Fillable Arizona Peace Officer Standards and Training Board STATEMENT (Arizona)

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Arizona Peace Officer Standards and Training Board STATEMENT (Arizona)

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SSN #:
AZ POST Form PH (July 2019) Page 1 of 10
Arizona Peace Officer Standards and Training Board
STATEMENT OF PERSONAL HISTORY AND
APPLICATION FOR CERTIFICATION
I. TO THE APPLICANT
Certification by the Arizona Peace Officer Standards and Training Board is required by state law, A.R.S. §41-
1823.B, prior to a person being authorized to act in the capacity of a peace officer. To be considered for
certification under the rules of AZ POST, you must complete this application and RETURN IT TO THE
DEPARTMENT TO WHICH YOU ARE APPLYING.
II. A FALSE OR MISLEADING STATEMENT ON THIS FORM IS A CRIME UNDER A.R.S. § 13-2704,
13-2907.01 AND 39-161 AND IS CAUSE TO DENY OR REVOKE PEACE OFFICER CERTIFICATION.
The existence of any of the following conditions may result in rejection from the selection process. These
areas will be explored extensively during a background investigation including a polygraph examination:
a. Illegal drug use,
b. Participation in criminal activity or behavior,
c. Poor driving record,
d. Dishonesty/providing false information.
III. PUBLIC DISCLOSURE OF INFORMATION
Your Social Security Number is required by A.R.S. §25-320 and is requested for identification and record
keeping purposes. AZ POST does not disclose Social Security Numbers in response to public record
requests.
IV. INSTRUCTIONS
Read every question carefully. Answer every question. If the question does not apply to you, write "DNA"
in the answer space. Please print clearly. When using the Continuation Sheet, please note the question
number you are referring to. Applications that are incomplete or cannot be read will not be accepted.
V. PEACE OFFICER CODE OF ETHICS
I will exercise self-restraint and be constantly mindful of the welfare of others. I will be exemplary in obeying
the laws of the land and loyal to the state of Arizona and my agency and its objectives and regulations.
Whatever I see or hear of a confidential nature or that is confided to me in my official capacity will be kept
secure unless revelation is necessary in the performance of my duty.
I will never take selfish advantage of my position and will not allow my personal feelings, animosities or
friendships to influence my actions or decisions. I will exercise the authority of my office to the best of my
ability, with courtesy and vigilance, and without favor, malice, ill will, or compromise. I am a servant of the
people and I recognize my position as a symbol of public faith. I accept it as a public trust to be held so long
as I am true to the law and serve the people of Arizona.
CERTIFICATION:
I hereby certify that I have read the above Code of Ethics and agree to abide by it.
SIGNATURE OF APPLICANT:
DATE:
AZ POST Form PH (July 2019) Page 2 of 10
Arizona Peace Officer Standards and Training Board
AUTHORIZATION FOR RELEASE OF INFORMATION
I, , DO HEREBY AUTHORIZE any and all persons,
(print name)
employers, partnerships, corporations and all civilian and government entities, military agencies, law
enforcement agencies, private, and city, county, state and federal entities to release, furnish and
exchange any and all available information relating to me for the purpose of determining my
suitability to be appointed and certified as a peace officer. This includes, but is not limited to, all
information related to my employment, performance, disciplinary history, character, integrity,
reputation, conduct, behavior and fitness for duty.
This authorizes release to the ARIZONA PEACE OFFICER STANDARDS AND TRAINING BOARD
and the . This release is in addition to,
(print agency name)
and not intended to curtail or diminish the authorization and immunity provided by statute. I DO
HEREBY RELEASE from any and all liability, all persons or entities disclosing information pursuant
to this release.
SIGNATURE OF APPLICANT:
DATE:
Sworn and Subscribed to Before Me This: Day of , 20_______
BY:
STATE OF:
COUNTY OF:
SIGNATURE OF NOTARY PUBLIC:
Name:
SSN #:
AZ POST Form PH (July 2019) Page 3 of 10
Arizona Peace Officer Standards and Training Board
STATEMENT OF PERSONAL HISTORY AND
APPLICATION FOR CERTIFICATION
ARIZONA ADMINISTRATIVE CODE R13-4-106: A person who seeks to be appointed shall complete and submit to the
appointing agency a personal history statement on a form prescribed by the Board before the start of a background
investigation. The history statement shall contain answers to questions that aid in determining whether the person is
eligible for certified status as a peace officer. The questions shall concern whether the person meets the minimum
requirements for appointment, has engaged in conduct or a pattern of conduct that would jeopardize the public trust in
the law enforcement profession and is of good moral character.
