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HALTOM CITY POLICE DEPARTMENT
LAW ENFORCEMENT CENTER
5110 Broadway Avenue
Haltom City, Texas 76117-3640
(817) 222-7000 Fax (682) 647-1686
September 12, 2020
Congratulations on passing the written and physical fitness examination!
The next step for each applicant is to complete the entire Personal History Statement (PHS). Please read
the instructions carefully before completing the packets. Incomplete background packets can result in
failure to move on to the next phase of hiring.
The packets MUST to be turned in at the police department no later than 1700 hours (5:00pm) on
Friday, September 25, 2020. No packets will be taken after this time. There are pages that will need
to be notarized prior to turning in the packet and the Haltom City Police Department will NOT notarize any
documents for applicants. Please write legibly. If we cannot read your writing, we cannot complete your
background. Be sure to sign and/or initial the appropriate forms. Failure to sign the documents will result
in the applicant being rejected.
The supporting documents (copies, certificates, transcripts, etc) need to be turned in with the packet. If
you are unable to acquire the documents before turning in the packets, add a note to the packet
explaining why the documents are not attached and when the documents will be provided. You will need
to submit the missing documents when you get them. We understand that certified documents cost
money and can take time to acquire. If you wish to keep the certified document(s), you may submit a copy
along with a note explaining you have possession of the certified document. However, you must be able
to produce the certified document(s) during the interview process.
If your address or phone number changes during the process, please let us know. If you wish to withdraw
from the process, please send notice in writing of your withdrawal.
Do not call and ask for the status of your background. This may result in your removal from the
process.
The steps for the hiring process include: background investigation, preliminary interview, oral board,
polygraph, psychological evaluation, medical exam, and an interview with the Chief.
If you need any additional information, please contact me at (817) 222-7029.
Respectfully,
Detective M. Spillane
mspillane@haltomcitytx.com
817-222-7029
HALTOM CITY POLICE DEPARTMENT
PERSONAL HISTORY PACKET
Police Officer Applicant
Name:
Phone Number:
Work/School Schedule:
This completed packet must be returned or
postmarked by: September 25, 2020
Send to:
Haltom City Police
Attn: Detective Spillane
5110 Broadway Ave.
Haltom City, TX 76117
Issued: September 12, 2020
1
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Issued: September 12, 2020
Haltom City Police Department Personal History Statement
3
Applicant Qualification Section
Before you begin to fill out this personal history statement, please ensure that you meet the following
requirements. You must meet all five of these requirements to qualify for licensure as a police officer,
detention officer, or telecommunicator in the State of Texas.
Initial:
______ I am a citizen of the United States of America.
______ I have earned a high school diploma or a GED.
______ I have never been convicted, plead guilty (nolo contendere), nor have I been on
court-ordered community service/probation or deferred adjudication for a Class A
misdemeanor or a felony.
______ During the last ten (10) years, I have not been convicted, plead guilty (nolo
contendere), been on community service/probation or deferred adjudication for a Class B
misdemeanor in this state, other state, or while serving in the military.
______ I have never had a military court martial that resulted in a dishonorable or bad
conduct discharge.
DISQUALIFICATION
There are very few automatic basis for rejection. Even issues of prior misconduct, employee
terminations, and arrests are usually not, in and of themselves, automatically disqualifying. However,
deliberate misstatements or omissions can and often will result in your application being rejected,
regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason
individuals “fail” background investigations is because they deliberately withhold or misrepresent
job-relevant information from their prospective employer.
This personal history statement is a governmental document. Be truthful, as there are criminal
consequences for lying on a governmental document.
Issued: September 12, 2020
Personal History Statement
4
Haltom City Police Department
Applicant Identification Section
The information in this section is used for identification purposes.
