain? ☐YES ☐NO

Have you ever withheld any evidence seized in the course of your official duties? ☐YES ☐NO

Have you ever been the subject of an internal investigation by your department? ☐YES ☐NO

SO, EXPLAIN:

CURRENT ASSETS CURRENT LIABILITIES (BALANCE DUE)

Savings Real Estate Indebtedness

Checking Charge Accounts

Real Estate Equity Auto Loans

Other Assets – Describe Personal Loans

Other Liabilities – Describe

Total Assets $ Total Liabilities $

Page 3 of 3 Initial this page to indicate that you have read the instructions:

POLICE OFFICER

WAIVER AND AUTHORIZATION TO RELEASE INFORMATION

To Whom it May Concern:

I am an applicant for a police officer position with the Everett Police Department. I do hereby authorize you to

release to the Everett Police Department any and all records and/or information which you may have concerning me,

including, but not limited to, information/records related to my reputation, employment and attendance records,

school transcripts, military service records and financial status. Information of a confidential or privileged nature may

be included. Your rep

ly will be used to assist the Everett Police Department in determining my qualifications and

fitness for the position I am seeking with the Department.

I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974 and waive those rights

with the understanding that information furnished will be used by the Everett Police Department in conjunction with

employment procedures.

initials

I understand that any information obtained by the Everett Police Department for its personal history background

investigation that is developed directly or indirectly, in whole or in part, upon this release authorization becomes the

property of the Everett Police Department and I will not have access to any of the background investigation. I further

understand and acknowledge that the Everett Police Department may provide certain types of information that is

obtained in the course of its ba

ckground investigation to my current employer, such as information about criminal

activity or serious policy violations. initials

I hereby waive and release you, your organization, employees, and agents from any and all claims, liability, personal

injuries, damages or losses, of any nature, which may result from furnishing the requested information.

I hereby waive, release and hold harmless the City of Everett, its officers, employees, agents, and any current or

former employers, any schools or educational and technical institutions and their employees or agents, and the

employment references specifically named from any and all claims, lawsuits, personal/bodily injuries, damages or

losses, of any nature, resulting from the release of any information requested by the City of Everett in connection

with my application for emplo

yment by the City. My authorization and release from liability are voluntary acts and

shall be effective only for employment investigations by the City of Everett.

Print Applicant Name Signature of Applicant

Subscribed and sworn to before me on the day of , 20 .

Notary Public for State of WA

Note: A photocopy reproduction of this request form shall be, for all intent and purposes, as valid as the original. You

may retain this form in your files.

POLICE OFFICER

WAIVER AND AUTHORIZATION TO RELEASE INFORMATION

To Whom it May Concern:

I am an applicant for a police officer position with the Everett Police Department. I do hereby authorize you to

release to the Everett Police Department any and all records and/or information which you may have concerning me,

including, but not limited to, information/records related to my reputation, employment and attendance records,

school transcripts, military service records and financial status. Information of a confidential or privileged nature may

be included. Your rep

ly will be used to assist the Everett Police Department in determining my qualifications and

fitness for the position I am seeking with the Department.

I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974 and waive those rights

with the understanding that information furnished will be used by the Everett Police Department in conjunction with

employment procedures.

initials

I understand that any information obtained by the Everett Police Department for its personal history background

investigation that is developed directly or indirectly, in whole or in part, upon this release authorization becomes the

property of the Everett Police Department and I will not have access to any of the background investigation. I further

understand and acknowledge that the Everett Police Department may provide certain types of information that is

obtained in the course of its ba

ckground investigation to my current employer, such as information about criminal

activity or serious policy violations. initials

I hereby waive and release you, your organization, employees, and agents from any and all claims, liability, personal

injuries, damages or losses, of any nature, which may result from furnishing the requested information.

I hereby waive, release and hold harmless the City of Everett, its officers, employees, agents, and any current or

former employers, any schools or educational and technical institutions and their employees or agents, and the

employment references specifically named from any and all claims, lawsuits, personal/bodily injuries, damages or

losses, of any nature, resulting from the release of any information requested by the City of Everett in connection

with my application for emplo

yment by the City. My authorization and release from liability are voluntary acts and

shall be effective only for employment investigations by the City of Everett.

Print Applicant Name Signature of Applicant

Subscribed and sworn to before me on the day of , 20 .

Notary Public for State of WA

Note: A photocopy reproduction of this request form shall be, for all intent and purposes, as valid as the original. You

may retain this form in your files.

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