Fill - Free fillable CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION MEDICAL (Brunswick Community College) PDF form

Page 1 F-1(LE) Rev. 6/11

CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION

CRIMINAL JUSTICE STANDARDS DIVISION

Post Office Drawer 149, Raleigh, NC 27602

Telephone: (919) 661-5980

Fax (919) 779-8210

MEDICAL HISTORY STATEMENT Form F-1(LE)

(Rev. 6/11)

This information is for official use only and will not be released to unauthorized persons.

Payment for services rendered is the responsibility of the hiring agency or the individual.

The Criminal Justice Standards Division is NOT responsible for payment.

Mail form to hiring agency or individual

DO NOT mail form to Criminal Justice Standard Division

Instructions:

To be completed by applicant for a certifiable position prior to the physical examination and presented to the examining qualified

medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to practice medicine in North Carolina), or

Physician and/or Surgeon authorized to practice medicine in accordance with the rules and regulations of the U.S. Armed Forces,

at the time of examination [12 NCAC 9B .0104(a)]. All questions must be answered completely and accurately. The original or a

copy must be retained in personnel files by the appointing agency.

Date: _____________________

Name: _________________________________________________________ Date of Birth: _____________________

Last First Middle

Address: ____________________________________________________________________________________________

City: ___________________________________ State: ___________________ Zip Code: _____________________

Telephone: ___________________________________ Last 4 Digits of SSN: ______________________________

Current Medications

Prescription Medications: (Include pain relievers, birth control pills, etc.)

______________________________________________________________________________________________________________

Over the Counter Medications: ( Include all cold allergy, headache, vitamins, supplements, herbal remedies, etc.)

______________________________________________________________________________________________________________

Allergies

Drug Allergies: (Include your reaction to the mediation)

______________________________________________________________________________________________________________

All Other Allergies: food, insects, seasons, animals, materials, etc. (Include reaction)

______________________________________________________________________________________________________________

Page 4 F-1(LE) Rev. 6/11

Explanation of any “Yes” answers: (Identify by number)

Additional pages may be attached and must include your name, the last four digits of your social security number, and must

be signed and dated.

________________________________________________________________________________________________

Penalty:

Any falsification, withholding or failure to answer all questions completely and accurately may disqualify you from receiving

or retaining employment or certification as a criminal justice officer. Falsification regarding pre-existing conditions may

disqualify you from receiving benefits from your employer.

Certification:

I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and

answers to questions, and that all statements and answers are true and correct to the best of my knowledge and belief.

______________________________________________ _______________________________________

Signature of Applicant (Use Ink) Date Signed

Qualified Medical Professional Review:

______________________________________________

_______________________________________

Signature of Qualified Medical Professional Date Reviewed

(Use Ink)

Name, Title and Address of qualified medical professional completing review – Please Type.

Page 1 Form F-2(LE) rev. 3/16

CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION

CRIMINAL JUSTICE STANDARDS DIVISION

Post Office Drawer 149, Raleigh, NC 27602

Telephone: (919) 661-5980

Fax (919) 779-8210

MEDICAL EXAMINATION REPORT Form F-2(LE)

(Rev. 3/16)

This information is for official use only and will not be released to unauthorized persons.

Payment for services rendered is the responsibility of the hiring agency or the individual.

The Criminal Justice Standards Division is NOT responsible for payment.

Mail form to hiring agency or individual

DO NOT mail form to Criminal Justice Standard Division

Instructions:

To be completed by a qualified medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to

practice medicine in North Carolina, or Physician and/or Surgeon authorized to practice medicine in accordance with the rules

and regulations of the U.S. Armed Forces, [12 NCAC 9B .0104(a)], following an actual physical examination. The original or a

copy of this report must be retained in personnel files by the appointing agency.