Last Name: ______________________________ First Name: ______________________________________
Middle Name: ___________________________ Maiden Name: ___________________________________
Street Address: _____________________________________________________________________________
City, State, and Zip Code: ____________________________________________________________________
Home Telephone: ________________________ Cell Phone: ______________________________________
Work Telephone: ________________________ Primary Email: ___________________________________
Additional Emails: __________________________________________________________________________
Date of Birth: ___________________________ Race: ______________ Sex: ___________________
Drivers License Number and State: _____________________________________________________________
Social Security No.: ______________________ Place of Birth: ___________________________________
Are you a US Citizen by Birth? [ ] Yes [ ] No Are you a naturalized US Citizen? [ ] Yes [ ] No
Height: __________ Weight: ______________ Hair Color: _____________ Eye Color: _______________
Texas Commission on Law Enforcement PID (if applicable): ________________________________________
Any additional names you’ve gone by: __________________________________________________________
Scars, identifying marks, and tattoos including description and location: _______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List all social networking sites you use: _________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
5
Marital History
Check your current status:
[ ] Single [ ] Married [ ] Engaged [ ] Divorced [ ] Widowed [ ] Co-habiting
Spouse’s/Co-habitant‘s Name (include maiden name):
Street Address
City, State, and Zip Code: ______________________________________________________________
Date of Birth: ___________________ Date of Marriage
Home Telephone: ________________________ Cell Phone: ________________________________
Work Telephone: ________________________ Primary Email: _____________________________
Employer(s)
Employer Address
If you have been divorced, provide details below.
Former Spouse’s Name (include maiden name): ___________________________________________________
Street Address
City, State, and Zip Code: ______________________________________________________________
Date of Birth: Date of Marriage
Home Telephone: ________________________ Cell Phone: ________________________________
Primary Email: __________________________ Date of Divorce: ____________________________
Court and State Where Divorce Issued: ____________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
6
Family History
Identify children related to you or your spouse (including natural, step-children, adopted, or foster children).
Name/Relationship
Date of
Birth
Complete Address
Telephone
Email Address
Identify all immediate family members (including those related by marriage) including parents, step parents,
brothers, and sisters.
Name/Relationship
Date of
Birth
Complete Address
Telephone
Email Address
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
7
Residential History
Identify all residences where you have lived within the last ten (10) years beginning with the most
recent (current) address. Include military assignments and apartment numbers.
From
(Month/Year)
To
(Month/Year)
Street Address
City, State, Zip Code
Present
Have you ever been evicted or asked to move from any place you lived? [ ] Yes [ ] No
Identify all non-family members you currently reside with.
Full Name
Date of
Birth
Dates of
Cohabitation
Telephone
Email Address
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
8
Personal References
List five (5) persons that can provide current information about you. Do not list relatives, spouses,
girlfriends/boyfriends, past or present employers, or supervisors.
Reference 1
Name: ____________________________________ Relationship: ______________________________
Occupation: ________________________________ Years Known: _____________________________
Address: ___________________________________ Phone No.: ________________________________
Alternate Phone No.: _________________________ Email: ____________________________________
Reference 2
Name: ____________________________________ Relationship: ______________________________
Occupation: ________________________________ Years Known: _____________________________
Address: ___________________________________ Phone No.: ________________________________
Alternate Phone No.: _________________________ Email: ____________________________________
Reference 3
Name: ____________________________________ Relationship: ______________________________
Occupation: ________________________________ Years Known: _____________________________
Address: ___________________________________ Phone No.: ________________________________
Alternate Phone No.: _________________________ Email: ____________________________________
Issued: September 12, 2020
Personal History Statement
9
Relationship: ______________________________
Years Known: _____________________________
Phone No.: ________________________________
Email: ____________________________________
Relationship: ______________________________
Years Known: _____________________________
Phone No.: ________________________________
Haltom City Police Department
Reference 4
Name: ____________________________________
Occupation: ________________________________
Address: ___________________________________
Alternate Phone No.: _________________________
Reference 5
Name: ____________________________________
Occupation: ________________________________
Address: ___________________________________
Alternate Phone No.: _________________________
Email: ____________________________________
Identify any employees of the Texas Commission on Law Enforcement with whom you are acquainted:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
Personal History Statement
10
Haltom City Police Department
Traffic Record
Identify all vehicles that you currently own, lease, and/or operate:
Year
Make
Model and Body
Style
Color
License Plate
and State
Owner
What company carries your automobile insurance policy? ___________________________________________
Policy Number: _____________________________ Expiration: ________________________________
Have you ever possessed a driver’s license issued by any state other than Texas? [ ] Yes [ ] No
Other State Driver’s License No.: ________________________ State: ______________________________
Other State Driver’s License No.: ________________________ State: ______________________________
Have you ever had your driver’s license suspended or revoked? [ ] Yes [ ] No
If yes, give reason, date, and length of suspension: _________________________________________________
__________________________________________________________________________________________
Have you ever driven a motor vehicle while your driver’s license was suspended or revoked? [ ] Yes [ ] No
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
11
Identify all motor vehicle accidents you have been involved in during the last 10 years.
