Fillable Animal Control Employment (City of Mansfield, Texas (TX))

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Animal Control Employment (City of Mansfield, Texas (TX))

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Animal Control Officer/Kennel Technician
Page 1 of 4
The City of Mansfield is an Equal Opportunity Employer
4.10.18
1200 East Broad Street, 2
nd
Floor Human Resources
Mansfield, Texas 76063
Telephone: 817-276-4267
Fax: 817-473-7487
Email: hr@mansfieldtexas.gov
JOB CLASSIFICATION: Animal Control Officer-Kennel Technician Full-time /Non- Exempt
DEPARTMENT: Animal Control STARTING SALARY: $39,520
JOB DESCRIPTION:
Under general supervision of the Animal Control Manager, responsible for picking up stray
dogs, cats and other animals which run loose in the community and are not licensed and may
pose a potential health hazard to residents of the community, and responsible for the
maintenance and cleaning of the kennel and perform routine kennel tech work among many
other duties.
EXAMPLES OF WORK TO BE PERFORMED:
• MUST BE ABLE TO WORK ANY SHIFT INCLUDING DAYS, AND EVENINGS. (Shifts are typically
eight (8) hours with actual hours being established by operational necessity) MUST BE ABLE
TO WORK SATURDAYS, SUNDAYS AND HOLIDAYS.
• MUST BE ABLE TO WORK PAST NORMAL ASSIGNED SHIFT.
• WILL BE SUBJECT TO CALL-BACK.
•
Patrol the City and enforce the Animal Control Ordinances of the City and applicable
State Laws regarding animals
•
Confine stray animals for specified periods in the animal shelter
•
Transport animals, maintain animal shelter, and feed detained animals
•
Apprehend animals which may be vicious in nature, sick, or dead on any public road,
right-of-way; or other property as authorized within the City
•
Maintain accurate records and logs all of animals apprehended and locations, and
communicate with owners and others of the general public
•
Operate mobile radio in receiving and communication information
•
Investigate complaints that dogs or other animals are creating a nuisance
•
Answer questions regarding the licensing and disposal of animals
•
Assist with rabies control programs
•
Write reports and complete various records keeping forms
•
Investigate animal bite cases as required by Department Policy and State and Local Laws
• Clean dog kennels, cat room and adjacent work spaces
• Animal handling including feeding, exercising, intake and assessment
• All tasks associated with euthanasia
• Daily animal inventory including posting details such as breed, sex, and color of each
animal in a database
• Assist with volunteers and community services by scheduling and recording hours worked,
trained, etc.
Animal Control Officer/Kennel Technician
Page 2 of 4
The City of Mansfield is an Equal Opportunity Employer
4.10.18
• Coordinate with rescue groups, foster groups and other area shelters for placement or
adoption of animals
•
All other duties as may be required
OTHER DUTIES:
Please note this job description is not designed to cover or contact a comprehensive listing of
activities, duties or responsibilities that are required of the employee for this job. Duties,
responsibilities and activities may change at any time with or without notice.
REQUIRED KNOWLEDGE SKILLS AND ABILITIES:
•
Ability to read and interpret regulations governing animal control department policies
•
Knowledge in the care and handling of animals
•
Ability to deal in a professional manner with members of the general public
•
Customer Service experience preferred
• Knowledge of various animal breeds, types and characteristics and their associated
animal behavior with the ability to capture and restrain all types of animals and detect
signs of illness or injury to animals
• Ability to deal with members of the general public in a calm and courteous manner,
answering and responding to complaints and request
• Ability to speak and comprehend standard business oriented English
• Ability to read and write clearly in completing service requests, work orders, and messages
• Computer skills including basic level of Microsoft © Word and Excel
• Must be able to operate cellular phone, two-way radio, fax machine, copy machine,
calculator, computer, printer and various software
• Must be able to drive a truck while towing a livestock or utility trailer
•
Must be able to pass medical-drug screening, polygraph, and thorough background
investigation
•
Must be willing and able to work various hours and shifts as assigned, including weekends
and holidays
REQUIRED EDUCATION, TRAINING AND EXPERIENCE:
• High school diploma or equivalent required.
• Minimum age of 18 years old
• Must have completed within the last three years, or complete within 120 days of
employment, a training course in the proper methods and techniques of euthanizing
animals.
• Must possess a valid Texas Driver’s License “Class C”
• Previous animal control or related experience preferred
•
Certification by the Texas Department of Health Services as a Basic Animal Control Officer
preferred, or must complete a certification course within 1 year of employment
DESIRED TRAINING AND EXPERIENCE:
• Previous experience with animals
• Minimum of 2 years of experience working in a municipal animal control facility as a Animal
Control Officer and Kennel Technician
•
Certification by Texas Department of Health as an Animal Control Officer
•
Certification by Texas Department of Health for Euthanasia or ability to obtain within one
year of employment
Animal Control Officer/Kennel Technician
Page 3 of 4
The City of Mansfield is an Equal Opportunity Employer
4.10.18
ESSENTIAL PHYSICAL FUNCTIONS:
1. The physical activity of this position
• Climbing. Ascending or descending ladders, stairs, scaffolding, ramps, poles and the
like, using feet and legs and/or hands and arms. Body agility is emphasized.
• Balancing. Maintaining body equilibrium to prevent falling and walking, standing or
crouching on narrow, slippery, or erratically moving surfaces.
• Stooping. Bending body downward and forward by bending spine at the waist.
• Kneeling. Bending legs at knee to come to a rest on knee or knees.
• Crouching. Bending the body downward and forward by bending leg and spine.
• Reaching. Extending hand(s) and arm(s) in any direction.
• Standing. Particularly for sustained periods of time.
• Walking. Moving about on foot to accomplish tasks, particularly for long distances or
moving from one work site to another.
• Pushing. Using upper extremities to press against something with steady force in order to
thrust forward, downward or outward.
• Pulling. Using upper extremities to exert force in order to draw, haul or tug objects in a
sustained motion.
• Lifting. Raising objects from a lower to a higher position or moving objects horizontally
from position-to-position. This factor is important if it occurs to a considerable degree
and requires substantial use of upper extremities and back muscles.
• Fingering. Picking, pinching, typing or otherwise working, primarily with fingers rather
than with the whole hand as in handling.
• Grasping. Applying pressure to an object with the fingers and palm.