Date: __________________________ Last 4 Digits SSN: _______________

Name: ___________________________________________________ Date of Birth: _____________________

Last First Middle

Employing Agency: __________________________________________________________________________

Height: ___________________ Weight: ________________

Vision

Visual Acuity: If applicant wears glasses or contacts, test and record acuity with and without glasses

Without glasses: R - 20 / ______________ L- 20 / ____________ Both - 20 / _______________

With glasses: R - 20 / ______________ L- 20 / ____________ Both - 20 / _______________

With contacts: R - 20 / ______________ L- 20 / ____________ Both - 20 / _______________

How long have contacts been worn? ________________

Color Perception: Normal Abnormal: _______________________________________________

Peripheral Vision: Normal Abnormal: _______________________________________________

Hearing

Hearing Acuity: Audiogram or 15' whispered conversation (check one)

Right ear: Normal Abnormal: ___________________________________________________

Left Ear: Normal Abnormal: ____________________________________________________

Page 3 Form F-2(LE) rev. 3/16

Tuberculosis Risk Questionnaire

1) Were you born outside the USA in one of the following parts of the world: Yes No

Africa, Asia, Central America, South America or Eastern Europe?

2) Have you traveled outside the USA and lived for more than one month in one

of the following parts of the world: Africa, Asia Central America, South America Yes No

or Eastern Europe?

3) Do you have a compromised immune system such as from any of the following

conditions: HIV/AIDS, organ or bone marrow transplantation, diabetes, Yes No

immunosuppressive medicines (e.g. prednisone, Remicade), leukemia, lymphoma,

cancer of the head or neck, gastrectomy or jejeunal bypass, end-stage renal disease

(on dialysis), or silicosis?

4) Have you ever done one of the following: used crack cocaine, injected illegal drugs,

worked or resided in jail or prison, worked or resided at a homeless shelter, or worked Yes No

as a healthcare worker in direct contact with patients?

5) Have you ever been exposed to anyone with infectious tuberculosis? Yes No

Tuberculosis Symptom Questionnaire

Do you currently have any of the following symptoms?

1) Unexplained cough lasting more than 3 weeks Yes No

2) Unexplained fever lasting more than 3 weeks Yes No

3) Night sweats (sweating that leaves bedclothes and sheets wet) Yes No

4) Shortness of breath Yes No

5) Chest Pain Yes No

6) Unintentional weight loss Yes No

7) Unexplained fatigue (very tired for no reason) Yes No

F-3(LE)

Rev. 12.2.13

NORTH CAROLINA CRIMINAL JUSTICE

E

DUCATION AND TRAINING STANDARDS COMMISSION

CRIMINAL JUSTICE STANDARDS DIVISION

It is the determination of the Commission that these questions are necessary in

order to fully and adequately evaluate applicants for law enforcement and

criminal justice certification. These questions are designed to ascertain whether

the applicant meets the minimum standards for certification and serve no other

purpose.

PERSONAL HISTORY STATEMENT

NOTE: This form is not designed for use as an initial application for employment

and must not be used for that purpose. Rather, the applicant for a CERTIFIED

position should complete this form prior to beginning his/her background

investigation. This form should only be completed by applicants for a

Commission-certified position.

F-3(LE) Rev. 12.2.13

2

NORTH CAROLINA

CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION

PERSONAL HISTORY STATEMENT

INSTRUCTIONS: Using the online form or legibly printing in ink fill out this form completely and accurately. If you

need extra space, add additional pages and identify the information by item number. If an item does not apply to you,

indicate by entering N/A in the blank.

NOTE: All statements are subject to verification and any incorrect statements or omissions may bar or remove you from

certification. Truthful statements to any item requested will not necessarily exclude you from consideration.

THIS FORM MUST BE NOTARIZED UPON COMPLETION.

NOTE: The Social Security Number is used to make positive identification of applicant and/or law enforcement

personnel. DISCLOSURE IS VOLUNTARY. However, failure to provide this information may result in a delay in the

processing of application materials and may result in inaccurate records being assigned to you.