INSTRUCTIONS: Print in ink or type all answers. Read every question carefully and answer every question. If the
question does not apply to you, print or type "DNA" in that answer block. DO NOT LEAVE BLANK SPACES.
Incomplete or unsigned statements cannot be processed. If additional space is required, use the Continuation Sheet.
Also, use the Continuation Sheet to expound or explain your answer. All information provided is subject to verification.
Information on this form may constitute a "public record or other matter" requiring public disclosure under Arizona's Public
Records Law, A.R.S. §39-121 et seq.
1. Name (Last, First, Middle)
2. Email Address
3. Physical Address
4. City
6. Mailing Address
7. City
9. Date of Birth
(Month/Day/Year)
10. Place of Birth
(City, State, Country)
11. Social Security Number
12. List here any other names, DOB’s or SSN’s you have used:
13. Current Marital Status
14. Spouse’s Name Before Marriage
15. Home Telephone Number
16. Work Telephone Number
17. Cell/Mobile Number
18. Are you a citizen of the United States?
Yes No
Please attach a copy of Birth Certificate or other verification of citizenship.
If naturalized, please provide date: .
19. Do you have (check one) (please attach copy of one of the below) (If G.E.D. please explain why on continuation sheet).
High School Diploma G.E.D. Certificate Home School
20. Institution, when and where did you receive it?
21. Military Service If YES, attach the MEMBER 4 copy of the DD 214 and continue with this section.
Yes No If NO, provide Selective Service # ________________________ and skip to #22.
Branch of Service
Date Entered
Date Separated
Honorable Discharge:
Yes No
If NO, list type of discharge/separation and explain on
the Continuation Sheet.
Were you ever arrested, cited or apprehended by military police?
Yes No If YES, explain on the Continuation Sheet.
Are you currently a member of a U.S. Reserve or National Guard Unit?
Yes No If YES, list current assignment:
___________________________________________________________
Were you ever the subject of a report or investigation by Military Police or
other investigative service (i.e., CID, NCIS, OSI)?
Yes No If YES, explain on the Continuation Sheet.
Did you ever receive a court martial or non-judicial punishment for a violation of the Uniform Code of Military Justice (UCMJ)
Yes No If YES, explain on the Continuation Sheet.
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
U.S. Citizen (Documentation on File) High School Diploma/GED (Documentation on File)
21 Years of Age Military Service if applicable (Documentation on File)
Name:
SSN #:
AZ POST Form PH (July 2019) Page 4 of 10
22. PERSONAL REFERENCES: List at least three people who have known you for over one year, excluding relatives or former employers, who can
answer questions concerning your past conduct and character as it applies to your meeting the minimum standards for appointment.
Use the Continuation Sheet if necessary.
NAME:
STREET ADDRESS, CITY, STATE, ZIP CODE
HOME TELEPHONE NO.
YEARS
KNOWN
EMAIL:
WORK TELEPHONE NO.
NAME:
STREET ADDRESS, CITY, STATE, ZIP CODE
HOME TELEPHONE NO.
YEARS
KNOWN
EMAIL:
WORK TELEPHONE NO.
NAME:
STREET ADDRESS, CITY, STATE, ZIP CODE
HOME TELEPHONE NO.
YEARS
KNOWN
EMAIL:
WORK TELEPHONE NO.
NAME:
STREET ADDRESS, CITY, STATE, ZIP CODE
HOME TELEPHONE NO.
YEARS
KNOWN
EMAIL:
WORK TELEPHONE NO.
23. EXCLUDING FAMILY MEMBERS, LIST ALL PERSONS YOU HAVE LIVED WITH DURING THE PAST FIVE YEARS.
Use the Continuation Sheet if necessary.
Name
Street Address, City, State, Zip Code
Primary Telephone No.