• Feeling. Perceiving attributes of objects, such as size, shape, temperature or texture by
touching with skin, particularly that of fingertips.
• Talking. Expressing or exchanging ideas by means of the spoken word. Those activities in
which they must convey detailed or important spoken instructions to other workers
accurately, loudly, or quickly.
• Hearing. Perceiving the nature of sounds at normal speaking levels with or without
correction. Ability to receive detailed information through oral communication, and to
make the discriminations in sound.
• Repetitive motion. Substantial movements (motions) of the wrists, hands, and/or fingers.
2. The physical requirements of this position
• Very heavy work. Exerting in excess of 100 pounds of force occasionally, and/or in
excess of 50 pounds of force frequently, and/or in excess of 20 pounds of force
constantly to move objects.
3. The visual acuity requirements including color, depth perception, and field vision.
• The worker is required to have close visual acuity to perform an activity such as:
preparing and analyzing data and figures; transcribing; viewing a computer terminal;
extensive reading; visual inspection involving small defects, small parts, and/or
operation of machines (including inspection); using measurement devices; and/or
assembly or fabrication parts at distances close to the eyes.
• The worker is required to have visual acuity to perform an activity such as: operates
machines, such as lathes, drill presses, power saws, and mills where the seeing job is at
or within arm's reach; performs mechanical or skilled trades tasks of a non-repetitive
Animal Control Officer/Kennel Technician
Page 4 of 4
The City of Mansfield is an Equal Opportunity Employer
4.10.18
nature, such as carpenter, technicians, service people, plumbers, painters, mechanics,
etc.
• The worker is required to have visual acuity to operate motor vehicles and/or heavy
equipment.
• The worker is required to have visual acuity to determine the accuracy, neatness, and
thoroughness of the work assigned (i.e., custodial, food services, general laborer, etc.)
or to make general observations of facilities or structures
4. The conditions the worker will be subject to in this position
• The worker is subject to both environmental conditions. Activities occur inside and
outside.
• The worker is subject to extreme cold. Temperatures typically below 32° for periods of
more than one hour. Consideration should be given to the effect of other
environmental conditions, such as wind and humidity.
• The worker is subject to extreme heat. Temperatures above 100° for periods of more
than one hour. Consideration should be given to the effect of other environmental
conditions, such as wind and humidity.
• The worker is subject to noise. There is sufficient noise to cause the worker to shout in
order to be heard above ambient noise level.
• The worker is subject to hazards. Includes a variety of physical conditions, such as
proximity to moving mechanical parts, moving vehicles, electrical current, working on
scaffolding and high places, exposure to high heat or exposure to chemicals.
• The worker is subject to atmospheric conditions. One or more of the following conditions
that affect the respiratory system of the skin: fumes, odors, dust, mists, gases, or poor
ventilation.
• The worker is frequently in close quarters, crawl spaces, shafts, man holes, small
enclosed rooms, small sewage and line pipes, and other areas that could cause
claustrophobia.
• The worker is required to function in narrow aisles or passageways.
AMERICANS WITH DISABILITIES
The City of Mansfield complies with the Americans with Disabilities Act of 1990 and it is our policy to
ensure that no person is discriminated against based on their disability. The City of Mansfield offers
equal employment opportunity to qualified individuals and strictly prohibits the discrimination
against qualified individuals on the basis of disability. The City of Mansfield shall provide
reasonable accommodates to applicants and employees who are otherwise qualified to perform
the essential job duties when doing so does not create an undue hardship for the city.
EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
The City of Mansfield is an Equal Opportunity Employer who is committed to hiring and retaining
highly qualified persons and a diverse workforce. The City of Mansfield is mandated by federal law
to provide a drug-free working environment for the safety of its employees and the public. All
employment is contingent upon passing a post offer pre-employment drug test and/or physical. It
is the policy of the city not to discriminate against any person in recruitment, examination,
appointment, training, promotion, discipline or any other aspect of personnel administration
because of religious opinions or affiliations, membership or non-membership in employee
organizations, or because of race, color, national origin, ancestry, marital status, age, gender,
veteran, disability or any other basis prohibited by federal, state, or local laws.
APPLICATION FOR EMPLOYMENT
City of Mansfield
Attn: Human Resources
1200 E. Broad Street, Mansfield, Texas 76063
Phone: (817) 276-4267 FAX: (817) 473-7487
Email: applymansfield@mansfieldtexas.gov
Please print. All information must be legible. Application must be completed in full or will not be considered. Resumes may
be attached to completed application. Applicants requiring reasonable accommodation to the application and/or interview
process should contact the Human Resources Department for assistance. Equal access to programs, services, and employment
is available to all qualified persons. The City of Mansfield is an Equal Opportunity Employer.
Position applied for: _____________________________________ Date: _____________ Salary Expected: _____________
NAME: _______________________________ _____________________________________ ____________________
(Last) (First) (Middle)
ADDRESS: ________________________________________________________________________________________________
(Street) (City) (State) (Zip)
E-MAIL ADDRESS: _________________________________________________________________________________________
TELEPHONE: (Home) ______________________ (Work) ______________________ (Cell) ________________________
Please check all that apply: Do you want Regular Full Time Regular Part Time Temporary Full Time
Temporary Part Time Seasonal (as needed)
How did you learn of this position? Newspaper* Internet* Professional Magazine* Employee Referral
HR Office Employment Agency Texas Workforce Commission (employment office)
*Specify which____________________________________________________________________________________________
Do you have a valid Texas Driver’s License? No
Yes Type of License: Operator CDL Chauffer
License Number: ______________________________________ Expiration Date: _________________________________
Does anyone related to you (by blood or marriage) work here or is currently a member of the City Council? Yes No
City Board Commissions? Yes No If yes, list name, their position, and relationship:
_________________________________________________________________________________________________________
Have you ever worked here before? Yes No If yes, give dates and position held: _______________________________
__________________________________________________________________________________________________________
Are you legally eligible for employment in the United States of America? Yes No
Answering “yes” to the following question will not be an automatic bar to employment. Factors such as date of the offense,
seriousness, and nature of the violation, rehabilitation and position applied for will be taken into consideration.