Date
Location
Cause of Accident
Police Report?
Your Fault?
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
List all traffic citations you have received within the last 10 years, excluding parking tickets.
Date
Violation (include alleged speed
an speed limit if applicable)
Issuing Agency
Disposition (e.g., defensive
driving, dismissed)
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
12
Arrests, Detentions, and Litigation
Have you ever been arrested or detained by law enforcement? [ ] Yes [ ] No
If yes, complete the following table:
Agency
Offense
Date
Location
Outcome
Have members of your immediate family or close relatives have ever been arrested? [ ] Yes [ ] No
If yes, complete the following table:
Name/Relationship
Outcome
Year
Agency
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
13
If you answer yes to any question in this section, include an explanation with date, charge, police agency
investigating, disposition, and penalty.
Have you ever committed an act of family violence? (“Family violence” means an act by a
member of a family or household against another member of the family or household that is
intended to result in physical harm, bodily injury, assault, or sexual assault or that is a threat
that reasonably places the member in fear of imminent physical harm, bodily injury, assault, or
sexual assault, but does not include defensive measures to protect oneself.) (Texas Family
Code Section 71.004)
[ ] Yes [ ] No
Have you ever assaulted another person since the age of seventeen (17)? (“Assault” means to
cause bodily injury to another, threaten another with imminent bodily injury, or to cause
physical contact with another when the person knows or should reasonably believe that the
other will regard the contact as offensive or provocative.) (Texas Penal Code Section 22.01)
[ ] Yes [ ] No
Have you ever been considered or named a suspect in a criminal investigation or criminal
offense?
[ ] Yes [ ] No
Have you ever been a party to a civil suit or action?
[ ] Yes [ ] No
Have you ever been involved in any incident (do not include vehicular accidents) in which a
police report was made or law enforcement was called?
[ ] Yes [ ] No
Other than crimes that would have been sealed by juvenile records, have you ever committed –
or assisted another person in the commission of – a felony crime, serious misdemeanor, or a
crime involving moral turpitude that went undetected or unreported to law enforcement?
[ ] Yes [ ] No
Do you anticipate being sued or named in any type of lawsuit or proceeding?
[ ] Yes [ ] No
Have you ever been the respondent of a protective order?
[ ] Yes [ ] No
Explanation for any “Yes” answers above, including dates: _______________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
14
Financial History
Your current net monthly income: __ Spouse’s current net monthly income: ___
Sources of Income for You or Spouse (indicate which)
Amount
Frequency
Do you have any accounts with a financial institution? [ ] Yes [ ] No
Name(s) of financial institution(s) and types of accounts: ___________________________________________
__________________________________________________________________________________________
Identify any person or entity to whom you are indebted, and the extent of your indebtedness. Include
mortgages, vehicle payments, charge accounts, credit cards, loans, child support payments, and any other debts
or payments.
Name of Creditor (e.g., Sears, Citi
financial)
Type of Debt (e.g., student loan,
automobile)
Monthly
Payment
Approx
Balance
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
15
If you answer yes to any question in this section, include a complete explanation to include dates.