Relationship
24. FAMILY: List ALL immediate relatives (living and deceased) (i.e., parents, siblings, spouse, ex-spouse(s) and all children).
Use the Continuation Sheet if necessary.
Name
Relationship
Age
Street Address, City, State, Zip Code
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
Personal References Contacted and Results Documented Residences and Family Listed
Name:
SSN #:
AZ POST Form PH (July 2019) Page 5 of 10
25. EMPLOYMENT HISTORY: Show ALL employment beginning with your most recent employer. Use the Continuation Sheet if necessary.
Start Date
End Date
Name of Employer
Employer Address (include city, state, zip code)
Supervisor Name
Supervisor’s Phone Number
Supervisor’s Email Address
Job Title
Duties
Reason for Leaving
Start Date
End Date
Name of Employer
Employer Address (include city, state, zip code)
Supervisor Name
Supervisor’s Phone Number
Supervisor’s Email Address
Job Title
Duties
Reason for Leaving
Start Date
End Date
Name of Employer
Employer Address (include city, state, zip code)
Supervisor Name
Supervisor’s Phone Number
Supervisor’s Email Address
Job Title
Duties
Reason for Leaving
Start Date
End Date
Name of Employer
Employer Address (include city, state, zip code)
Supervisor Name
Supervisor’s Phone Number
Supervisor’s Email Address
Job Title
Duties
Reason for Leaving
Start Date
End Date
Name of Employer
Employer Address (include city, state, zip code)
Supervisor Name
Supervisor’s Phone Number
Supervisor’s Email Address
Job Title
Duties
Reason for Leaving
26. LIST ALL COLLEGES OR UNIVERSITIES YOU HAVE ATTENDED (Beginning with the most recent):
School
Dates
Attended
Course of Study
Degree Received or
Total Credit Hours
(AA, BA, BS, MA, etc.)
27. RESIDENCES: List ALL residences during the past TEN years. Use the Continuation Sheet if necessary.
Dates of Residence
Street Address City, State Zip/County/Country
From
To
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
Employment Verified and Results Documented
Certificates or Degrees, Documentation in file
Residences Verified and Results Documented in file
Name:
SSN #:
AZ POST Form PH (July 2019) Page 6 of 10
28. POLICE CONTACTS: List ANY and ALL incidents in which you had contact with police or were cited, arrested, accused, questioned about,
suspected of, or charged with a crime OTHER THAN TRAFFIC VIOLATIONS. Include incidents that occurred as a juvenile, any that were expunged,
set aside, dismissed, referred to pre-trial diversion or pardoned. Provide a full explanation on the Continuation Sheet.
Date
Location
Police Agency
Original Charge
Disposition / Court Action
29. CIVIL ACTIONS: List ALL civil actions in which you were a party, (i.e., divorces, bankruptcy, small claims court, lawsuits, restraining orders,
injunctions prohibiting harassment, etc.).
Use the Continuation Sheet if necessary.
Date
Location/Court
Action or Proceeding
Disposition / Court Action
30. CURRENT DRIVER’S LICENSE
31. PREVIOUS DRIVER’S LICENSE INFORMATION
State
Expiration Date
List all states / countries where you have been licensed and provide driver’s license
number if known:
____________ ____________ ____________
____________ ____________ ____________
License Number
32. HAVE YOU EVER HAD YOUR DRIVER’S LICENSE REVOKED OR SUSPENDED?
Yes No
If YES, provide a full explanation on the Continuation Sheet .
33. MOTOR VEHICLE OPERATION: List ALL moving violations for which you were stopped and/or cited. Use the Continuation Sheet if necessary.
Date Location and Issuing Agency Violation (not code) Collision Related Court Disposition
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
Police Contacts Queried and Results Documented in file Civil Actions Queried and Results Documented in file
Motor Vehicle Records Queried and Results Documented in file
Name:
SSN #:
AZ POST Form PH (July 2019) Page 7 of 10
34. ILLEGAL / NON-MEDICAL USE OF OR CRIMINAL INVOLVEMENT WITH DRUGS/CONTROLLED SUBSTANCES:
In this section, disclose all illegal drug use, (or criminal involvement) prescription or otherwise. Prescribed drug use for medical purposes will be
disclosed in a different portion of the application process.