Have you ever plead “guilty” or “no contest” (nolo contendere) to, or been convicted of a crime? Yes No
If you answered “yes,” please provide the date(s), location, and details: ______________________________________________
Have you served in the armed forces, armed forces reserve, or national guard of the United States of America? Yes No
If “yes,” please complete the following: BRANCH ______________________ DATE ENTERED _______________________
DATE OF DISCHARGE ________________________ RANK AT DISCHARGE __________________
LIST DUTIES AND TRAINING _____________________________________________________________________________
_________________________________________________________________________________________________________
ARE YOU CURRENTLY A MEMBER OF THE RESERVES OR NATIONAL GUARD? Yes No
EMPLOYMENT HISTORY
List all periods of employment or volunteer activities. If currently UNEMPLOYED, write “unemployed” in the CURRENT
Revised 2019
Revised 2019
2
EMPLOYER block and go to the next block. Start with your current status and work backward. If you need additional
space, use a plain sheet of paper using the format below for each additional position. You may attach a resume or other
documents. COMPLETE EACH SECTION FULLY.
CURRENT EMPLOYER: __________________________________________________________________________________
BUSINESS ADDRESS: ___________________________________________________ PHONE NO. _____________________
JOB TITLE: _________________________________________ SUPERVISOR’S NAME: ____________________________
DATES OF EMPLOYMENT: From ________________ To ________________
REASON FOR DESIRING CHANGE: ______________________________________________________________________
STARTING SALARY: $_____________ ENDING SALARY $_________MAY WE CONTACT THIS EMPLOYER? ____
YOUR DUTIES: __________________________________________________________________________________________
__________________________________________________________________________________________________________
LAST EMPLOYER: ______________________________________________________________________________________
BUSINESS ADDRESS: ___________________________________________________ PHONE NO. ____________________
JOB TITLE: _________________________________________ SUPERVISOR’S NAME: ___________________________
DATES OF EMPLOYMENT: From ________________ To ________________
REASON FOR LEAVING: ____________________________________________________________________________
STARTING SALARY: $______________ ENDING SALARY $________MAY WE CONTACT THIS EMPLOYER? ___
YOUR DUTIES: _________________________________________________________________________________________
_________________________________________________________________________________________________________
NEXT PREVIOUS EMPLOYER: ___________________________________________________________________________
BUSINESS ADDRESS: ___________________________________________________ PHONE NO. _____________________
JOB TITLE: _________________________________________ SUPERVISOR’S NAME: ____________________________
DATES OF EMPLOYMENT: From ________________ To ________________
REASON FOR LEAVING: _____________________________________________________________________________
STARTING SALARY: $___________ ENDING SALARY $_________ MAY WE CONTACT THIS EMPLOYER? ___
YOUR DUTIES: _________________________________________________________________________________________
_________________________________________________________________________________________________________
NEXT PREVIOUS EMPLOYER: ___________________________________________________________________________
BUSINESS ADDRESS: ___________________________________________________ PHONE NO. _____________________
JOB TITLE: _________________________________________ SUPERVISOR’S NAME: ____________________________
DATES OF EMPLOYMENT: From ________________ To ________________
REASON FOR LEAVING: ______________________________________________________________________________
STARTING SALARY: $____________ ENDING SALARY $________ MAY WE CONTACT THIS EMPLOYER? ___
YOUR DUTIES: _________________________________________________________________________________________
_________________________________________________________________________________________________________
PLEASE EXPLAIN IN DETAIL ANY TIME LAPSES DUE TO UNEMPLOYMENT OR OTHER REASONS.
________________________________________________________________________________________________________
Revised 2019
3
________________________________________________________________________________________________________
LIST LICENSES or CERTIFICATIONS RELATED TO THE JOB FOR WHICH YOU ARE APPLYING.
_____________________________________________________________________________________________
_______________________________________________________________________________________________________
LIST PROFESSIONAL OR TECHNICAL LICENSES, REGISTRATION, CERTIFICATES, OR
MEMBERSHIPS YOU POSSESS.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
CHECK ALL SKILLS OR ABILITIES, BELOW, THAT YOU POSSESS THAT RELATE TO THE POSITION
FOR WHICH YOU ARE APPLYING.
Typing / Speed ____________ WPM Ten-Key Calculator
Computer List programs in which proficient: _______________________________________________________________
_______________________________________________________________________________________________________
FOR TRADES JOBS ONLY:
Truck List type(s): _______________________________________________________
Backhoe List type(s): _______________________________________________________
Grader List type(s): _______________________________________________________
Dozer List type(s): _______________________________________________________
Tractor List type(s): _______________________________________________________
Mower List type(s): _______________________________________________________
Other equipment List type(s): ________________________________________________
EDUCATION
____________________________________________________________________________________________________________
SCHOOL NAME AND LOCATION FROM TO GRADUATED/COMPLETED
____________________________________________________________________________________________________________
High School
Diploma
GED
____________________________________________________________________________________________________________
Trade School Course of Study _______________
Certification__________________
____________________________________________________________________________________________________________
College Degree obtained ______________
Major _______________________
Minor _______________________
____________________________________________________________________________________________________________
Other
Revised 2019
4
ACKNOWLEDGEMENT
READ THE FOLLOWING CAREFULLY BEFORE SIGNING
I understand that if I am employed, any misrepresentation or material omission made by me on this application will be
sufficient cause for cancellation of this application or immediate discharge from employment with the City of Mansfield
whenever it is discovered.
I give the City of Mansfield the right to contact and obtain information from all references, employers, educational
institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from
liability the City of Mansfield and its representatives for seeking, gathering, and using such information and all other
persons, corporations, or organizations for furnishing such information.
The City of Mansfield does not unlawfully discriminate in employment and no question on this application is used for the
purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state, or
federal law.
This application is current for only six (6) months for the position for which application is made. I acknowledge that this
application, once submitted to the City of Mansfield, becomes the property of the City of Mansfield.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the City
of Mansfield reserves the same right to terminate my employment during the probationary period at any time, with or
without cause and without prior notice, except as may be required by law. This application does not constitute an
agreement or contract for employment for any specified period or definite duration. I understand that no representative of
the City of Mansfield, other that an authorized officer, has the authority to make any assurances to the contrary. I further
understand that any such assurances must be in writing and signed by an authorized officer.
I understand it is the policy of the City of Mansfield not to refuse to hire a qualified individual with a disability because of
that person’s need for a reasonable accommodation as required by the ADA.
I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.
I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.
