Fillable Instructions to the Applicant (Town of Boxborough)

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Instructions to the Applicant (Town of Boxborough)

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BROWSE TOWN OF BOXBOROUGH (MA) FORMS

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Boxborough Police Department
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 1 of 26
Initi
al this page to indicate that you have read the instructions: _____
Instructions to the Applicant
• The information you provide in this Personal History Statement will be used in the background investigation to assist
in determining your suitability for the position of Police Officer, in accordance with the Rules and Regulations of the Boxborough
Police Department.
• Upon completion of this form, please scan and e-mail to wobrien@boxborough-ma.gov (preferred) or print the form and send the
signed original to the above address; Attention: Lieutenant Warren J. O'Brien. Type or neatly print in ink, responses to all items
and questions. If a question does not apply to you, write “N/A” (not applicable) in the space provided for your response. If you
cannot obtain or remember certain information, indicate so in your response.
• If you need more space for any response, use page 25 of this form and identify the additional information by the question number.
Disqualification
There are so
me automatic reasons for rejection. However, even issues of prior misconduct, such as prior illegal drug use, theft or
even arrest or conviction are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or
omissions will result in your application being rejected, regardless of the nature or reason for the misstatements or omissions. In fact,
the number one reason individuals “fail” background investigations are because they deliberately withhold or misrepresent job-
relevant information from their prospective employer.
BOTTOM LINE: Be as complete, honest and specific as possible in your responses.
Disclosure of Medically-Related Information
In accordance with the U.S. Americans with Disabilities Act at this stage of the hiring process applicants are not expected or
required to reveal any medical or other disability-related information about themselves in response to questions on this form.
Boxborough Police Department
520 Massachusetts Avenue
Boxborough, MA 01719
Under M.G.L. Chapter 149, Section 19B it is unlawful for an employer to require any person to take a lie detector (polygraph) as a
condition of employment.
Under M.G.L. Chapter 41, Section 101A, no person who smokes any
tobacco product shall be eligible for appointment as a police
officer.
Signature of Candidate acknowledging the above two references to lie detectors and smoking
_______________________________________________
click to sign
signature
click to edit
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 2 of 26 Boxborough Police Department
Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 1: PERSONAL
1. YOUR FULL NAME
LAST
1. YOUR FULL NAME
FIRST
1. YOUR FULL NAME
MIDDLE
2. OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOWN BY
3. ADDRESS WHERE YOU RESIDE
NUMBER / STREET APT / UNIT
CITY STATE ZIP
4. MAILING ADDRESS, IF DIFFERENT FROM ABOVE
5. CONTACT NUMBERS
HOME ( )
WORK ( )
EXT
CELL FAX PAGER
6. EMAIL ADDRESS
HOME BUSINESS
7. If you were born outside of the United States, are you a U.S. citizen? .............................................................................................. Yes No
If no, are you a resident alien who is eligible and has applied for U.S. citizenship?........................................................................... Yes No
8. BIRTH PLACE (CITY / COUNTY / STATE / COUNTRY)
9. BIRTHDATE
10. SOCIAL SECURITY NUMBER
– –
11. DRIVER’S LICENSE
12. PHYSICAL DESCRIPTION
NO.
STATE
EXP
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
SECTION 2: RELATIVES AND REFERENCES
13. IMMEDIATE FAMILY
• Provide all applicable information in the spaces below.
• Mark “N/A” if a category is not applicable or if the individual is deceased.
• If more space is needed, continue your response on page 25.
N/A
A. Father
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
N/A
B. Step-father
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
N/A
C. Mother
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 3 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES
continued
13. IMMEDIATE FAMILY continued
N/A
D. Step-mother
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
N/A
E. Spouse / Registered Domestic Partner
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
YEARS OF MARRIAGE
Is there, or has there been, a restraining or stay-
away order in effect for this individual?
Yes No
N/A
F. Father-in-law
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
N/A
G. Mother-in-law
NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
N/A
H. Former Spouse(s) / Former Registered Domestic Partner(s)
1) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
YEAR OF DISSOLUTION
Is there, or has there been, a restraining or stay-
away order in effect for this individual?
Yes No
2) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
YEAR OF DISSOLUTION
Is there, or has there been, a restraining or stay-away order in effect for this individual?