Have you ever filed bankruptcy personally or on behalf of a business?
[ ] Yes [ ] No
Have you ever had any personal or real property repossessed or foreclosed?
[ ] Yes [ ] No
Have you ever failed to pay Federal, state, or other taxes?
[ ] Yes [ ] No
Have you ever failed to file a tax return, when required by law?
[ ] Yes [ ] No
Have you ever had a lien placed against your property for failing to pay taxes or other debts?
[ ] Yes [ ] No
Have you ever had a judgment entered against you?
[ ] Yes [ ] No
Have you ever defaulted on any type of loan?
[ ] Yes [ ] No
Have you ever had bills or debts turned over to a collection agency?
[ ] Yes [ ] No
Have you ever had any credit account suspended, charged off, or cancelled for failure to pay?
[ ] Yes [ ] No
Have you ever written a check that was later returned for Non Sufficient Funds (NSF)?
[ ] Yes [ ] No
Have you ever been delinquent on court-imposed alimony or child support payments?
[ ] Yes [ ] No
Have you ever been disciplined regarding the use of a travel/credit card provided by an
employer?
[ ] Yes [ ] No
Are you currently more than sixty (60) days delinquent on any debts?
[ ] Yes [ ] No
Have you ever applied for unemployment compensation?
[ ] Yes [ ] No
Have you ever received unemployment compensation?
[ ] Yes [ ] No
Explanation for any “Yes” answers above, including dates: _______________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
16
Identify any person or entity to which you are more than 30 days late in paying. Include mortgages, vehicle
payments, charge accounts, credit cards, loans, child support payments, and any other debts or payments.
Name of Creditor (e.g.,
Sears, Citi financial)
Type of Debt (e.g., student
loan, automobile)
Number of
Days Late
Reason
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
17
Employment History
Beginning with your present or most recent job, list all employment since the age of seventeen (17). Include
full-time, part-time, temporary, seasonal, military assignments, or unpaid internships, plus all periods of
unemployment.
If you are currently employed, may we contact your present employer? [ ] Yes [ ] No
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
1. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
18
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
2. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
19
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
3. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
20
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
4. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
21
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
5. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
22
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
6. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
23
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
7. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
24
Check Appropriate Job Type(s): [ ] Full [ ] Part [ ] Temporary [ ] Seasonal [ ] Volunteer [ ] Internship
8. Employer: From: To:
Employer’s Full Address:
Job Title: _____________________________________ Employer Phone No.: ________________________
Beginning Salary: ______________________________ Ending Salary: _____________________________
Work Schedule: ________________________________ Name of Supervisor: ________________________
Supervisor Phone No.: __________________________ Supervisor Email: ___________________________
Name of co-worker: ____________________________ Co-worker Phone No.
Co-worker Email: _____________________________ Eligible for Rehire? [ ] Yes [ ] No [ ] Unknown
Duties: ___________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
25
List any period of unemployment since the age of 18 (a period of unemployment is any time you did not
have a job).
From
(Month/Year)
To
(Month/Year)
Reason
If you answer yes to any question in this section, include a complete explanation to include dates.
Have you ever been terminated from employment for any reason?
[ ] Yes [ ] No
Have you ever resigned in lieu of termination?
[ ] Yes [ ] No
Have you ever resigned because you suspected you were going to be terminated or disciplined?
[ ] Yes [ ] No
Have you ever collected unemployment or welfare benefits, including food stamps, when you
were not entitled to them?
[ ] Yes [ ] No
Have you ever failed to report to work without contacting your employer?
[ ] Yes [ ] No
Have you ever quit a job without 2 weeks notice?
[ ] Yes [ ] No
Have you ever taken money, merchandise, materials, equipment, etc. from an employer without
their direct permission?