Signature of Applicant: _________________________________________ Date: _____________________________
Human Resources
1200 East Broad Street
Mansfield, Texas 76063
(817) 276-4267
READ CAREFULLY BEFORE SIGNING
Prior to employment, applicants will be investigated as to convictions for prior criminal offenses. A prior
conviction will not automatically disqualify an applicant for employment and will be considered only as it
relates to the job applied for and as it may assist in determining character traits of the applicant.
However, falsification of the application will result in disqualification for employment.
All applicants for full time or regular part-time positions are requested to take a physical examination,
INCLUDING DRUG SCREENING.
All job offers are contingent on the successful completion of reference checks, police check, driver’s license
check (if applicable), and physical exam (if applicable).
All applications become the property of the City of Mansfield. Applications will be kept on file six months.
I hereby request and authorize you to render any information regarding my employment, character,
qualifications, habits, reputation, credit, medical history, past record of performance, or any other pertinent
information to the City of Mansfield. Any information furnished is at my express request and for my benefit.
I hold said representative or agent furnishing aforesaid information harmless, and I do hereby release them
from any and all liability for damage of whatsoever nature because of furnishing such information.
I further understand that this information will be “confidential” between the City of Mansfield and all other
parties involved.
Signature of Applicant Date
Before me personally appeared who stated this document and its
intent was explained to him/her that he/she has full knowledge of its purpose and that he/she executed this
instrument of his/her free will and accord.
Sworn to and subscribed before me on this______ day of ,
_________________________________________
SEAL or STAMP Signature of Notary
My Commission Expires: ____________________
Revised 2019
Print Name:
Today's
Date:
Last First Middle Maiden Month Day Year
The information on this card is used for statistical reporting to various regulatory agencies only. It will be detached from your
application and will in no way be used in consideration of your application for employment.
Position applying:
How did you learn of this position?
Dallas Morning News
Race/Sex:
Female
Male
Employee Referral
Fort Worth Star Telegram
A.
American Indian or Alaska Native
HR Office
B.
Asian
Mansfield News-Mirror
C.
Black or African American
Professional Magazine*
D.
Hispanic or Latino
Texas Workforce Commission
E.
Native Hawaiian or Other Pacific Islander
Other
*
F.
Two or more races
G.
White Internet Site
*Specify Which:
*
Career Builder
City
Birth Date:
Monster
Month Day Year
TML
Other *
Other *
Birthplace:
U.S. Citizen
Yes
No
Have you previously worked for the City? No
Yes
Mo. Year to Mo. Year
Department:
Position:
Under what other names have you been employed?
SUPPLEMENTAL INFORMATION CARD
If yes, when?
IMPORTANT INFORMATION
TCOLE Personal History Statement
Template Instructions
The attached Personal History Statement (PHS) is intended as a sample of what TCOLE considers to
be the minimum information necessary to meet the required background investigation (BI) for any law
enforcement licensee appointed to an agency, as defined under TCOLE Rule 211.1(a)(8).
Agency administrators may add additional information or agency identifiers without deletion or
elimination of any information in this document. They may also decide at which stage in the pre-
appointment process the PHS/BI will be completed as long as it is done before the applicant is
appointed. The objective is to help the agency’s chief administrator to make an informed decision
based on factual and verifiable information.
The PHS/BI is an auditable document which must be retained along with all other required TCOLE
appointment documents through the licensee’s employment and five (5) years after he or she leaves
the agency. For training academies the record must be retained for five (5) years from the last date
at the academy.
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 2 of 34
TEXAS COMMISSION ON LAW ENFORCEMENT
TCOLE
APPLICANT’S PERSONAL HISTORY STATEMENT
PERSONAL HISTORY STATEMENT FOR TEXAS
Appointment/Employment
Name: ________________________________
Date Issued: ___________________________
Complete and Return by: _________________
I am applying for:
Peace Officer PID#: ____________________
County Jailer PID#: _____________________
Telecommunicator PID#: _________________
Civilian Employment:
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 3 of 34
Personal History Statement Instructions
Employees are exposed to confidential and law enforcement sensitive information. A thorough background investigation
is required to properly evaluate the suitability of applicants for employment with the agency. Although it is an achievement
to reach the background phase of the hiring process, this is still a competitive process and does not, in any way, guaranty
selection.
These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is
essential that the information is accurate in all respects so please read all instructions carefully before proceeding. The
Personal History Statement will be used as a basis for a background investigation that will determine your eligibility for
becoming an employee.
1. Your application must be printed legibly in BLACK INK by the applicant or typed. Answer all questions truthfully
and accurately.
2. If a question is not applicable to you, enter N/A in the space provided.
3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is
accurate and in proper sequence before you begin.
4. You are responsible for obtaining correct and full addresses. If you are not sure of an address, personally verify
before making that entry on this history statement. Errors will not be viewed favorably.
ALL ADDRESSES MUST
BE COMPLETE WITH ZIP CODES.
5. If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to.
6. An accurate and complete form will help expedite your investigation. Omissions or falsifications will result in
disqualification.
7. You are responsible for furnishing any changes and/or updating your application as needed, such as address
changes or telephone changes in writing.
8. Any candidate submitting an incomplete application WILL NOT BE CONSIDERED FOR EMPLOYMENT. Your
application will be evaluated on completeness and neatness.
9. All documents requested must be submitted with the application (photocopies are acceptable in most cases).
Required documents vary according to the position being sought and the history of the applicant. Hiring agency
please check off documents required- modify list as necessary.
Completed Personal History Statement
Copy of your Social Security card.
Original certified copy of your birth certificate. (No photo copy)
Copy of your valid Texas driver license or a copy of another State’s driver license. Applicant must possess a valid
Texas driver license prior to being offered employment.
Copy of your High School diploma or GED certificate or an honorable discharge from the armed forces of the United
States after at least twenty four months of active service.
Sealed original certified copy of your college transcript. (No photo copy)
Photocopy of your college diploma.
Copy of your Peace Officer Certificate from your police academy. (Peace Officer Applicants Only)
Copy of your Texas peace officer license and all training certificates awarded to you. (Peace Officer Applicants Only)
Copy of your DD-214 if applicable. Must possess an honorable discharge.
Original certified copy of your Naturalization papers, if applicable. (No photo copy)
Copy of current proof of automobile liability insurance.
Copy of a TCOLE approved Firearms Qualifications within the last 12 months.
10. If you have any questions, please contact your assigned background investigator
11. When submitting the completed documents, please place them in a sealed envelope marked Personal and
Confidential to your assigned background investigator.