Yes No
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 4 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES
continued
13. IMMEDIATE FAMILY continued
N/A
I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc.
1) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
M
F
UNDER AGE 18
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
2) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
M
F
UNDER AGE 18
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
3) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
M
F
UNDER AGE 18
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
4) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
M
F
UNDER AGE 18
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
5) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
M
F
UNDER AGE 18
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
6) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
M
F
UNDER AGE 18
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
N/A
J. Children
List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you. Provide the
name and contact information of the custodial parent or guardian, if other than you.
1) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
M
F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
2) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
M
F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 5 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES
continued
13. IMMEDIATE FAMILY (Section J. Children) continued
3) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
M
F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
4) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
M
F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
5) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
M
F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
6) NAME
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
M
F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
SECTION 2: RELATIVES AND REFERENCES continued
14. CURRENT & FORMER PARTNERS (GIRLFRIENDS/BOYFRIENDS) (Section K. Partners)
1) NAME
Current Former
M
F
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
2) NAME
M
F
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
3) NAME
M
F
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
4.) NAME
M
F
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER
( )
EMAIL
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 6 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
15. REFERENCES
List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or
housemates, or other individuals listed elsewhere.
A) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)
HOW LONG HAVE YOU KNOWN THIS PERSON?
B) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)
HOW LONG HAVE YOU KNOWN THIS PERSON?
C) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)
HOW LONG HAVE YOU KNOWN THIS PERSON?
D) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)
HOW LONG HAVE YOU KNOWN THIS PERSON?
E) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)
HOW LONG HAVE YOU KNOWN THIS PERSON?
F) NAME
HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE
( )
WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
WORK PHONE
( )
CELL PHONE
( )
EMAIL
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)
HOW LONG HAVE YOU KNOWN THIS PERSON?
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 7 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 3: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.
16. Check applicable: High School Diploma from an accredited U.S. institution GED
17. List high schools attended:
A) NAME
FROM
TO
DID YOU GRADUATE?
Yes
No
CITY
STATE
B) NAME
FROM
TO
DID YOU GRADUATE?
Yes
No
CITY
STATE
18. List all colleges or universities attended:
A) NAME
FROM
TO
TOTAL UNITS EARNED
TYPE OF DEGREE
EARNED
CITY
STATE
B) NAME
FROM
TO
TOTAL UNITS EARNED
TYPE OF DEGREE
EARNED
CITY
STATE
C) NAME
FROM
TO
TOTAL UNITS EARNED
TYPE OF DEGREE
EARNED
CITY
STATE
19. List any trade, vocational, or business schools/institutes attended:
A) NAME
FROM
TO
DID YOU COMPLETE
THE COURSE?
Yes
No
TYPE OF SCHOOL OR TRAINING
CITY
STATE
B) NAME
FROM
TO
DID YOU COMPLETE
THE COURSE?
Yes
No
TYPE OF SCHOOL OR TRAINING
CITY
STATE
C) NAME
FROM
TO
DID YOU COMPLETE
THE COURSE?
Yes
No
TYPE OF SCHOOL OR TRAINING
CITY
STATE
20. Have you ever attended a Police Academy?................................................................................................................................................................................. Yes No
If yes, provide the following information:
A) ACADEMY NAME
FROM
TO
DID YOU GRADUATE?
Y N
LOCATION (CITY / STATE)
NAME OF TRAINING OFFICER / ACADEMY COORDINATOR
CONTACT NUMBER
( )
B) ACADEMY NAME
FROM
TO
DID YOU GRADUATE?
Y
N
LOCATION (CITY / STATE)
NAME OF TRAINING OFFICER / ACADEMY COORDINATOR
CONTACT NUMBER
( )
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 8 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 3: EDUCATION
continued
21. Have you ever been placed on academic discipline, suspended, or expelled from any high school, college/university,
business or trade school? .............................................................................................................................................................
Yes No
If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution. Include when the
disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
SECTION 4: RESIDENCE
22. LIST OF RESIDENCES
• List all residences during the last ten years or since age 15. Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit or
apartment number). Do not use P.O. Boxes.
• If the residence is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LIST military barracks mates unless you shared
individual quarters.
• If more space is needed continue on page 25.
A) ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT)
FROM
TO
Present
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you live:
B) FORMER ADDRESS (NUMBER / STREET / APT)
FROM
TO
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you lived:
Reason for moving:
C) FORMER ADDRESS (NUMBER / STREET / APT)
FROM
TO
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you lived:
Reason for moving:
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 9 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 4: RESIDENCE
continued
22. LIST OF RESIDENCES continued
D) FORMER ADDRESS (NUMBER / STREET / APT)
FROM
TO
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you lived:
Reason for moving:
E) FORMER ADDRESS (NUMBER / STREET / APT)
FROM
TO
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you lived:
Reason for moving:
F) FORMER ADDRESS (NUMBER / STREET / APT)
FROM
TO
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you lived:
Reason for moving:
G) FORMER ADDRESS (NUMBER / STREET / APT)
FROM
TO
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT)
CONTACT NUMBER
( )
CITY
STATE
ZIP
EMAIL
Names of those with whom you lived:
Reason for moving:
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 10 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 4: RESIDENCE
continued
23. Provide contact information for all housemates listed in Question 22 with whom you have resided during the past 10 years, or since the age of 15. DO NOT list anyone
for whom you have already provided contact information. If more space is needed, continue your response on page 25.
A) NAME
CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
B) NAME
CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
C) NAME
CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
D) NAME
CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
E) NAME
CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
F) NAME
CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)
EMAIL
24. Have you ever been evicted or asked to leave a residence? ......................................................................................................... .. Yes No
25. Have you ever left a residence owing rent? ..................................................................................................................................... Yes No
If you answered yes to Questions 24 and/or 25, explain (include when, where and circumstances):
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 11 of 26 Boxborough Police Department
In
itial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT
26. JOB EXPERIENCE
• List ALL jobs you have had, including part-time, temporary, military, self-employment and volunteer. (Begin with your most current. If more space is needed
continue your response on page 25.)
• If you have military experience, including reserve duty, enter your military base, assignments, or unit of assignment.
• List ALL periods of unemployment in excess of 30 days.
A) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR WANTING TO LEAVE
Would there be a problem if we
contact your current employer?
Yes No
IF YES, EXPLAIN:
B) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM TO
C) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
D) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM TO
E) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 12 of 26 Boxborough Police Department
I
nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT
continued
26. JOB EXPERIENCE continued
F) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM
TO
G) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
H) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM
TO
I) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
J) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM TO
K) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
L) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM TO
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 13 of 26 Boxborough Police Department
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT
continued
26. JOB EXPERIENCE continued
M) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
N) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM TO
O) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
P) PERIOD OF UNEMPLOYMENT
Check applicable: Student Between jobs Leave of absence Travel Other
FROM
TO
Q) NAME OF EMPLOYER OR MILITARY UNIT
FROM
TO
ADDRESS (NUMBER / STREET OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
JOB TITLE
EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS
1)
X
2)
REASON FOR LEAVING
27. Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling, reprimands,
suspensions, reductions in pay, reassignments or demotions) .......................................................................................................
Yes No
28. Have ever you ever been fired, released from probation, or asked to resign from any place of employment? ................................. Yes No
29. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer? .............................................. Yes No
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT
continued
30. Have you ever quit without giving proper notice? ........................................................................................................................... Yes No
31. Have you ever resigned in lieu of termination? .............................................................................................................................. Yes No
32. Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.)
by a co-worker, superior, subordinate or customer? ......................................................................................................................
Yes No
33. Were you ever the subject of a written complaint at work? ............................................................................................................ Yes No
34. Have you ever been counseled at work due to lateness or absences? .......................................................................................... Yes No
35. Did you ever receive an unsatisfactory performance review? ........................................................................................................ Yes No
36. Have you ever sold, released, or given away legally confidential information? ............................................................................... Yes No
37. Have you ever called in sick when you were neither sick nor caring for a sick family member? ...................................................... Yes No
If yes, how many sick days have you used in the past five years which were not due to illness?
If you answered yes to any of Questions 27–37, explain (include when, where and circumstances; indicate corresponding number):
38. In the past three years, have you missed days or been late to work due to drug or alcohol consumption? .................................... Yes No
If yes, how often?