[ ] Yes [ ] No
Explanation for any “Yes” answers above, including dates: _______________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
26
Educational History
Check highest grade completed: [ ] High School Diploma [ ] GED
Check all education earned: [ ] Some College [ ] Associate’s [ ] Bachelor’s [ ] Master’s [ ] Ph.D.
Identify all high schools you have attended:
High School(s)
Attended
Address
Dates Attended
From-To
Graduated
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
Identify all colleges, universities, or technical schools you have attended regardless if you earned a degree:
Name
City & State
Dates Attended
Hours
Completed
Degree/Major
Were you ever expelled from school? [ ] Yes [ ] No
If yes, give details: __________________________________________________________________________
__________________________________________________________________________________________
List any awards, honors, or other academic achievements related to your education: ______________________
__________________________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
27
Military Obligation
Have you ever served in the U.S. Armed Forces or State Military? [ ] Yes [ ] No
Have you ever been rejected by any branch of the U.S. Armed Forces or State Military? [ ] Yes [ ] No
Branch of Service: ________________________ Unit: ___________________________________________
Service Dates: ___________________________ Highest Rank held: ________________________________
Job Title(s): _____________________________ Duty Stations: ___________________________________
__________________________________________________________________________________________
Discharge: [ ] Honorable [ ] General [ ] Other than Honorable [ ] Bad Conduct [ ] Dishonorable
Are you actively serving in a Reserve Unit (including State Military Forces)? [ ] Yes [ ] No
Service Dates: ___________________________ Current Rank Held: _______________________________
Branch of Service: _______________________ Unit: ___________________________________________
Job Title(s): ____________________________ Duty Stations: ___________________________________
__________________________________________________________________________________________
Have you ever been subject to court martial or any other disciplinary proceeding under the Uniform Code of
Military Justice? (Include non-judicial, Captain's mast, etc.) [ ] Yes [ ] No
If "Yes," provide dates, charges, military courts or authorities, and outcomes. ___________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
28
Special Qualifications and Skills
Identify any special licenses you hold (e.g., pilot, radio operator, concealed handgun): _________________
__________________________________________________________________________________________
If you know a foreign language, indicate your fluency in each block below (excellent, good, fair).
Language
Understanding
Speaking
Reading
Writing
Do you have any experience with firearms? [ ] Yes [ ] No
Explain your experience with firearms including what weapons systems you are familiar with: ______________
__________________________________________________________________________________________
_________________________________________________________________________________________________
Memberships and Organizations
Name & Address
Type (e.g., social,
fraternal, professional)
From
(Month/Year)
To
(Month/Year)
If you answer “Yes” to any of the below questions, please include a detailed explanation, including dates
of involvement.
Have you ever been an officer or a member of, or made a contribution to, an organization that
advocates or practices the commission of acts of force or violence to discourage others from
exercising their rights under the U.S. Constitution or right granted by law.
[ ] Yes [ ] No
Have you ever been involved with, funded or supported a terrorist cell or organization
designated a terrorist group by the United States or any other government?
[ ] Yes [ ] No
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
29
Law Enforcement Applications and Service
List all law enforcement agencies that you have applied for (to include municipal, county, state, federal,
other governmental, or private law enforcement agency). In addition, list position you applied for, the
steps in the application process you have complete, and the status of the application. Attach an additional
page if you need to list more agencies.
Date
Appplied
Law Enforcement Agency and
Position
Steps Completed
Application Status
Written
Test
PT
Test
Oral
Board
Back-
ground
Poly-
graph
Psycho-
logical
Hired
On
List
Disqu-
alified
Are you currently a licensed as a Texas peace officer by TCOLE?
[ ] Yes [ ] No
Are you currently a licensed peace officer in another state?
[ ] Yes [ ] No
Has your TCOLE license ever been denied or revoked?
[ ] Yes [ ] No [ ] N/A
Have you ever attended a police academy?
[ ] Yes [ ] No
Police Academy Name: ____________________________________________________
Police Academy Address: __________________________________________________
Police Academy Dates: ____________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
30
Personal Declarations
If you answer yes to any question in this section, include a complete explanation to include dates.