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 4 of 34
Instructions to the Applicant
Before you begin to fill out this personal history statement, please ensure that you meet the following requirements. You
must meet all five of these requirements to qualify for licensure as a peace officer, jailer or telecommunicator in Texas.
I am a citizen of the United States of America.
I have earned a high school diploma, a GED or an honorable discharge from the armed services of the United States
after at least two years active service.
I have never been convicted, plead guilty (nolo contendere), nor have I been on court-ordered community
service/probation or deferred adjudication for a Class A misdemeanor or a felony.
During the last ten (10) years, I have not been convicted, plead guilty (nolo contendere), been on community
service/probation or deferred adjudication for a Class B misdemeanor in this state, other state, or while serving in the
military.
I have never had a military court martial that resulted in a dishonorable or other discharge based on misconduct
which bars future military service.
DISQUALIFICATIONS
There are very few automatic
bases for rejection. Even issues of prior misconduct, employee terminations, and
arrests are usually not, in and of themselves, automatically disqualifying. However, 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.
This personal history statement is a governmental document. Be truthful, as there are criminal consequences for
lying on a governmental document.
Once you begin:
• 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 additional space for your answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to
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.
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 5 of 34
SECTION 1: PERSONAL
1. Last Name
First
M I
Suffix
2. Other Names, including nicknames, you have used or been known by.
3. Street Address, (Apt, Unit)
City
State
Zip
4. Address if different from above.
5. Phone #. Home
Cell
Work Ext.
Fax
Other
6. Email: Home
Business
Other
7. Birth Place (City / County / State / Country)
8. DOB
9. Social Security #
10. Driver License #
11. Physical description
HT.
WT.
Hair
Color
Eye
Color
State:
Exp:
12. Have you ever attended a basic licensing course? Yes No
If yes, provide the PID you were assigned: _______________________
A. Academy Name
From
To
Did you Graduate?
Yes No
Location (City / State)
Name of Training Coordinator
Contact Number
B. Academy Name
From
To
Did you Graduate?
Yes No
Location (City / State)
Name of Training Coordinator
Contact Number
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 6 of 34
13. Have you ever applied to any other law enforcement agency in the last ten years (city, county, state or federal)?
Yes No
• If yes, list ALL agencies you have applied to, starting with the most recent (give complete and accurate
addresses).
• All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for each
agency.
• If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to.
A. Name of Agency
Position Applied For
Date Applied
Address Street
City
State
Zip
Background Investigators Name (if know)
Contact Number Ext
Email
Check each step in the process that you completed, and your status:
Steps: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral
Conditional job offer Psychological Examination Date________________ Medical Date:__________________
Status: Hired On List Withdrawn Disqualified
B. Name of Agency
Position Applied For
Date Applied
Address Street
City
State
Zip
Background Investigators Name (if known
Contact Number Ext
Email
Check each step in the process that you completed, and your status:
Steps: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral
Conditional job offer Psychological Examination Date________________ Medical Date:__________________
Status: Hired On List Withdrawn Disqualified
C. Name of Agency
Position Applied For
Date Applied
Address Street
City
State
Zip
Background Investigators Name (if known)
Contact Number Ext
Email
Check each step in the process that you completed, and your status:
Steps: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral
Conditional job offer Psychological Examination Date________________ Medical Date:__________________
Status: Hired On List Withdrawn Disqualified
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 7 of 34
SECTION 2: RELATIVES AND REFERENCES
14. IMMEDIATE FAMILY
• Provide all applicable information in the spaces below.
• Mark “N/A” if a category is not applicable or if the individual is deceased.
• If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to.
NA
A. Father Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
NA
B. Step-Father Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
NA
C. Mother Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
NA
D. Step-Mother Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 8 of 34
NA
E. Spouse / Registered Domestic Partner
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
Years of Marriage
Is there, or has there been a restraining or stay-away order in effect for this individual?
Yes No
NA
F. Father-in-Law Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
NA
G. Mother-in-Law Name
DOB
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
NA
H. Former Spouse(s)
Cohabitant
1. Name
DOB
Male
Female
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
Year of Dissolution
Is there, or has there been a restraining or stay-away order in effect for this individual?
Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 9 of 34
NA
I. Former Spouse(s)
Cohabitant
2. Name
DOB
Male
Female
Home Address
City
State
Zip
Work Address
City
State
Zip
Home Phone
Cell
Work Phone
Email
Year of Dissolution
Is there, or has there been a restraining or stay-away order in effect for this individual?
Yes No
N A
J. Brothers and Sisters: List all living siblings, including half-siblings, foster siblings, etc.
1. Name
DOB
Male Female
Home Address
City
State
Zip
Phone #
Work Address
City
State
Zip
Phone #
Cell
Email
2. Name
DOB
Male Female
Home Address
City
State
Zip
Phone #
Work Address
City
State
Zip
Phone #
Cell
Email
3. Name
DOB
Male Female
Home Address
City
State
Zip
Phone #
Work Address
City
State
Zip
Phone #
Cell
Email
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 10 of 34
4. Name
DOB
Male Female
Home Address
City
State
Zip
Phone #
Work Address
City
State
Zip
Phone #
Cell
Email
5. Name
DOB
Male Female
Home Address
City
State
Zip
Phone #
Work Address
City
State
Zip
Phone #
Cell
Email
6. Name
DOB
Male Female
Home Address
City
State
Zip
Phone #
Work Address
City
State
Zip
Phone #
Cell
Email
N A
K. CHILDREN
List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with
you. Provide the name and contact information of the custodial parent or guardian, if other than you.
1. Name
Custodial parent or guardian (If other than you.)
Male
Female
Address
City
State
Zip
DOB
Contact Number
Email
2. Name
Custodial parent or guardian (If other than you.)
Male
Female
Address
City
State
Zip
DOB
Contact Number
Email
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 11 of 34
3. Name
Custodial parent or guardian (If other than you.)
Male
Female
Address
City
State
Zip
DOB
Contact Number
Email
4. Name
Custodial parent or guardian (If other than you.)
Male
Female
Address
City
State
Zip
DOB
Contact Number
Email
5. Name
Custodial parent or guardian (If other than you.)
Male
Female
Address
City
State
Zip
DOB
Contact Number
Email
6. Name
Custodial parent or guardian (If other than you.)
Male
Female
Address
City
State
Zip
DOB
Contact Number
Email
15. REFERENCES
List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include
relatives, employers or housemates, or other individuals listed elsewhere.
A. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person?
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 12 of 34
B. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person?
C. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person
D. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person?
E. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person?
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 13 of 34
F. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person?
G. Name
Address
City
State
Zip
Company / Work address
City
State
Zip
Home Phone
Work Phone
Cell
Email
How do you know this person? (friend, teacher, family, co-worker)
How long have you known this
person
SECTION 3: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.
16. Check applicable: High School Diploma GED Discharge documents from armed services with 2 years active duty
17. List High Schools Attended or where you obtained your GED.
A. Name
City
State
From
To
Did you graduate? Yes No
B. Name
City
State
From
To
Did you graduate? Yes No
18 List all colleges or universities attended:
A. Name
City
State
From
To
Type of Degree Earned
Total Units Earned
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 14 of 34
B.. Name
City
State
From
To
Type of Degree Earned
Total Units Earned
C. Name
City
State
From
To
Type of Degree Earned
Total Units Earned
19. List any trade, vocational, or business schools / institutes attended.
A. Name
From
To
Did you complete the course?
Yes No
Type of school or training
City
State
B. Name
From
To
Did you complete the course?
Yes No
Type of school or training
City
State
C. Name
From
To
Did you complete the course?
Yes No
Type of school or training
City
State
SECTION 3: EDUCATION continued.
20. Have you ever been placed on academic discipline, suspended or expelled from any high school, college/university,
business or trade school? Yes No
If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or
educational institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation of
circumstances.
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 15 of 34
SECTION 4: RESIDENCE
21. LIST OF RESIDENCES
• List all residences during the last ten years or since age 17. Provide complete addresses (include markers such
as Street, Drive, Road, East, West, etc., and unit or apartment number). Do not use P.O. Boxes.
• If the residence is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LIST
military barracks mates unless you shared individual quarters.
• If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what
question number and page this refers to.
A. Current residence Street
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you live
B. Former Address
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you lived.
Reason for moving
C. Former Address
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you lived.
Reason for moving
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 16 of 34
D. Former Address
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you lived.
Reason for moving
E. Former Address
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you lived.
Reason for moving
F. Former Address
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you lived.
Reason for moving
G. Former Address
City
State
Zip
From
To
If renting; property manager, rent collector or owner
Contact Number
Address of property mgr., rent collector, owner
City / State / Zip
Email
NA
Names of those with whom you lived.
Reason for moving
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 17 of 34
22
.
Provide contact information for all housemates listed in Question 21 with whom you have resided during the past 10
years, or since the age of 17. DO NOT list anyone for whom you have already provided contact information. If you need
additional space for your answers, attach additional sheets as needed. Be sure to indicate what question number and
page this refers to.
A. Name
Contact Number
Current Address Street
City
State
Zip
Nature of relationship (friend, relative, landlord, housemate only)
Email
B. Name
Contact Number
Street
City
State
Zip
Nature of relationship (friend, relative, landlord, housemate only)
Email
C. Name
Contact Number
Street
City
State
Zip
Nature of relationship (friend, relative, landlord, housemate only)
Email
D. Name
Contact Number
Street
City
State
Zip
Nature of relationship (friend, relative, landlord, housemate only)
Email
E. Name
Contact Number
Street
City
State
Zip
Nature of relationship (friend, relative, landlord, housemate only)
Email
F. Name
Contact Number
Street
City
State
Zip
Nature of relationship (friend, relative, landlord, housemate only)
Email
23. Have you ever been evicted or asked to leave a residence? Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 18 of 34
24. Have you ever left a residence owing rent? Yes No
If you answered yes to Questions 23 and / or 24 explain (include when, where and circumstances).
SECTION 5: EXPERIENCE AND EMPLOYMENT
25. JOB EXPERIENCE
• Have you EVER served as a Peace Officer, Jailer, or Telecommunicator in another state OR another country?
Yes No
If YES, list below
• List ALL jobs you have had in the last ten years, including part-time, temporary, self-employment and volunteer.
(Begin with your most current. If more space is needed, continue your response on page 33.)
• If you have military experience, including reserve duty, enter your military base, assignments, or unit of
assignment. Include ALL military services.
• List ALL periods of unemployment in excess of 30 days.
A. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
Would there be a problem if we contact
your current employer? Yes No
If yes, explain.
B. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 19 of 34
C. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
D. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
E. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
F. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 20 of 34
G. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
H. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
I. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
J. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 21 of 34
K. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
L. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
M. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
N. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 22 of 34
O. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
P. PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel
Other
From
To
Q. Name of employer or military unit.
From
To
Address or Base
City
State
Zip
Supervisor
Contact Number Ext.
Email
Job Title
Reason for leaving
Duties /Assignments
F-T P-T Temp
Self-employed Volunteer
Names of co-workers
Co-workers Phone Number
26. Have you ever been disciplined at work? (This includes written warnings, formal letters of
reprimands, suspensions, reductions in pay, reassignments or demotions?
Yes No
27. Have ever you ever been fired, released from probation, or asked to resign from any place of
employment?
Yes No
28. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer?
Yes No
29. Have you ever resigned without giving two weeks-notice?
Yes No
30. Have you ever resigned in lieu of termination?
Yes No
31. Have you ever been accused of discrimination (such as sexual harassment, racial bias,
sexual orientation harassment, etc.) by a co-worker, superior, subordinate or customer?
Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 23 of 34
32. Were you ever the subject of a written complaint at work?
Yes No
33. Have you ever been counseled at work due to lateness or absences
Yes No
34. Did you ever receive an unsatisfactory performance review?
Yes No
35. Have you ever sold, released, or given away legally confidential information?
Yes No
36. Have you ever called in sick when you were neither sick nor caring for a sick family member?
If yes, how many sick days have you used in the past five years which were not due to illness?
Yes No
37. If you answered yes to any of Questions 26–36, explain (include when, where and circumstances; indicate
corresponding number):
38. Has your work performance ever been affected by your use of alcohol or drugs? Yes No
When?
Name of Employer
39. In the past ten years, have you been warned by an employer about your drinking or drug habits and their impact on
your performance? Yes No
When?
