F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 1 of 27 Alaska Police Standards Council Version Date April 6, 2018
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 an APSC Certified Officer, in accordance with Alaska Police
Standards Council (APSC) regulations.
It is your responsibility to complete this form and provide all required information.
If you are filling out a printed copy of this form, neatly print in blue or black ink.
You must respond 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 need more space for any response, use the last
page of this form (page 27) and identify the additional
information by the question number.
Send the completed form to your background investigator or the agency to which you are applying. Do NOT send
the form to APSC.
Disqualification
There are very few automatic bases for rejection. Even issues of prior misconduct, such as prior illegal drug use,
driving under the influence, theft, or even arrest or conviction 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.
BOTTOM LINE: You are responsible for providing complete, accurate, and truthful responses.
Disclosure of Medically-Related Information
In accordance with the U.S. Americans with Disabilities Act, and the Genetic Information Nondiscrimination Act
(GINA), applicants are not expected or required to reveal any medical or other disability-related information about
themselves or their family members in response to questions on this form.
I have read and I understand the above instructions.
Signature: _________________________________________________ Date: ________________________
Alaska Police Standards Council
PO Box 111200
Juneau, Alaska 99811
click to sign
signature
click to edit
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 2 of 27 Ver. April 6, 2018
Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 1: PERSONAL
1. YOUR FULL NAME
LAST FIRST MIDDLE
2. OTHER NAMES YOU HAVE USED OR BEEN KNOWN BY (INCLUDE MAIDEN NAME AND NICKNAMES)
N/A
3. ADDRESS WHERE YOU LIVE
NUMBER / STREET APT / UNIT
CITY STATE ZIP
4. MAILING ADDRESS, IF DIFFERENT FROM ABOVE (FOR EXAMPLE, PO BOX)
5.
CONTACT NUMBERS
HOME WORK EXT OTHER CELL FAX
6. CONTACT EMAIL
7. LIST ALL OTHER EMAIL ADDRESSES (SEPARATED BY COMMAS)
8. CITIZENSHIP
Are you a U.S. citizen? ....................................................................................................................................................................... Yes No
IF NATURALIZED, provide your certificate number and date, place, and court naturalized
9. BIRTH PLACE (CITY / COUNTY / STATE / COUNTRY)
10. BIRTHDATE (MM/DD/YYYY)
12. DRIVER’S LICENSE
NUMBER: STATE: EXPIRES:
13. PHYSICAL DESCRIPTION
HEIGHT: WEIGHT: HAIR COLOR: EYE COLOR:
SECTION 2: RELATIVES AND REFERENCES
14. IMMEDIATE FAMILY
Provide all applicable information in the spaces below.
Mark “N/A” if a category is not applicable.
Mark “Deceased,” if appropriate.
If more space is needed, continue on page 27 reference corresponding numbers.
14.A
Spouse / Domestic Partner Deceased N/A
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
DATE OF MARRIAGE/REGISTRATION
BIRTHDATE (MM/DD/YYYY)
(MM/YYYY)
Is there, or has there ever been, a civil or criminal restraining or stay-away
order in effect involving you and this individual? ....................... Yes No
14.B Former Spouse / Former Domestic Partner / Former Significant Other
Deceased N/A
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
DATE OF MARRIAGE/REGISTRATION
DATE OF DISSOLUTION
BIRTHDATE (MM/DD/YYYY)
(MM/YYYY)
(MM/YYYY)
Is there, or has there ever been, a civil or criminal restraining or stay-away
order in effect involving you and this individual? ....................... Yes No
Attach a copy of birth certificate or passport or if
applicable certification of naturalization (mandatory)
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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SECTION 2: RELATIVES AND REFERENCES continued
14.C Parents / Guardians
List ALL parents/guardians, living or deceased, including biological, adoptive, foster, step-parents, in-laws, etc.
14.C.1 Parent / Guardian: Mother Father Step-mother Step-father In-law Other:
Deceased
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.C.2 Parent / Guardian: Mother Father Step-mother Step-father In-law Other:
Deceased
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.C.3 Parent / Guardian: Mother Father Step-mother Step-father In-law Other:
Deceased
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.C.4 Parent / Guardian: Mother Father Step-mother Step-father In-law Other:
Deceased
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.D
Brothers / Sisters
N/A
List ALL LIVING siblings, including half-siblings, step-siblings, foster-siblings, etc.