Have you provided alcohol to a minor (under 21) who was not your child?
[ ] Yes [ ] No
Have you ever operated a motor vehicle while intoxicated on alcohol or drugs?
[ ] Yes [ ] No
In the past five years, what it the maximum number of times you have operated a motor vehicle while
intoxicated on drugs or alcohol? _________ times
Are there any incidents in your life, or details not mentioned herein, which may influence this department’s
evaluation of your suitability for employment as a police officer? [ ] Yes [ ] No
If yes, please explain: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
31
Complete the following chart regarding drug usage. Usage includes ingestion of the drug into your system by
any means (regardless if it had any effect) including: snort, sniff, inject, smoke, oral, or absorbed through any
means. When asked for the maximum number of times you have used the drug, give the absolute maximum
number of times you might have used the drug.
Type of Drug
Ever Used?
Maximum
Times
Used
Date First
Used
(Month/Year)
Date Last
Used
(Month/Year)
Ever Sold,
Manufactured,
or
Transported?
Any prescription drug not
prescribed to you:
_____________________
[ ] Yes [ ] No
[ ] Yes [ ] No
Any prescription drug not
prescribed to you:
_____________________
[ ] Yes [ ] No
[ ] Yes [ ] No
Marijuana
[ ] Yes [ ] No
[ ] Yes [ ] No
Hashish, Hash Oil, THC
[ ] Yes [ ] No
[ ] Yes [ ] No
K2, Synthetic Marijuana
[ ] Yes [ ] No
[ ] Yes [ ] No
Cocaine, Crack
[ ] Yes [ ] No
[ ] Yes [ ] No
Heroin, Black Tar, Cheese
[ ] Yes [ ] No
[ ] Yes [ ] No
Methamphetamine,
Amphetamine, Ecstasy
[ ] Yes [ ] No
[ ] Yes [ ] No
PCP
[ ] Yes [ ] No
[ ] Yes [ ] No
Hallucinogens, LSD, Acid,
Mushrooms
[ ] Yes [ ] No
[ ] Yes [ ] No
Barbiturates, Quaaludes,
Benzodiazepines, Xanax,
GHB
[ ] Yes [ ] No
[ ] Yes [ ] No
Inhalants
[ ] Yes [ ] No
[ ] Yes [ ] No
Anabolic Steroids
[ ] Yes [ ] No
[ ] Yes [ ] No
Any illegal drug not listed
here:
____________________
[ ] Yes [ ] No
[ ] Yes [ ] No
Do you consume alcohol?
[ ] Yes [ ] No
If “Yes”, how often? ________________________________________________________________________
Issued: September 12, 2020
Haltom City Police Department Personal History Statement
32
In 200-500 words, why do you think you should be considered for the position you have applied for?
_________________________________________________________________________________________
_
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Issued: September 12, 2020
33
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Issued: September 12, 2020
City of Haltom City
Notice of Disclosure & Consumer Consent
(Related to Fair Credit Reporting Act)
Consumer Information (Applicant/Employee/Volunteer/Vendor/Solicitor)
The information you provide below will be used solely for the purpose of obtaining consumer reports for employment or business-related purposes. The
City of Haltom City will not use this information for any reason that violates applicable Federal or State equal employment opportunity laws or
regulations.
Legal Name: Social Security #: Date/Birth:
Home Address: City: ST: Zip:
Driver’s License # Type: Operator Commercial Other Class: A B C Other State/Issued:
Current employee applying for new position. Name of New Position:
Volunteer applying for position. Hosting Dept: Name of Position:
Other Employment or Business-Related Activity. Description:
Disclosure Requirements
In compliance with the Fair Credit Reporting Act (FRCA), the City of Haltom City is notifying you as a consumer that information
provided by you on the City’s employment applications or other similar documents may be verified using “consumer reports” provided
by a “consumer reporting agency” (CRA) for employment purposes or other legitimate business-related purposes. The City of Haltom
City has contracted with a number of CRA’s to verify certain information provided by you for employment or business-related purposes.