Name of Employer
SECTION 6: MILITARY EXPERIENCE (Complete for all branches of military served. Add pages if necessary)
40. Are you required to register for the Selective Service
Yes No
If yes, have you registered Yes No
If no explain: ___________________________________________________________________
41. Branch of Service
Date of Service
From
To:
42. Type of Discharge Entry Level Honorable General Other than Honorable
Re-entry Code (1-4) if applicable; refer to your DD-214
43. Are you currently participating in one of the following?
Military Reserve National Guard
If checked, date obligation ends:
44. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s
mast, office hours, company punishment)? Yes No
45. Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded, either military or
any other federal, state, or municipal clearance? Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 24 of 34
If you answered YES to questions 44 and or 45, Explain ( Include dates and circumstances)
SECTION 7 FINANCIAL
46. INCOME AND EXPENSES
For each of the following questions fill in the amounts to the nearest dollar
A. From your employer(s), what is your take home monthly income? $__________________
B. Do you have income other than from your salary or wages? Yes No
If yes, fill in amount: $___________________per month Explain:_________________________________
C. Approximately how much do you spend each month? $___________________________
Estimate your monthly living expenses, include housing, utilities, credit cards or other loan payments, food, gas and car
maintenance, entertainment, etc. as well as any other obligations you may have.
47. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)
Yes
No
48. Have any of your bills ever been turned over to a collection agency? Yes No
49. Have you ever had purchased goods repossessed? Yes No
50. Have your wages ever been garnished? Yes No
51. Have you ever been delinquent on income or other tax payments? Yes No
52. Have you ever failed to file income tax or cheated/lied on an income tax form Yes No
53. Have you ever had an employment bond refused? Yes No
54. Have you ever avoided paying any lawful debt by moving away? Yes No
55. Have you ever defaulted on a loan, including a student loan? Yes No
56. Have you ever borrowed money to pay for a gambling debt?
If yes, do you currently have any outstanding debts as a result of gambling
Yes No
Yes No
57. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase
fraudulent documents, etc.)?
Yes No
58. Have you ever failed to make or been late on a court-ordered payment
e.g., child support, alimony, restitution, etc.)?
Yes No
59. Have you written three or more bad checks in a one-year period? Yes No
60. Are you in arrears on court ordered child support? Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 25 of 34
If you answered YES to questions 47-60, indicate question number. Explain (include, when, where and why).
SECTION 8: LEGAL
Disclosure of Citations, Arrests, and Convictions
This section requires you to report detentions, arrest and convictions, including diversion programs and in some cases,
offenses that may have been pardoned. As a peace officer applicant, you are required to disclose this information,
unless specifically exempted by state or federal law.
• ALL detentions or arrests, whether they resulted in a conviction or not
• ALL convictions
• ALL diversion programs
• ALL citations (excluding traffic tickets) May have been detained and or received Class C for disorderly conduct,
prostitution, assault, etc. without actual arrest.
If you need additional space for your answers, attach additional sheets as needed. Be sure to indicate what question
number and page this refers to.
61. Have you EVER been detained for investigation, held on suspicion, questioned, fingerprinted, arrested,
indicted, criminally charged, or convicted of any misdemeanor or felony offense in this state or in any other
legal jurisdiction (including offenses punishable under the Uniform Code of Military Justice)?
Yes No
If yes, explain each incident.
A. Approximate Date
Arresting or detaining agency
Charge
Disposition or Penalty
B. Approximate Date
Arresting or detaining agency
Charge
Disposition or Penalty
C. Approximate Date
Arresting or detaining agency
Charge
Disposition or Penalty
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 26 of 34
D. Approximate Date
Arresting or detaining agency
Charge
Disposition or Penalty
62. Have you ever been placed on court probation as an adult?
Yes No
63. Have you ever been convicted of any charge that would prevent you from legally possessing a
firearm or ammunition?
Yes No
64. Were you ever required to appear before a juvenile court for an act which would have been a
crime if committed as an adult?
Yes No
65. Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions,
child custody, paternity, support, etc.)?
Yes No
66. Have the police ever been called to your home for any reason?
Yes No
67. Have you or your spouse/partner ever been referred to Child Protective Services? Yes No
68. Have you ever been the subject of an emergency protective, restraining or stay-away order? Yes No
69. Have you settled any civil suit in which you, your insurance company, or anyone else on your
behalf was required to make payment to the other party?
Yes No
70. Have you ever fraudulently received welfare, unemployment compensation,
compensation or other state or federal assistance?
Yes No
71. Have you ever filed a false insurance or workers’ compensation claim? Yes No
If you answered yes to any of Questions 62–71, explain (include court case or document, dates, and circumstances;
indicate corresponding number):
72. UNDETECTED ACTS – PART 1
Within the past seven years OR at any time after you were first employed in law enforcement, have you ever
committed any of the following misdemeanors?
A. Annoying / obscene phone calls
Yes No
B. Assault (use of force or violence upon another) Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 27 of 34
C. Assault (use of force or violence upon a family member) Yes No
D. Brandishing a weapon (any type of weapon) Yes No
E. Carrying a concealed weapon without a permit Yes No
F. Contributing to the delinquency of a minor Yes No
G. Defrauding an innkeeper (not paying for food or room at a hotel/motel) Yes No
H. Driving under the influence of alcohol and/or drugs Yes No
I. Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) Yes No
J. Hit and run collision (no injuries) Yes No
K. Hunting or fishing without a license. Yes No
L. Illegal gambling Yes No
M. Impersonating a peace officer Yes No
N. Indecent exposure (including flashing or mooning) Yes No
O. Joyriding (using a car or other vehicle without owner’s permission Yes No
73. UNDETECTED ACTS - PART 2
At any time in your life have you ever committed any of the following?
A. Arson (intentionally destroying property by setting a fire) Yes No
B. Assault with a deadly weapon Yes No
C. Theft of a vehicle and / or vehicle parts Yes No
D. Burglary (entering a structure or vehicle to commit theft or other crime) Yes No
E. Child molestation (performing unlawful acts with a child) Yes No
F. Accessing, producing, or possessing child pornography Yes No
G. Injury to a child/elderly/or disabled Yes No
H. Embezzlement (theft of money or other valuables entrusted to you) Yes No
I. Felony drunk driving (involving injuries) Yes No
J. Forcible rape or other act of unlawful intercourse / sexual activity Yes No
K. Forgery (falsifying any type of document, check certificate, license, currency, etc.) Yes No
L. Hit and run (with injuries) Yes No
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 28 of 34
M. Hate crime Yes No
N. Insurance fraud Yes No
O. Theft (value of over $500, or any firearm) Yes No
P. Murder, homicide, or attempted murder Yes No
Q. Perjury (lying under oath) Yes No
R. Possession of an explosive / destructive device Yes No
S. Robbery (theft from another person using a weapon, force, or fear) Yes No
T. Stalking Yes No
U. Blackmail or extortion Yes No
V. Any other act amounting to a felony Yes No
If you answered yes to any item(s) in section 72 - 73 fully explain circumstances, including dates(s), names of
individuals involved and resolution. Indicate the corresponding letter (73-A etc) for each explanation.