14.D.1 Sibling: Brother Sister Half-brother Half-sister Other:
NAME
AGE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.D.2 Sibling: Brother Sister Half-brother Half-sister Other:
NAME
AGE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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SECTION 2: RELATIVES AND REFERENCES continued
14.D.3 Sibling: Brother Sister Half-brother Half-sister Other:
NAME
AGE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.D.4 Sibling: Brother Sister Half-brother Half-sister Other:
NAME
AGE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
14.E
Children
N/A
List ALL 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/guardian, if other than you.
14.E.1 Child: Son Daughter
NAME
Other:
AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
CONTACT NUMBER
EMAIL
14.E.2 Child: Son Daughter
NAME
Other:
AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
CONTACT NUMBER
EMAIL
14.E.3 Child: Son Daughter
NAME
Other:
AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
CONTACT NUMBER
EMAIL
14.E.4 Child: Son Daughter
NAME
Other:
AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
CONTACT NUMBER
EMAIL
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES continued
15. LIST OF REFERENCES
List at least 5 people who know you well, such as close personal relationships, social and family friends, teachers, military colleagues, and/or
co-workers. Do NOT include relatives, employers, housemates, or any individuals listed elsewhere.
15.1
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.2
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.3
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.4
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.5
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.6
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES continued
15.7
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.8
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.9
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
15.10
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
MAILING ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
EMAIL
How do you know this person? How long have you known this person?
SECTION 3: EDUCATION
You will be required to furnish unopened official transcripts or other proof to support all of your educational claims before hire or
certification.
If more space is needed, continue your response on page 27.
16. CHECK APPLICABLE
MM/YYYY MM/YYYY
High School Diploma: GED:
17. LIST HIGH SCHOOL(S) ATTENDED
17.1
NAME OF HIGH SCHOOL FROM (MM/YYYY) TO (MM/YYYY)
PUBLIC/PRIVATE OR HOMESCHOOL? CITY STATE
17.2
NAME OF HIGH SCHOOL FROM (MM/YYYY) TO (MM/YYYY)
PUBLIC, PRIVATE, OR HOMESCHOOL? CITY STATE
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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SECTION 3: EDUCATION continued
18. LIST ALL COLLEGES AND UNIVERSITIES ATTENDED
18.1
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM SEM SYSTEM
ADDRESS (NUMBER / STREET)
TYPE OF DEGREE EARNED
CITY
STATE
ZIP
MAJOR / AREA OF STUDY
18.2
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM SEM SYSTEM
ADDRESS (NUMBER / STREET)
TYPE OF DEGREE EARNED
CITY
STATE
ZIP
MAJOR / AREA OF STUDY
18.3
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM SEM SYSTEM
ADDRESS (NUMBER / STREET)
TYPE OF DEGREE EARNED
CITY
STATE
ZIP
MAJOR / AREA OF STUDY
18.4
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM SEM SYSTEM
ADDRESS (NUMBER / STREET)
TYPE OF DEGREE EARNED
CITY
STATE
ZIP
MAJOR / AREA OF STUDY
19. LIST ALL TRADE, VOCATIONAL, AND BUSINESS SCHOOLS / INSTITUTES ATTENDED
19.1
NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE
FROM (MM/YYYY)
TO (MM/YYYY)
DID YOU COMPLETE THE COURSE?
Yes No
CITY
STATE
TYPE OF SCHOOL OR TRAINING
19.2
NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE
FROM (MM/YYYY)
TO (MM/YYYY)
DID YOU COMPLETE THE COURSE?
Yes No
CITY
STATE
TYPE OF SCHOOL OR TRAINING
20. Have you ever taken an Arrest and/or Firearms Course? ................................................................................................................ Yes No
IF YES, provide the following information:
A. COURSE PRESENTER NAME
LOCATION (CITY / STATE)
B. COURSE COMPLETION
Did you successfully complete the course? .................................................................. Yes No
COMPLETION DATE (MM/YYYY)
21. Have you ever attended a Basic Law Enforcement Academy: Police, Corrections, Probation/Parole, Village Police ...................... Yes No
IF YES, provide the following information:
21.1
NAME OF ACADEMY FROM (MM/YYYY) TO (MM/YYYY) DID YOU PASS/GRADUATE?