Position(s) applied for: ________________________________________________________________________

Agency: _____________________________________ Month: _________ Day: _______ Year: ______

PERSONAL

1. Name: __________________________________________ 2. Social Security Number: ______________

First Middle Last

Maiden Name: ___________________________________________________________________

Other Previous Last Names: ________________________________________________________________

Nicknames or Aliases: ___________________________________________________________________

Has your name been legally changed after age 12? Yes No

If yes, submit documentation with date and attach to this form.

3. Present Mailing ____________________________________________________________________

Address: Street & Number City County State Zip Code

Permanent Mailing ____________________________________________________________________

Address: Street & Number City County State Zip Code

Telephone Number: ____________________________ ______________________________________

(Include Area Code) Home Work

Cell Phone: ________________________________ Email Address: ______________________________

4. Date of Birth: _______________________________ 5. Place of Birth: _____________________________

6. Citizenship: U.S. Born U.S. Naturalized Other – Specify _______________________

F-3(LE) Rev. 12.2.13

3

NOTE: Data solicited in this box will be used for Equal Employment statistical purposes only.

7. Ethnic Background

American Indian Spanish American

Asian American White

Black Other ______________________

8. Sex Male Female

9. Have you previously submitted an application for employment with this agency?

Yes No Approximate Date: _________________________________________________

EDUCATIONAL

10. Indicate below the schools you have attended. (Include incomplete courses)

Indicate the type of High School you attended:

Traditional Home School

Distance Learning Did not attend high school Other: _____________________________

Name

Address (City & State)

No. Full

Yrs Work

Completed

When

Attended

Graduated

(Yes/No)

Degree

Awarded

Major

Field

High Schools

Universities or

Colleges

Extension or

Correspondence

Courses

11. If you did not graduate from high school, have you passed the General Educational Development (GED) Test?

Yes No If yes, when and where did you complete the GED?

_________________________________________________________________________________________

NOTE: Questions included in the next section are intended to assist in the conducting of a background investigation and

are not intended for use by the employing agency as disqualifying factors for employment as a criminal justice officer.

MARITAL

12. Marital Status (check one) Single Married Divorced

Engaged Separated Widowed

F-3(LE) Rev. 12.2.13

4

13. Name of Spouse: _________________________________________________________________________

Name of Former Spouse(s): _________________________________________________________________

________________________________________________________________

14. List all of your children, including any adopted or stepchildren.

Name

Birth Date

Relationship

Address

Phone Number

(1).

(2).

(3).

(4).

(5).

(6).

FAMILY HISTORY

15. Are you related by blood or marriage to any person(s) now employed by this agency? Yes No

If yes, give name(s) and details:

_________________________________________________________________________________________

16. Is any member(s) of your immediate family now in prison or on either probation or parole? Yes No

If yes, give name(s) and details:

_________________________________________________________________________________________

RESIDENCES

17. List every city/county in which you have lived since attaining the age of 16, with present address at top:

From

Mo/Yr

To

Mo/Yr

Address of Residence

City County State

Landlord

F-3(LE) Rev. 12.2.13

5

FINANCIAL

18. What income other than salary do you have at present? ____________________________________________

_________________________________________________________________________________________

19. List all businesses you currently own or have financial interest in (do not list any stocks and bonds): _______

_________________________________________________________________________________________

20. Are you now supporting all children born to you, adopted by you and stepchildren?

Yes No If not, give details: __________________________________________________

_________________________________________________________________________________________

21. Are there persons, other than your spouse and listed children, who are presently dependent upon you for

support? Yes No If yes, give name and details: ____________________________________

_________________________________________________________________________________________

22. Have you ever been sued with a civil judgment being rendered against you? Please note this includes

repossessions, evictions, executions, failure to pay child support, etc. (Do not include divorce)

Yes No Not sure (explain) If yes, give details: _____________________________________