39. Has your work performance ever been affected by your use of alcohol or drugs? .......................................................................... Yes No
WHEN?
NAME OF EMPLOYER
40. In the past three years, have you been warned by an employer about your drinking or drug habits and their impact on
your performance? ........................................................................................................................................................................
Yes No
WHEN?
NAME OF EMPLOYER
41. Have you ever applied to any other law enforcement agency (city, county, state or federal)? ............................................................................ Yes No
• If yes, list EVERY agency you have applied to, starting with the most recent (give complete and accurate addresses).
• All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for each agency.
•
If more space is needed, continue your response on page 25.
A) NAME OF AGENCY
DATE APPLIED
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process that you completed, and your status:
STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer
STATUS: Hired On List Withdrawn Disqualified
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT
continued
41.
Have you ever applied to any other law enforcement agency… continued
B) NAME OF AGENCY
DATE APPLIED
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process that you completed, and your status:
STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer
STATUS:
Hired On List Withdrawn Disqualified
C) NAME OF AGENCY
DATE APPLIED
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY
STATE
ZIP
CONTACT NUMBER
( )
EXT
POSITION APPLIED FOR
EMAIL
Check each step in the process that you completed, and your status:
STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer
STATUS:
Hired On List Withdrawn Disqualified
SECTION 6: MILITARY EXPERIENCE
42. Are you required to register for the Selective Service? .................................................................................................................. Yes No
If yes, have you registered? .......................................................................................................................................................... Yes No
If no, explain:
43. BRANCH OF SERVICE
44. DATES OF SERVICE
From
To
45. TYPE OF DISCHARGE:
Entry Level Honorable General OTH (Other than Honorable) Bad Conduct Dishonorable
Re-entry Code (1–4) if applicable – refer to your DD-214:
46. Are you currently participating in one of the following? Military Reserve
National Guard
If checked, date obligation ends:
47. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s mast,
office hours, company punishment)? ..............................................................................................................................................
Yes No
48. Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded? ......................................... Yes No
If you answered yes to Questions 47 and/or 48, explain (include dates and circumstances):
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 7: FINANCIAL
49. INCOME AND EXPENSES
For each of the following questions fill in the amounts to the nearest dollar.
A) From your employer(s), what is your take-home monthly income? ................................................................
...........
$ per month
B) Do you have income other than from your salary or wages? .......................................................................................................................... Yes No
If yes, fill in amount:................................................................................................................................................................
.....
$ per month
Explain:
C) How much do you spend each month? .........................................................................................
$ per month
Estimate your monthly living expenses; include housing, utilities, credit cards or other loan payments, food, gas and
car maintenance, entertainment, etc., as well as any other obligation(s) you may have.
50. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)?............................................................................................... Yes No
51. Have any of your bills ever been turned over to a collection agency?................................................................................................. Yes No
52. Have you ever had purchased goods repossessed? .......................................................................................................................... Yes No
53. Have your wages ever been garnished? ............................................................................................................................................ Yes No
54. Have you ever been delinquent on income or other tax payments? ................................................................................................... Yes No
55. Have you ever failed to file income tax or cheated/lied on an income tax form? ................................................................................. Yes No
56. Have you ever had an employment bond refused? ............................................................................................................................ Yes No
57. Have you ever avoided paying any lawful debt by moving away? ....................................................................................................... Yes No
58. Have you ever defaulted on (failed to pay) a loan? ............................................................................................................................ Yes No
60.
Have you ever borrowed money to pay for a gambling debt? ............................................................................................................. Yes No
If yes, do you currently have any outstanding debts as a result of gambling? .................................................................................... Yes No
61. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)? .............. Yes No
62. Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)? ..................... Yes No
63. Have you written three or more bad checks in a one-year period? ..................................................................................................... Yes No
If you answered yes to any of Questions 50–63, explain (include when, where, and why; indicate corresponding number):
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 17 of 26 Boxborough Police Department
Initi
al this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL
64. Either as an adult or a juvenile, have you EVER been detained for investigation, held on suspicion,
questioned, fingerprinted, arrested, indicted, criminally charged, or convicted of any misdemeanor or
felony offense in this state or in any other legal jurisdiction (including offenses punishable under
the Uniform Code of Military Justice)?
.............................................................................................................................. Yes No
If yes, explain each incident.