TYPE OF DRUG
HAVE YOU EVER SOLD,
SMUGGLED, OR TRANSPORTED
FOR SALE OR PERSONAL GAIN?
HAVE YOU EVER USED,
POSSESSED OR
EXPERIMENTED WITH?
IF YES, NUMBER OF TIMES
USED, POSSESSED OR
EXPERIMENTED WITH?
TOTAL
LIFETIME
USE
DATE LAST
USED
UNDER AGE
21
AGE 21 AND
OVER
MARIJUANA (in any form)
Yes No Yes No
COCAINE/CRACK
Yes No Yes No
METHAMPHETAMINE
/SPEED/ADDERALL
Yes No Yes No
HEROIN
Yes No Yes No
OPIUM
Yes No Yes No
LSD/ACID/ECSTASY
Yes No Yes No
PEYOTE/MESCALINE
Yes No Yes No
STEROIDS/
TESTOSTERONE/HGH
Yes No Yes No
ANY OTHER ILLEGAL
DRUG OR NARCOTIC
Yes No Yes No
ILLEGAL USE OF
PRESCRIPTION DRUGS
Yes No Yes No
ANY USE OF OTHER’S
PRESCRIPTIONS
Yes No Yes No
SYNTHETIC/DESIGNER
DRUGS (Spice, K2, etc.)
Yes No Yes No
35. IF YOU ANSWERED YES, ON ANY OF THE AREAS IN QUESTION #34, PROVIDE A FULL EXPLANATION ON THE CONTINUATION SHEET.
INCLUDE, IF APPLICABLE, THE FOLLOWING:
a. How the drug was ingested, consumed or topically applied,
b. The duration of usage,
c. The motivation for use,
d. How the drug was obtained,
e. Why you stopped using the drug,
f. Any other factors you believe are relevant (i.e., Name of Drug).
36. CRIMINAL CONDUCT (includes detected and undetected crimes)
a. Have you ever committed a felony or an offense which would be a felony if committed in this state?
b. Have you ever committed a criminal offense involving dishonesty, theft (i.e., shoplifting), unlawful sexual conduct or
physical violence?
If YES to either 36a or 36b, provide a full explanation on the Continuation Sheet.
Yes No
Yes No
37. Are you now, or have you ever been a member of any foreign or domestic organization, association, movement, group or
combination of persons which has adopted or shows a policy of advocating the commission of force or violence to deny
other persons their rights under the Constitution of the United States of America or the state of Arizona; or which seeks to
alter the form of government of the United States of America by unconstitutional means?
If YES, provide a full explanation on the Continuation Sheet.
Yes No
38. Do you have any knowledge or information, in addition to that specifically required in this questionnaire, which is or may
be relevant, directly or indirectly, to an investigation of your eligibility or fitness for the position you are seeking? This
includes but is not limited to character traits, temperance habits, employment, education, subversive activities, family
associations or traffic violations?
If YES, provide a full explanation on the Continuation Sheet.
Yes No
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
Applicant Meets Drug Standards
Applicant Does Not Meet Drug Standards
ACIC / ACCH Checked
Criminal History Check Completed and Documented NCIC / III Checked
Name:
SSN #:
AZ POST Form PH (July 2019) Page 8 of 10
39. DO YOU HAVE PRIOR PEACE OFFICER CERTIFICATION / EMPLOYMENT IN ARIZONA OR ANY OTHER STATE(S)?
Yes
No
If YES, provide the following information:
DATES OF EMPLOYMENT
CITY STATE
NAME OF AGENCY
From
To
a. If prior Arizona certification, attach verification of most current AZ POST continuing training, proficiency training, and firearms qualifications.
b. Have you ever been the subject of an internal investigation, resigned during an investigation or resigned to avoid an
investigation?
If YES, provide a full explanation on the Continuation Sheet.
Yes No
c. Has your peace officer certification been revoked, suspended, canceled or denied for any reason?
If YES, provide a full explanation on the Continuation Sheet.
Yes No
d. Have you, while on duty as a peace officer and without authorization, used or been under the influence of spirituous
liquor?
If YES, provide a full explanation on the Continuation Sheet.