_________________________________________________________________________________________

23. What is the total amount of all your debts at present? $ __________________________________________

24. What is the average monthly total of all of your bills, payments, and current living expenses? $ ___________

25. List credit references, including creditors to which you make monthly payments:

A. _________________________________________________ Amount Owing $ ________________

Name of Business

___________________________________________________________________________________

Street Address City and State

B. _________________________________________________ Amount Owing $ ________________

Name of Business

___________________________________________________________________________________

Street Address City and State

C. _________________________________________________ Amount Owing $ ________________

Name of Business

___________________________________________________________________________________

Street Address City and State

F-3(LE) Rev. 12.2.13

6

D. _________________________________________________ Amount Owing $ ________________

Name of Business

___________________________________________________________________________________

Street Address City and State

E. _________________________________________________ Amount Owing $ ________________

Name of Business

___________________________________________________________________________________

Street Address City and State

F. _________________________________________________ Amount Owing $ ________________

Name of Business

___________________________________________________________________________________

Street Address City and State

WORK HISTORY

26. Have you ever been denied employment by a law enforcement agency, corrections agency, or security

agency which required certification or licensure from any Commission, Board or Agency after a conditional

offer of employment was made?

Yes No If yes, list agency name and give details: _________________________________

_________________________________________________________________________________________

27. Have you ever held a position in any capacity which required certification or licensure from any Commission, Board

or Agency established to certify or license that position? (Note: List any such Commission, Board, or Agency,

whether in or out of North Carolina.) Yes No

27a. If yes, was such certification or license ever suspended, revoked, or any sanctions taken against it by the

issuing authority? Yes No

27b. If such certification or license was ever suspended, revoked, or any sanctions taken against it by the

issuing authority, please list the agency’s name taking the action against the certification or license, date

of the action, reason for the action, and the period of time for the suspension, revocation, or sanction.

_______________________________________________________________________________

F-3(LE) Rev. 12.2.13

7

28. Have you ever been discharged, requested to resign, or allowed to resign in lieu of termination, from any position

because of criminal or personal misconduct or rules violations?

Yes No If yes, list organization name and give details: ___________________________________

_________________________________________________________________________________________

__________________________________________________________________________________

29. Do you object to wearing a uniform? Yes No

30. Do you object to working nights? Yes No

31. Do you object to working rotating shifts? Yes No

32. Do you object to occasionally being away from home overnight and for other periods of time attending meetings,

acquiring training and otherwise performing official duties?

Yes No

33. List ALL jobs, positions or appointments you have held in the last ten years to include temporary, part-time, paid or

not paid employment, active or inactive reserve, and internships. Put your present or most recent job first. List a

Reason for Leaving for each job. Include military service in proper time sequence and temporary part-time jobs. If

there are gaps in your employment please provide an explanation for each period of unemployment.

A. Title of present or last position _______________________________________________________________

Employer Address and Phone Number _________________________________________________________

Name Phone Number

________________________________________________________________________________________

Street City State Zip Code

Date Employed _______________ Starting Salary ____________ Last Salary _____________________

Date Separated _______________ Name/Title of Supervisor ______________________________________

Full Time ___ Yrs _____ Mos Part Time ____ Yrs ____ Mos

If part time, number of hours worked per week _________ No. employees supervised by you ___________

Duties: __________________________________________________________________________________

________________________________________________________________________________________

F-3(LE) Rev. 12.2.13

8

Reason for leaving: _______________________________________________________________________

__________________________________________________________________________________

B. Title of present or last position _______________________________________________________________

Employer Address and Phone Number _________________________________________________________

Name Phone Number

________________________________________________________________________________________

Street City State Zip Code

Date Employed _______________ Starting Salary ____________ Last Salary _____________________

Date Separated _______________ Name/Title of Supervisor ______________________________________

Full Time ___ Yrs _____ Mos Part Time ____ Yrs ____ Mos

If part time, number of hours worked per week _________ No. employees supervised by you ___________

Duties: __________________________________________________________________________________

________________________________________________________________________________________

Reason for leaving: _______________________________________________________________________

__________________________________________________________________________________

C. Title of present or last position _____________________________________________________________

Employer Address and Phone Number _________________________________________________________

