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 2 F-1(LE) Rev. 6/11
Past Medical History
List ALL hospitalizations and operations since childhood:
(Include type of surgery, date of surgery, any complications or other significant information)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Have you EVER, in your life, had any of the following types of medical problems? [check all that apply to you]
1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia?
2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever and others?
3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe headache, skull fracture,
recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington=s chorea,
peripheral neuropathy and others?
4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post traumatic
stress disorder and others?
5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma,
blindness in one or both eyes, very poor vision when not corrected and others?
6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection,
Meniere=s disease, moderate to severe hearing loss in one or both ears and others?
7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long
lasting infections and others?
8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic
or long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator
and others?
9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or
lung abscess and others?
10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, hypertension
(high blood pressure) irregular rhythm, valve abnormalities, varicose veins, phlebitis, peripheral vascular
disease, Raynaud=s disease and others?
11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of
colitis, Crohn=s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall
stones, stomach or intestinal bleeding and others?
12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal
problems and others?
13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single
functioning kidney, polycystic kidney disease, repeated bladder infections and others?
14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias?
15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain, numbness fibromyalgia, back
or neck disk disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, carpal tunnel
syndrome loss of a finger or toe, and others?
16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell
abnormality and others?
(Continued on next page)
Page 3 F-1(LE) Rev. 6/11
Males Only:
17. Prostate problems such as enlargement or prostatitis?
18. Genital problems such as epididymitis or testicular injury?
Females Only:
19. Currently pregnant?
20. History of endometriosis, pelvic inflammatory disease, abnormal Pap smear, PMS or other problem with your
menstrual cycle?
Immunizations
21. Have you ever had a positive TB test?
22. Have you received Hepatitis B vaccinations?
23. When did you receive your last tetanus (lockjaw) immunization? __________________________________
Occupational History
Have you ever been exposed to any of the following, whether at home, work, military or any other setting? [check all that
apply]
24. Repetitive Loud Noises (Including guns, jet engines, loud machinery)?
25. Chemical exposure to skin or lungs?
26. Dusty conditions (sandblasting, grinding, mining or drilling of rock, coal, silica, asbestos)?
Check all YES answers:
27. Have you ever sustained an injury while at work that necessitated extended care by a health care provider?
28. Have you ever had a motor vehicle accident or other injury event causing back or neck pain?
29. Are you limited or unable to perform any physical activity because of muscle or joint discomfort?
30. Do you have any missing limbs or non-functional joints?
31. Do you have numbness, weakness, or pain in your upper extremities (including your hands)?
32. Have you ever been advised by a physician to avoid sitting or standing over a certain time?
33. Have you ever worked in law enforcement?
33a.If yes, have you ever missed more than three consecutive days of work for any medical or psychological
problem?
34. Have you ever served in any of the armed forces?
34a.If yes, have you ever missed more than three consecutive days or service for any medical or psychological
problem?
35. Do you have any medical condition that would prevent you from working extended shift periods, rotating shifts,
or night shifts?
36. Do you have difficulty sitting for any extended period of time?
37. Have you ever been advised by a physician to avoid lifting above a certain weight limit?
38. Do you have any difficulty in properly holding, aiming or firing a handgun, rifle or shotgun?
39. Do you have any difficulty driving at high speeds in a motorized vehicle?
40. Have you ever had an automobile accident while driving over sixty (60) miles per hour?
41. Have you ever had any automobile accidents as a result of losing control of your vehicle?
42. Do you have any difficulty driving for three (3) consecutive hours without stopping?
43. Do you have any difficulty running for five (5) consecutive minutes without stopping?
44. Have you ever passed out, temporarily lost control of any part of your body, or had blackout spells (episodes you
do not remember)?
(Continued on reverse side)
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 2 Form F-2(LE) rev. 3/16
Cardiovascular
Blood Pressure: ____________________ Resting Pulse: ____________________
Cardiac Examination: Normal Abnormal: ________________________________________________
Peripheral Circulation: Normal Abnormal: ________________________________________________
ECG: Indicated by hx or exam: __________________ (If resting pulse is less than 50 or greater than 100)
Abnormal Findings
HEENT: Normal Abnormal ______________________________________________________________
Lungs: Normal Abnormal ______________________________________________________________
Abdomen: Normal Abnormal ______________________________________________________________
Musculoskeletal: Normal Abnormal ______________________________________________________________
Genitourinary: Normal Abnormal ______________________________________________________________
Neurological: Normal Abnormal ______________________________________________________________
Skin: Normal Abnormal ______________________________________________________________
Urinalysis Normal Abnormal ______________________________________________________________
TB Risk Questionnaires Administered: Yes No Additional Screening Required: Yes No
Specify Additional Screening: ________________________________________________________________________
Are there any conditions, physical, emotional or mental, which, in your opinion, suggest further examination?
No Yes:
Do you have any reservations about this candidate’s ability to physically perform required duties?
No Yes:
I have read and fully understand the Medical Screening Guidelines Implementation Manual for the certification
of Criminal Justice Officers in the State of North Carolina.
___________________________________ ______________________ _____________
Signature of Qualified Medical Professional Medical License # Date
________________________________________________________________________________________________
Name and Address of Qualified Medical Professional (Please Type)
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: _____________________________
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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