A) APPROXIMATE DATE
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
B) APPROXIMATE DATE
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
C) APPROXIMATE DATE
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
D) APPROXIMATE DATE
ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
65. Have you ever been placed on court probation as an adult?........................................................................................................... Yes No
66. Were you ever required to appear before a juvenile court for an act which would have been a crime if
committed as an adult? ..................................................................................................................................................................
Yes No
67.
Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity,
support, etc.)? ................................................................................................................................................................................ Yes No
68. Have the police ever been called to your home for any reason? ..................................................................................................... Yes No
69. Have you or your spouse/partner ever been referred to Child Protective Services? ........................................................................ Yes No
With regard to this section, under Massachusetts law, you may answer 'no record' if any of the following circumstances apply:
a) You have never been arrested for a violation of a criminal statue;
b) You have been arrested but have never been tried for a criminal offense;
c) You have been tried for a criminal offense but never convicted;
d) You have a first conviction of any of the following: drunkenness, simple assault, speeding, minor traffic violation,
affray, disturbance of the peace;
f) You hav
e felony or misdemeanor convictions which have been sealed pursuant to Massachusetts law;
g) You have a juvenile delinquency or child requiring assistance (formerly CHINS) complaint which was
not transferred to Superior Court for prosecution.
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL
continued
70. Have you ever been the subject of an emergency protective order/restraining order/stay-away order? .......................................... Yes No
71.
Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf was
required to make payment to the other party? ................................................................................................................................ Yes No
72. Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or other
state or federal assistance? ............................................................................................................................................................
Yes No
73. Have you ever filed a false insurance or workers’ compensation claim? ......................................................................................... Yes No
If you answered yes to any of Questions 64–73, explain (include court case or document, dates, and circumstances; indicate corresponding number):
74. UNDETECTED ACTS – PART 1
Within the past seven years OR at any time after you were first employed in law enforcement, have you ever
committed any of the following misdemeanors?
A) Annoying / obscene phone calls ...................................................................................................................................................... Yes No
B) Battery (use of force or violence upon another) ............................................................................................................................... Yes No
C) Brandishing a weapon (any type of weapon) ................................................................................................................................... Yes No
D) Carrying a concealed weapon without a permit ................................................................................................................................ Yes No
E) Contributing to the delinquency of a minor ....................................................................................................................................... Yes No
F) Defrauding an innkeeper (not paying for food or room at a hotel/motel) ........................................................................................... Yes No
G) Driving under the influence of alcohol and/or drugs ......................................................................................................................... Yes No
H) Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) ....................................................... Yes No
I) Hit & run collision (no injuries) ......................................................................................................................................................... Yes No
J) Hunting/fishing without a license ...................................................................................................................................................... Yes No
K) Illegal gambling ............................................................................................................................................................................... Yes No
L) Impersonating a peace officer (pretending to be a police officer) ..................................................................................................... Yes No
M) Indecent exposure (including flashing or mooning) .......................................................................................................................... Yes No
N) Joyriding (using a car or other vehicle without owner’s permission) ................................................................................................. Yes No
O) Petty theft (value up to $400, including shoplifting/switching price tags) ........................................................................................... Yes No
P) Possession of alcohol as a minor ..................................................................................................................................................... Yes No
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL
continued
74. UNDETECTED ACTS – PART 1 continued
Q) Possession of falsified or altered identification, including use of another person’s ID (for any reason) ............................................. Yes No
R) Possession of stolen property (including vehicles) ........................................................................................................................... Yes No
S) Prostitution or soliciting a prostitute .................................................................................................................................................. Yes No
T) Resisting arrest (including running from the police) .......................................................................................................................... Yes No
U) Trespassing ..................................................................................................................................................................................... Yes No
V) Vandalism (including “tagging,” malicious mischief and/or property damage) ................................................................................... Yes No
W) Intentionally writing a bad check ...................................................................................................................................................... Yes No
X) Filing a false police report ................................................................................................................................................................ Yes No
Y) Any other act amounting to a misdemeanor within the past seven years .......................................................................................... Yes No
I
f you answered yes to any item(s) in Question 74, fully explain circumstances, including date(s), names of
individuals involved, and resolution. Indicate the corresponding letter (74-A, etc.) for each explanation
.