Name Phone Number

________________________________________________________________________________________

Street City State Zip Code

Date Employed _______________ Starting Salary ____________ Last Salary _____________________

Date Separated _______________ Name/Title of Supervisor ______________________________________

Full Time ___ Yrs _____ Mos Part Time ____ Yrs ____ Mos

If part time, number of hours worked per week _________ No. employees supervised by you ___________

Duties: __________________________________________________________________________________

________________________________________________________________________________________

_________________________________________________________________________________

F-3(LE) Rev. 12.2.13

9

Reason for leaving: ____ ___________________________________________________________________

__________________________________________________________________________________

D. Title of present or last position _______________________________________________________________

Employer Address and Phone Number _________________________________________________________

Name Phone Number

________________________________________________________________________________________

Street City State Zip Code

Date Employed _______________ Starting Salary ____________ Last Salary _____________________

Date Separated _______________ Name/Title of Supervisor ______________________________________

Full Time ___ Yrs _____ Mos Part Time ____ Yrs ____ Mos

If part time, number of hours worked per week _________ No. employees supervised by you ___________

Duties: __________________________________________________________________________________

________________________________________________________________________________________

Reason for leaving: _______________________________________________________________________

__________________________________________________________________________________

E. Title of present or last position _______________________________________________________________

Employer Address and Phone Number _________________________________________________________

Name Phone Number

________________________________________________________________________________________

Street City State Zip Code

Date Employed _______________ Starting Salary ____________ Last Salary _____________________

Date Separated _______________ Name/Title of Supervisor ______________________________________

Full Time ___ Yrs _____ Mos Part Time ____ Yrs ____ Mos

If part time, number of hours worked per week _________ No. employees supervised by you ___________

Duties: __________________________________________________________________________________

________________________________________________________________________________________

Reason for leaving: _______________________________________________________________________

__________________________________________________________________________________

F-3(LE) Rev. 12.2.13

10

F. Title of present or last position _______________________________________________________________

Employer Address and Phone Number _________________________________________________________

Name Phone Number

________________________________________________________________________________________

Street City State Zip Code

Date Employed _______________ Starting Salary ____________ Last Salary _____________________

Date Separated _______________ Name/Title of Supervisor ______________________________________

Full Time ___ Yrs _____ Mos Part Time ____ Yrs ____ Mos

If part time, number of hours worked per week _________ No. employees supervised by you ___________

Duties: __________________________________________________________________________________

________________________________________________________________________________________

Reason for leaving: ________________________________________________________________________

__________________________________________________________________________________

G. Explain Periods of unemployment of three months or more. _________________________________________

_________________________________________________________________________________________

MILITARY SERVICE

34. Were you ever in the U.S. Military Service or any other military organization? Yes No

Were you ever denied entrance into the military? Yes No If yes, why?__________________________

____________________________________________________________________________________________

_____________________________________________________________________________________

QUESTIONS 35 THROUGH 43 ARE APPLICABLE ONLY TO VETERANS

35. What is your service number? _______________________________________________________________

36. What was the highest rank that you held? _______________________________________________________

37. What was the last rank that you held? __________________________________________________________

38. What was the date and location of your first enlistment or commission? Date: ___________________________

F-3(LE) Rev. 12.2.13

11

39. List each tour of active duty where a DD-214 was issued:

Branch

Unit (Company or Ship)

Location

From

Mo./Yr.

To

Mo./Yr.

40. List all duty stations:

Branch

Unit (Company or Ship)

Location

From

Mo./Yr.

To

Mo./Yr.

41. Have you ever received any of the following types of discharge:

Uncharacterized Yes No

Honorable Yes No

General (Under honorable conditions) Yes No

Under other than honorable conditions Yes No

Bad Conduct Discharge Yes No

Dishonorable Discharge Yes No

Dismissal Yes No

42. Were you ever court-martialed, tried on charges, or the subject of a summary court, deck court, non-

judicial punishment, captain’s mast, company punishment, article 15, and/or any other disciplinary

action while a member of the military, national guard or reserve unit?

