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.
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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 _______________________
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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
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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
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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
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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.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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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: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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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: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________
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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: _______________________________________________________________________
__________________________________________________________________________________
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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: ___________________________
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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: _____________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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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.
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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.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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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:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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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 ___