75. UNDETECTED ACTS – PART 2
At any time in your life have you ever committed any of the following?
A) Arson (intentionally destroying property by setting a fire) ................................................................................................................. Yes No
B) Assault with a deadly weapon .......................................................................................................................................................... Yes No
C) Theft of a vehicle and/or vehicle parts .............................................................................................................................................. Yes No
D) Burglary (entering a structure or vehicle to commit theft or other crime) ........................................................................................... Yes No
E) Child molestation (performing unlawful acts with a child) ................................................................................................................. Yes No
F) Accessing and/or possessing child pornography .............................................................................................................................. Yes No
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL (Question 75) continued
G) Elder abuse/neglect ......................................................................................................................................................................... Yes No
H) Embezzlement (theft of money or other valuables entrusted to you) ................................................................................................ Yes No
I) Felony drunk driving (involving injuries) ........................................................................................................................................... Yes No
J) Forcible rape or other act of unlawful intercourse ............................................................................................................................. Yes No
K) Forgery (falsifying any type of document, check certificate, license, currency, etc.).......................................................................... Yes No
L) Hit & run (with injuries) ..................................................................................................................................................................... Yes No
M) Hate crime ....................................................................................................................................................................................... Yes No
N) Insurance fraud ................................................................................................................................................................................ Yes No
O) Theft (value of over $250, or any firearm) ......................................................................................................................................... Yes No
P) Murder, homicide, or attempted murder ........................................................................................................................................... Yes No
Q) Perjury (lying under oath) ................................................................................................................................................................. Yes No
R) Possession of an explosive/destructive device ................................................................................................................................. Yes No
S) Robbery (theft from another person using a weapon, force, or fear) ................................................................................................. Yes No
T) Stalking ............................................................................................................................................................................................ Yes No
U) Blackmail or extortion....................................................................................................................................................................... Yes No
V) Any other act amounting to a felony ................................................................................................................................................. Yes No
If you answered yes to any item(s) in Question 75, fully explain circumstances, including date(s), names of
individuals involved, and resolution. Indicate the corresponding letter (75-A, etc.) for each explanation.
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 21 of 26 Boxborough Police Department
Ini
tial this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL continued
Questions 76 and 77 ask about your current and past recreational drug use. This covers the use of any drug,
including the unauthorized use of prescription drugs or over-the-counter drugs. Your answers should include,
but not be limited to, your use of any of the following drugs:
– Amphetamines / Methamphetamines
(Uppers, Speed, Crank, etc)
– Barbiturates (Downers)
– Cocaine / Crack Cocaine
– Designer Drugs
(Ecs
tasy, Synthetic Heroin, etc.)
– GHB (Date Rape Drug)
– Glue
– Hallucinogens
(Peyote, LSD, Mushrooms)
– Hashish / Hashish Oil
– Heroin / Opium
– Marijuana (If medically prescribed,
attach copy of medical marijuana
license)
– Mescaline
– Morphine
– PCP / Angel Dust
– Quaaludes
– Steroids
– Tetrahydrocannabinal (THC)
76. Within the past six months, have you used any drug(s) as indicated above? .................... Yes No
If yes, give details, including drug(s) used, number of times, over what time period(s), and circumstances:
77.
Prior to the past six months (check all that apply):
I have never used any drug recreationally.
I have tried or used one or more drugs, but only under limited circumstances (for example, experimentation, at parties,
concerts, special events, etc.).
If checked, give details including drug(s) used, estimated number of times, over what time period(s), and
circumstances.
I used drugs on a regular basis (from one to several times a week or more).
If checked, ONLY indicate the time period(s) of drug use. DO NOT include the drug(s) used or
frequency of use.
78.
Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including marijuana?
Sold
Manufactured
Purchased
Furnished
Cultivated
Carried or held for another
If you checked any items above, give details including drug(s) involved, over what time period(s), and
circumstances.
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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nitial this page to indicate that you have provided complete and accurate information: _____
SECTION 9: MOTOR VEHICLE OPERATION
79. CURRENT DRIVER’S LICENSE NUMBER
STATE OF ISSUE
EXPIRATION DATE
NAME UNDER WHICH LICENSE WAS GRANTED
80. LIST OTHER STATES WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE:
State of issue
Type of license
Name under which license was granted and license number, if known
81.