Yes No If yes, explain what occurred and what type of punishment you received: _____________

_________________________________________________________________________________________

43. List all medals and decorations awarded you during your military service: _____________________________

_________________________________________________________________________________________

F-3(LE) Rev. 12.2.13

12

44. If you are presently a member of the National Guard or any military reserve, give the unit, location, and describe your

obligation:

_________________________________________________________________________________________

USE OF ALCOHOL OR DRUGS

45. Do you drink alcoholic beverages? Yes No

NOTE: In questions 46, and 47, the word ‘used’ means “one time or more, including experimentation.” If any answer

is yes, give full and complete details. (Attach extra sheets if necessary.)

46. Have you ever used, to include tasting, any illegal drugs including but not limited to, marijuana, steroids, opiates,

pills, heroin, cocaine, crack, LSD, designer or synthetic drugs, etc., to include even one-time use or experimentation?

Yes No I don’t know (explain below)

If yes, what were the circumstances, drugs used, and when did the usage last occur?

_________________________________________________________________________________________

When was the last time? _____________________________________________________________________

_________________________________________________________________________

47. Have you ever used prescription drugs other than under the supervision of, or as prescribed by, a physician?

Yes No I don’t know (explain below)

If yes, what were the circumstances, drug(s) used, and when did the usage last occur?

_________________________________________________________________________________________

48. Have you ever purchased, possessed, manufactured, grown, delivered or sold any amount of illegal drugs or

controlled substances for which you did not have a valid prescription? Yes No I don’t know

(explain below)

If yes, identify the drug(s) and provide details concerning the purchase, possession, manufacture, growth, delivery, or

sale.

_________________________________________________________________________________________

CRIMINAL OFFENSE RECORD AND DISCIPLINARY ACTIONS

NOTE: Answer all of the following questions completely and accurately. Any falsifications or misstatements of fact may

be sufficient to disqualify you. If any doubt exists in your mind as to whether or not you were arrested or charged with a

criminal offense at some point in your life or whether an offense remains on your record, you should answer “Yes.” You

must list any and all criminal charges regardless of the date of offense and the disposition (to include dismissals, not

guilty, nol pros, PJC, or any other disposition where you entered a plea of guilty). Juvenile charges or arrests should also

be listed.

Include all offenses other than minor traffic offenses. Specifically include DWI, DUI, driving while under the influence

of drugs, driving while license permanently revoked, speeding to elude arrest, or duty to stop in event of accident.

Attached to this form is an additional list of North Carolina traffic offenses which must be listed.

F-3(LE) Rev. 12.2.13

13

You must include any and all convictions regardless of whether or not the convictions were expunged pursuant to

NCGS 15A-145.4 and 15A-145.5. If you list a charge(s), please attach certified and true copies of warrant(s) and

judgment(s) for each offense, even if documentation and charges have previously been reported to this agency.

49. Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense?

(The term “charged” as used in this question includes being issued a criminal citation or summons.)

Yes No If yes, give details below:

A. Offense Charged ____________________________ Law Enforcement Agency _____________________

Date ____________________________ Disposition of Case _____________________

B. Offense Charged ____________________________ Law Enforcement Agency _____________________

Date ____________________________ Disposition of Case _____________________

C. Offense Charged ____________________________ Law Enforcement Agency _____________________

Date ____________________________ Disposition of Case _____________________

(ATTACH EXTRA SHEETS, IF NECESSARY)

50. Have you ever had a Domestic Violence Protection Order issued against you?

(Include both ex-parte Domestic Violence Protective Orders and those entered subsequent to a hearing.)

Yes No

Date of Issuance: ______________________________________________________________________

County of Issuance: _____________________________________________________________________

Name of Plaintiff: ______________________________________________________________________

Date of expiration: ______________________________________________________________________

51. Under federal law you may be disqualified to receive or possess a firearm if you meet any of the following conditions:

(a) currently under Indictment or Information in any court for a crime punishable by imprisonment for a term

exceeding one year.