Yes No
e. Have you received discipline for any improper conduct as a peace officer? Discipline: Letter of reprimand/counseling,
suspension, termination or demotion.
If YES, provide a full explanation on the Continuation Sheet.
.
Yes No
40. Have you applied with any law enforcement agencies?
If YES, please provide ALL Agencies and Positions. Use Continuation Sheet if Necessary
Yes No
Name of Agency Position Date of Application Was Polygraph taken?
Yes No
Yes No
Yes No
Yes No
41. CERTIFICATION:
I hereby certify under penalty of law that the entries on this statement and the attached Continuation Sheet are
true, complete and correct to the best of my knowledge and belief. These entries are made in good faith. I
understand that a false or misleading statement on this form constitutes a violation of the law and is cause to
deny, suspend or revoke peace officer certification.
SIGNATURE OF APPLICANT:
DATE:
AGENCY VERIFICATION:
INITIALS:
DATE:
INITIALS:
Previous Agencies Applied to Queried and Results
Documented
Certification History Verified and Results Documented
Training and Firearms Requirements Documentation on
file
Valid Certification Verified and Documentation on file
Improper Conduct Researched and Documentation on file Fingerprint Card Submitted - AZ DPS
Signature and Date Completed Fingerprint Card Submitted - FBI
Name:
SSN #:
AZ POST Form PH (July 2019) Page 9 of 10
Arizona Peace Officer Standards and Training Board
STATEMENT OF PERSONAL HISTORY AND
APPLICATION FOR CERTIFICATION
CONTINUATION SHEET
Please list the applicable question number for each entry made on this page. Use the space provided to complete answers for previously asked
questions or for necessary explanation and clarification.
Question
Number
Explanation, Clarification, etc.
Name:
SSN #:
AZ POST Form PH (July 2019) Page 10 of 10
Name: ____________________________
SSN #: ____________________________
Agency: ___________________________
AGENCY VERIFICATION OF APPLICANTS
QUALIFICATIONS AND DOCUMENTATION
PLEASE
INITIAL
Page 1
Code of Ethics read, signed and dated
Page 2
Authorization for Release of Information fully completed and notarized
Page 3
Agency verification completed, and results documented in file
Page 4
Agency verification completed, and results documented in file
Page 5
Agency verification completed, and results documented in file
Page 6
Agency verification completed, and results documented in file
Page 7
Agency verification completed, and results documented in file
Page 8
Agency verification completed, and results documented in file
Lateral Applicants - Prior Agency personnel file reviewed for past performance and / or prior misconduct
Applicant has applied with other agencies - inquiry completed with agency to determine status and/or
disqualifiers identified
Inconsistent information from applicant during background process, including polygraph, corrected by applicant on
AZPOST PH form.
Applicant meets minimum qualifications and documentation is complete and in file.
Applicant does not meet minimum qualifications. Application Process Terminated
Reason for Disqualification
Medical Examination completed and in file and applicant meets standards
Medical Examination completed and in file and applicant does not meet standards.
M.E. and M.H. forms properly completed and in file.
F.B.I. / D.P.S. record checks completed and in file and no record found.
F.B.I. / D.P.S. record checks completed and in file and reflects arrest record.
F.B.I. / D.P.S. record checks have been submitted, no return yet.
NCIC / III / ACIC / ACCH records check completed and in file and no record found.
NCIC / III / ACIC / ACCH records check completed and in file and record found.
Polygraph completed and report in file and applicant passed.
Polygraph completed and report in file and applicant failed.
Applicant meets all requirements and may be employed.
Applicant does not meet all requirements. Application Process Terminated
Reason for Disqualification
AGENCY CERTIFICATION:
I hereby certify that I have reviewed this application for completeness and the required documentation in accordance with
R13-4-106(C)(7) and hereby attest that this person meets minimum qualifications for appointment, has not engaged in
conduct or a pattern of conduct that would jeopardize public trust in the law enforcement profession, is of good moral
character and have completed this report to document that finding.
NAME OF REVIEWER:
TITLE:
SIGNATURE OF REVIEWER:
DATE:
AUDITED BY AZ POST BY (name):
ON (date):
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Arizona Peace Officer Standards and Training Board STATEMENT (Arizona)

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Completed 20 July 2020

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