Under FCRA, “employment purposes” means a report used for evaluating a consumer for employment, promotion, reassignment, or
retention as an employee. “Business-related purposes” includes volunteer applicants, vendors/solicitors, license/permit applicants, or
others performing business-related services related to the City.
As defined in FCRA 603 (d) (1) (A), “consumer reports” include, but are not limited to, written communications from CRA’s reflecting an
applicant’s financial position, character, general reputation, personal characteristics or mode of living for employment purposes.
Examples of “consumer reports” that the City may use include, but are not limited to verifications and/or information on the following:
motor vehicle records, criminal and civil records, credit reports, education records, prior employment, and other public documents.
Your employment, continued employment, or affiliation with the City of Haltom City may be determined in whole or in part by the City
using data from consumer reports supplied by various CRA’s. Pursuant to section 609 of the FCRA, you may be entitled to a copy of
the consumer reports provided by the CRA.
In compliance with the FCRA, the City of Haltom City agrees information obtained through CRA’s will not be used in violation of any
applicable Federal or State equal employment opportunity law or regulation.
Consumer Acknowledgement and Consent
I understand and agree that one or more consumer reporting agencies will verify all or part of the information I have given the City of
Haltom City in employment applications, telephone conversations, interviews, or by other means during the application process for
employment, volunteer opportunities, licenses/permits, or other similar legitimate business-related activities. I understand that this
verification may include an inquiry into my credit history, motor vehicle driving records, criminal and civil records, prior employment
(including contacting prior employers), education (degree, GPA and attendance) as well as other public record information.
I release and hold harmless from all liability any individual or entity, including the City of Haltom City and the CRA’s it uses, for
requesting or supplying information with respect to my application for employment or other legitimate business-related purpose. If
employed or accepted by the City, I understand that this document will remain valid throughout my employment and/or affiliation with
the City. I agree that this document constitutes proper legal notice of FCRA disclosures and authorizes my consent to perform checks
related to my employment or business affiliation with the City.
I authorize and consent to the release of such information as may be necessary to verify the information I have provided. I am
also aware, and do further consent and authorize the City of Haltom City to use this information to evaluate my candidacy for
employment, my continued employment, or my affiliation with the City of Haltom City.
Printed/Typed Name of Consumer Signature of Consumer Date
For City of Haltom City Human Resources Use Only
CRA’s Used/Date Submitted: 1
st
Notice (Pre-Adverse Action Disclosure) Sent? Yes, date: N/A
2
nd
Notice (Adverse Action Notice) Sent? Yes, date: N/A
Issued: September 12, 2020
HALTOM CITY POLICE DEPARTMENT
5110 Broadway Avenue
Haltom City, TX 76117
Phone (817) 222-7029
Fax (682) 647-1686
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize the City of Haltom City and its authorized representatives bearing this release, or a copy thereof, within one year of
its date, to obtain any information in your files pertaining to my employment, military, credit, education or medical records, including
but not limited to academic, achievement, attendance, athletic, personal history, and disciplinary records, medical records, and credit
records.
I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and
understanding that the information is for official use. Consent is granted to all parties to furnish such information, as described above,
to third parties in the course of fulfilling its official responsibilities. I hereby release you, as custodian of such records, and any school,
college, university, or other educational institutions, hospital, or other repository of medical records, credit bureau, lending institution,
consumer reporting agency, or retail business establishment including its officers, employees, or related personnel, both individually
and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or
associates because of compliance with this authorization and request to release information, or attempt to comply with it.
I am furnishing my Social Security Number on a voluntary basis with the understanding such is not required by any law or regulation. I
have been advised that all parties will utilize this number only to facilitate the location of employment, military, credit, and educational
records concerning me in connection with this application. Should there be any question as to the validity of this release, you may
contact me as indicated below:
Applicant’s Printed Full Name:
Address:
Telephone Number:
Applicant’s Notarized Signature:
Sworn to and signed before me on this the ______ day of _______________, 20____, in and for ____________ County, in the
state of _________________.