Questions about your current and past recreational drug use. This covers the use of any drug, including the
unauthorized use of prescription drugs. Your answers should include, but not limited to, your use of any of the
following drugs.
Amphetamines / Methamphetamine Uppers, Speed, Crank, etc. Heroin / Opium
Barbiturates (Downers) Marijuana
Cocaine / Crack Cocaine Mescaline
Designer Drugs (Ecstasy, Synthetic Heroin, etc.) Morphine
GHB (Date Rape Drug) PCP / Angel Dust
Glue Quaaludes
Hallucinogens (Peyote, LSD, Mushrooms) Steroids
Hashish / Hashish Oil Tetrahydrocannabinol (THC)
74. Within the past ten years, have you used any non-prescribed drug(s) as indicated above
or unauthorized prescription drugs? Yes No
If yes, give details, including drug(s) used and circumstances:
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 29 of 34
75. Prior to the past ten years (check all that apply):
I have never used any drug recreationally.
I have tried or used one or more drugs listed above, but only under limited circumstances
(for example, experimentation, at parties, concerts, special events, etc.).
If checked, give details including drug(s) used, most recent date used, and circumstances
.
76. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including
marijuana?
Sold Manufactured Purchased Furnished Cultivated Carried or held for another
Any items check above, give details including drug(s) involved, over what time period(s) and circumstances.
SECTION 9: MOTOR VEHICLE OPERATION
77. Current Driver License #
State of Issue
Expiration date
Name under which license was granted
78. List other states where you have been licensed to operate a motor vehicle.
State of issue
Type of license
Name under which license was granted and license number
79. Have you ever been refused a driver’s license by any state Yes No
If yes, explain ( include when, where and circumstances):
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 30 of 34
80. Has your driver’s license ever been suspended or revoked? Yes No
If yes, explain ( include when, where and circumstances):
81. List your current liability insurance on your vehicle(s)
A. Type of Coverage
Insured Bonded Cash Deposit
Vehicle Make
Year
Vehicle License
Insurance Company
Policy number
Expires
Address
City
State
Zip
Contact Number
B. Type of Coverage
Insured Bonded Cash Deposit
Vehicle Make
Year
Vehicle License
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
C. Type of Coverage
Insured Bonded Cash Deposit
Vehicle Make
Year
Vehicle License
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
D. Type of Coverage
Insured Bonded Cash Deposit
Vehicle Make
Year
Vehicle License
Insurance Company
Policy Number
Expires
Address
City
State
Zip
Contact Number
82. List all traffic citations, excluding parking citations, you have received within the past seven years:
A. Nature of Violation
Location Street, City, State, Zip
Date Violation Occurred
Action Taken
Not Guilty Fined Traffic School Dismissed
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 31 of 34
B. Nature of Violation
Location Street, City, State, Zip
Date Violation Occurred
Action Taken
Not Guilty Fined Traffic School Dismissed
C. Nature of Violation
Location Street, City, State, Zip
Date Violation Occurred
Action Taken
Not Guilty Fined Traffic School Dismissed
D. Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following?
(Check all that apply.)
Failed to appear Failed to complete traffic school Failed to pay the required fine
If checked, explain circumstances:
83. Have you been involved as the driver in a motor vehicle accident within the past seven years? Yes No
If yes, give details.
A. Date
Location (Street, City, State, Zip)
Police Report
Yes No
Law Enforcement Agency
Injury Non Injury
A. Date
Location (Street, City, State, Zip)
Police Report
Yes No
Law Enforcement Agency
Injury Non Injury
A. Date
Location (Street, City, State, Zip)
Police Report
Yes No
Law Enforcement Agency
Injury Non Injury
84. Have you ever driven a vehicle without auto insurance, as required by law? Yes No
If yes, give reason
Date
Location Street, City, State, Zip
85. Have you ever been refused automobile liability insurance or a bond, or had policy cancelled? Yes No
If yes, give reason:
Insurance Company
Date
Location Street, City, State, Zip
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 32 of 34
86. Use this space for additional information you would like to include regarding your driving record.
87. Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other
group that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin,
nationality, gender, sexual preference, or disability?
Yes No
88. Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise, street
gang, or any other group that advocates violence against individuals because of their race, religion, political
affiliation, ethnic origin, nationality, gender, sexual preference, or disability
Yes No
89. Since the age of 17, have you ever been involved in an anger-provoked physical fight,
confrontation or other violent act? Yes No
90. Have you ever hit or physically overpowered a spouse, romantic partner or family members? Yes No
If you answered yes to any of Questions 87-90, give details dates and circumstances; indicate corresponding number.
SECTION 11: SOCIAL MEDIA SITES
91. Have you ever had a social media site (i.e. Facebook, My Space, etc.)? Yes No
92. List all social media sites, blogs or websites you have created. (Provide website URL and your username)
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 33 of 34
SECTION 12: CERTIFICATION
93. I hereby certify that I have personally completed and initialed each page of this form and any supplemental page(s)
attached, and that all statements made are true and complete to the best of my knowledge and belief. I understand
that any misstatement of material fact may subject me to disqualification; or, if I have been appointed, may
disqualify me from continued employment.
______________________________________________________
________/____________/___________
Signature of Applicant
Date
Sworn to and subscribed before me, this the __________day of ____________,________
Notary public in and for, State of ____________
My commission expires ______/______/______
______________________________________________
Printed Name of Notary
Notary Seal or Stamp
__________________________________________________
Signature of Notary
Personal History Statement 11.22.2016 Initial this page to indicate that you have provided complete and accurate information: _____
Page 34 of 34
ADDITIONAL SPACE
• Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g.,
additional family members, schools, residences, employers, explanations to questions, etc.
• Identify the corresponding question and specific item being referenced.
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Animal Control Employment (City of Mansfield, Texas (TX))

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Completed 13 July 2020

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