(b) have been convicted in any court of a crime punishable by imprisonment for a term exceeding one year. A person

would not be ineligible under this criteria if the person has been pardoned for the crime or conviction, the crime or

conviction has been expunged or set aside, or the person has had his/her civil rights restored, and under law where

the conviction occurred the person is not prohibited from receiving or possessing any firearm.

(c) are a fugitive from justice.

(d) are an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or any other

controlled substance.

(e) have been adjudicated mentally defective or have been involuntarily committed to a mental institution.

(f) have been discharged from the Armed Forces under dishonorable conditions.

(g) are illegally in the United States.

(h) have renounced your citizenship, having previously been a citizen of the United States.

NOTE: A “crime punishable by imprisonment for a term exceeding one year” as discussed in (a) and (b) above is

defined in federal law so as to exclude most misdemeanors in North Carolina.

If any of the above (a through h) apply, please note below and submit an explanation on a separate sheet of paper

which accompanies this form. Your signature on the attestation found on page 15 of this document indicates you have

read this section and understand each of the disqualifiers.

_________________________________________________________________________________________

F-3(LE) Rev. 12.2.13

14

52. Have you been convicted of a misdemeanor under federal or state law which has, as an element, the use or attempted

use of physical force or threatened use of a deadly weapon?

Yes No I don’t know (explain below) If so, did you commit the act(s) against a current or former spouse,

parent, or guardian or against a person with whom you were or are cohabiting with or a person similarly situated to a

spouse, parent, or guardian of the victim (Domestic Violence Offense)?

Yes No

Offense Charged: _________________________________________________________________

Law Enforcement Agency _________________________________________________________________

Date: _________________________________________________________________

Disposition _________________________________________________________________

53. Have you ever been charged with a felony? (including any charges expunged pursuant to NCGS 15A-

145.4 and 15A-145.5.)

Yes No If yes, give details:

_________________________________________________________________________________________

54. Have you ever been placed on probation? Yes No If yes, give details:

_________________________________________________________________________________________

55. Do you possess a valid driver’s license from the State of North Carolina? Yes No

Driver’s License Number _____________________________ Year Issued _________________________

56. Do you now possess, or have you ever possessed a driver’s license issued by any state other than North

Carolina? Yes No

If yes, give state and number ______________________________________________________________

57. Was your driver’s license ever suspended or revoked? Yes No If yes, state which and give

reasons:

_________________________________________________________________________________________

58. Was your driver’s license ever restored? Yes No When? ________________________

59. Have your driving privileges ever been restricted? Yes No If yes, give details:

_________________________________________________________________________________________

CAREER OBJECTIVES

60. Briefly explain your reasons for applying for this position:

_________________________________________________________________________________________

F-3(LE) Rev. 12.2.13

15

61. List special skills, training, fields of work for which you are licensed, registered, or certified, and hobbies which may

be useful in the performance of the duties of the position for which you have applied:

_________________________________________________________________________________________

62. What are your feelings about the use of deadly force it if became necessary in the performance of official duties?

_________________________________________________________________________________________

REFERENCES

63. Give the names of five responsible persons, other than relatives or past employers, who could provide information

about your character, ability, experience, personality, and other qualities.

Name

Address

Telephone

A.

B.

C.

D.

E.

STATE OF NORTH CAROLINA

COUNTY OF ___________________

I hereby certify that each and every statement made on this form is true and complete and understand that any

misstatement or omission of information will subject me to disqualification or dismissal. I also acknowledge that I have a

continuing duty to update all information contained in this document. I will report to the employing agency and forward to

the NC Criminal Justice Education and Training Standards Commission any additional information which occurs after the

signing of this document.