NOTARY SEAL Signature of Notary Public:
Printed name of Notary Public:
My commission expires:
HALTOM CITY POLICE DEPARTMENT
PROFESSION STANDARDS UNIT
CONFIDENTIAL INFORMATION AGREEMENT FORM
A thorough investigation will be conducted to determine your qualifications for employment with the Haltom City
Police Department. To a great extent, your employment will depend on information obtained in confidential
interviews with persons with whom you have been associated. Therefore, such information is confidential and the
Department cannot reveal the reason for rejection to those applicants who are not accepted. If the reasons for you
non-acceptance are of a temporary nature whereby you could be accepted at a later date, you will be notified.
I have read and fully understand the above statement.
Signature of Applicant:
Date:
THE STATE OF TEXAS
COUNTY OF TARRANT
BEFORE ME, the undersigned authority, a Notary Public in and for said County and State, on this day personally
appeared ______________________________, known to me to be the person whose name is subscribed to the
foregoing instrument, and acknowledged to me that he executed the same for the purpose and consideration therein
expressed.
Sworn to and signed before me on this the ______ day of _______________, 20___, in and for _____________
County, in the state of _______________.
NOTARY SEAL Printed Name of Notary:
Signature of Notary:
10/17
APPLICANT/CONTRACTOR CONSENT AND AUTHORIZATION TO RETAIN FINGERPRINTS
The Department of Public Safety (DPS) and Federal Bureau of Investigation (FBI) retain fingerprints to
provide notification to agencies of future events to the criminal history record at the state and national
level. In order for each applicant to participate in the Fingerprint-based Applicant Clearinghouse of
Texas (FACT) and “Rap Back” (notification services), please have each applicant provide the following
information:
Last Name First Name M.I. Maiden Name if Applicable
Date of Birth Last four SSN DL/ID# Employee/License# if Applicable
I certify that all information I provided in relation to this criminal history record check is true and
accurate. I authorize the Texas Department of Public Safety (DPS) to access Texas and Federal criminal
history record information that pertains to me and disseminate that information to the designated
agency with which I am or am seeking to be employed or to serve as a volunteer, through the DPS
Fingerprint-based Applicant Clearinghouse of Texas and as authorized by Texas Government Code
Chapter 411 and any other applicable state or federal statute or policy, including 28 U.S.C. 534 and 34
U.S.C. 41101.
I authorize the Texas Department of Public Safety to submit my fingerprints and other application
information to the FBI for the purpose of comparing the submitted information to available records in
order to identify other information that may be pertinent to the application. I authorize the FBI to
disclose potentially pertinent information to the DPS during the processing of this application and for as
long hereafter as may be relevant to the activity for which this application is being submitted. I
understand that the FBI may also retain my fingerprints and other applicant information in the FBI’s
permanent collection of fingerprints and related information, where all such data will be subject to
comparisons against other submissions received by the FBI and to further disseminations by the FBI as
may be authorized under the Privacy Act of 1974 (5 USC 552a). I understand my fingerprints will be
searched by and against civil, criminal and latent fingerprints in the Next Generation Identification (NGI)
system. I understand I am entitled to obtain a copy of any criminal history record check and challenge
the accuracy and completeness of the information before a final determination is made by the relevant
agency. I also understand the agency may deny me access to children, the elderly, or individuals with
disabilities until the criminal history record check is completed. If a need arises to challenge the FBI
record response, you may contact the agency that submitted the information to the FBI, or you may
send a written challenge request to the FBI's Criminal Justice Information Services (CJIS) Division at FBI
CJIS Division, Attention: Correspondence Group, 1000 Custer Hollow Road, Clarksburg, WV 26306.
Signature Date
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HALTOM CITY POLICE DEPARTMENT

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Completed 9 February 2021

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