Have you ever been refused a driver’s license by any state? ................................................................................................................... Yes No
If yes, explain (include when, where, and circumstances):
82. Has your driver’s license ever been suspended or revoked? ................................................................................................................... Yes No
If yes, explain (include when, where, and circumstances):
83. List your current liability insurance on your vehicle(s):
A) TYPE OF COVERAGE
Insured Bonded Cash Deposit
VEHICLE MAKE
YEAR
VEHICLE LICENSE
INSURANCE COMPANY
POLICY NUMBER
EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP
CONTACT NUMBER
( )
B) TYPE OF COVERAGE
Insured Bonded Cash Deposit
VEHICLE MAKE
YEAR
VEHICLE LICENSE
INSURANCE COMPANY
POLICY NUMBER
EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP
CONTACT NUMBER
( )
C) TYPE OF COVERAGE
Insured Bonded Cash Deposit
VEHICLE MAKE
YEAR
VEHICLE LICENSE
INSURANCE COMPANY
POLICY NUMBER
EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP
CONTACT NUMBER
( )
D) TYPE OF COVERAGE
Insured Bonded Cash Deposit
VEHICLE MAKE
YEAR
VEHICLE LICENSE
INSURANCE COMPANY
POLICY NUMBER
EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP
CONTACT NUMBER
( )
PERSONAL HISTORY STATEMENT – POLICE OFFICER
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itial this page to indicate that you have provided complete and accurate information: _____
SECTION 9: MOTOR VEHICLE OPERATION continued
84. List all traffic citations, excluding parking citations, you have received within the past seven years:
A) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED
Month Year
ACTION TAKEN
Not Guilty Fined Traffic School Dismissed
B) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED
Month Year
ACTION TAKEN
Not Guilty Fined Traffic School Dismissed
C) NATURE OF VIOLATION
LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED
Month Year
ACTION TAKEN
Not Guilty Fined Traffic School Dismissed
D) Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following? (Check all that apply.)
Failed to appear Failed to complete traffic school Failed to pay the required fine
If checked, explain circumstances:
85. Have you been involved as the driver in a motor vehicle accident within the past seven years? ...................................................................... Yes No
If yes, give details.
A) DATE
LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY NON-
INJURY
B) DATE
LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY NON-
INJURY
C) DATE
LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
POLICE REPORT
YES NO
LAW ENFORCEMENT AGENCY
INJURY NON-
INJURY
86. Have you ever driven a vehicle without auto insurance, as required by law? ........................................................................................ Yes No
IF YES, GIVE REASON:
DATE
Month Year
LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
87. Have you ever been refused automobile liability insurance or a bond, or had them cancelled? .......................................................... Yes No
IF YES, GIVE REASON:
INSURANCE COMPANY
DATE
Month Year
LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 24 of 26 Boxborough Police Department
Init
ial this page to indicate that you have provided complete and accurate information: _____
SECTION 9: MOTOR VEHICLE OPERATION continued
Use this space for additional information you would like to include regarding your driving record.
SECTION 10: OTHER TOPICS
88. Have you ever been refused a permit to carry a concealed weapon? ................................................................................................................ Yes No
89.
Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other group
that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,
gender, sexual preference, or disability? ........................................................................................................................................................... Yes No
90.
Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise,
street gang, or any other group that advocates violence against individuals because of their race, religion,
political affiliation, ethnic origin, nationality, gender, sexual preference, or disability? ................................................................................... Yes No
91. Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or other
violent act? .......................................................................................................................................................................................................
Yes No
92. Have you ever hit or physically overpowered a spouse or romantic partner? ................................................................................................. Yes No
If you answered yes to any of Questions 88–92, give details including dates and circumstances; indicate corresponding number.
__
________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 25 of 26 Boxborough Police Department
Initial
this page to indicate that you have provided complete and accurate information: _____
ADDITIONAL SPACE
• Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g., additional family members, schools, residences,
employers, explanations to questions, etc.)
• Identify the corresponding question and specific item being referenced.
Initial thi
s page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT – POLICE OFFICER
Page 26 of 26 Boxborough Police Department
SECTION 11: CERTIFICATION
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Completed 9 February 2021

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