This the _______ day of ______________, 20 ___ ______________________________________________

(Signature in Full)

Subscribed and sworn before me,

this the _______ day of _______________, 20 ___

______________________________________

Notary Public (Official Seal)

My Commission Expires: _____________, 20 ___

1

EXCERPT FROM CLASS B MISDEMEANOR MANUAL OF TRAFFIC OFFENSES WHICH ARE NOT MINOR

20-28

Driving while license permanently revoked (20-28(b)[(b) Repealed]

10/1/94 -11/12/96

1

20-28(d)(3)

Driving while license permanently revoked (3

rd

offense)

5/31/02-Present

1

20-30(5)

Fictitious name or address in any application for a driver’s license or learner’s permit

(20-35)

5/31/02-Present

2

20-37.7(e)

Special identification card (fraud or misrepresentation in application of or use thereof)

01/01/06-Present

2

20-37.8

Fraudulent use of a fictitious name for a special identification card (20-37.8(b))

[NOTE: violations of 20-37.8(b) became felonious eff. 12/1/99]

10/1/94-12/1/99

2

20-37.8

Fraudulent use of a fictitious name for a special identification card (20-37.8(c))

5/31/02-Present

2

20-63(g)

Registration of plates furnished by the Division, etc. (alteration, disguise, or

concealment of numbers)

01/01/06-Present

2

20-71.4

Failure to disclose damage to a vehicle

01/01/06-Present

2

20-102.1

False report of theft or conversion of a motor vehicle

10/1/94-Present

2

20-111(5)

Fictitious name or address in application for registration

10/1/94-Present

1

20-130.1

Use of red or blue lights on vehicles prohibited (20-130.1(e))

10/1/94-Present

1

20-136.2

Air bag installation

01/01/06-Present

1

20-137.2

Operation of vehicles resembling law-enforcement vehicles (20-137.2(b))

10/1/94-Present

1

20-138.1

Driving while impaired (punishment level 1; 20-179(g) or 2 (20-179(h))

10/1/94-5/31/02

M

20-138.1(d)

Driving while impaired (punishment level 1; 20-179(g) or 2 (20-179(h))

5/31/02-Present

M

20-138.2

Impaired driving in commercial vehicle (20-138.2(e))

10/1/94-Present

M

20-141(j)

At least 15 mph over; trying to elude arrest

[NOTE: Repealed paragraph (j) eff. 12/1/97; recodified under 20-141.5(a)]

10/1/94-12/1/97

1

20-141.3(a) & (c)

Unlawful racing on streets and highways

11/12/96-Present

1

20-141.5(a)

Speeding to elude arrest

11/17/99-Present

1

20-157(h)

Duty to Move Over

01/01/06-Present

1

20-166(b)

Duty to stop in event of accident or collision

10/1/94-Present

1

20-166(c)

Duty to stop in event of accident or collision

10/1/94-Present

1

20-166(c1)

Duty to stop in event of accident or collision

10/1/94-Present

1

20-183.8(b1)

Inspection violation by Inspector

3/1/11-Present

3

20-279.31(b)(1)

Other violation; penalties (gives information required in a report of a reportable

accident, knowing/having reason to believe information is false)

01/01/06-Present

1

20-279.31(b)(2)

Other violations; penalties (forges or without authority signs any evidence of proof of

financial responsibility)

01/01/06-Present

1

20-279.31(b)(3)

Other violations; penalties (forges/offers for filing any evidence of proof of financial

responsibility, knowing/having reason to believe that evidence is forged/signed

without authority)

01/01/06-Present

1

20-313.1

Making false certification or giving false information

01/01/06-Present

1

20-371

Regulation of professional house moving [increased punishment from Class 3 to Class

1 misdemeanor]

3/1/11-Present

1

*Note that violations of 20-138.1 Driving While Impaired (punishment levels 3, 4 & 5) are considered Class A

Misdemeanor and should also be listed in response to number 49.

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Fillable CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION MEDICAL (Brunswick Community College)

Fill Online, Printable, Fillable, Blank CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION MEDICAL (Brunswick Community College) Form

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