Yes No
LOCATION (CITY, STATE) NAME OF TRAINING OFFICER / ACADEMY COORDINATOR CONTACT NUMBER
21.2
NAME OF ACADEMY FROM (MM/YYYY) TO (MM/YYYY) DID YOU PASS/GRADUATE?
Yes No
LOCATION (CITY, STATE) NAME OF TRAINING OFFICER / ACADEMY COORDINATOR CONTACT NUMBER
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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SECTION 3: EDUCATION continued
22. Have you ever been subject to any disciplinary action, including academic probation, civil fine, suspension, expulsion, or resignation
from any high school(s), college/university, business, trade school, or basic course/academy? .......................................................
Yes No
IF YES, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school, educational institution, or
basic course. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
SECTION 4: RESIDENCE HISTORY
23. LIST OF RESIDENCES
List all residences during the last 10 years or since age 15.
Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit/apt number). Do NOT use PO 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 your response on page 27.
23.1
ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT) FROM (MM/YYYY) TO (MM/YYYY)
Present
CITY STATE ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX) CONTACT NUMBER
CITY STATE ZIP EMAIL
Name(s) of those with whom you live:
23.2
FORMER ADDRESS (NUMBER / STREET / APT) FROM (MM/YYYY) TO (MM/YYYY)
CITY STATE ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX) CONTACT NUMBER
CITY STATE ZIP EMAIL
Name(s) of those with whom you lived:
Reason for moving:
23.3
FORMER ADDRESS (NUMBER / STREET / APT) FROM (MM/YYYY) TO (MM/YYYY)
CITY STATE ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX) CONTACT NUMBER
CITY STATE ZIP EMAIL
Name(s) of those with whom you lived:
Reason for moving:
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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SECTION 4: RESIDENCE HISTORY continued
23.4
FORMER ADDRESS (NUMBER / STREET / APT) FROM (MM/YYYY) TO (MM/YYYY)
CITY STATE ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX) CONTACT NUMBER
CITY STATE ZIP EMAIL
Name(s) of those with whom you lived:
Reason for moving:
23.5
FORMER ADDRESS (NUMBER / STREET / APT) FROM (MM/YYYY) TO (MM/YYYY)
CITY STATE ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX) CONTACT NUMBER
CITY STATE ZIP EMAIL
Name(s) of those with whom you lived:
Reason for moving:
24. LIST OF HOUSEMATES
Provide contact information for all housemates listed in Question 23 with whom you have resided during the past 10 years or since age 15.
Do NOT list anyone for whom you have already provided contact information.
If more space is needed, continue your response on page 27.
24.1
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
24.2
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
24.3
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
24.4
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
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F-3: PERSONAL HISTORY STATEMENT APSC Officer
SECTION 4: RESIDENCE HISTORY continued
24.5
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
24.6
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
24.7
NAME OF HOUSEMATE CONTACT NUMBER
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT) CITY STATE ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.) EMAIL
25. Have you ever been evicted or asked to leave a residence? .......................................................................................................... Yes No
26. Have you ever left a residence with unpaid damage, owing rent, utilities, or other household expenses? ....................................... Yes No
If you answered “YES” to Questions 25 and/or 26, explain (include when, where, and circumstances):
SECTION 5: EXPERIENCE AND EMPLOYMENT
27. JOB EXPERIENCE
List ALL jobs you have had in last 10 years, including part-time, temporary, self-employment, and volunteer. (Begin with your most current.)
If you have military experience, including guard or reserve duty, enter your military base, assignments, or unit of assignment.
List ALL periods of unemployment in excess of 30 days.
If more space is needed, continue your response
on page 27.
27.1
NAME OF CURRENT EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
JOB TITLE / RANK EMAIL
DUTIES / ASSIGNMENTS TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
REASON FOR WANTING TO LEAVE NAMES OF CO-WORKERS
1) 2)
Is there any reason this employer may make negative statements about you if contacted?........................................................... Yes No
IF YES, explain:
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27.2
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
27.3
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
JOB TITLE / RANK EMAIL
DUTIES / ASSIGNMENTS TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS REASON FOR LEAVING
1) 2)
27.4
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
27.5
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
JOB TITLE / RANK EMAIL
DUTIES / ASSIGNMENTS TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
REASON FOR LEAVING NAMES OF CO-WORKERS
1) 2)
27.6
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
27.7
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
JOB TITLE / RANK EMAIL
DUTIES / ASSIGNMENTS TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
REASON FOR LEAVING NAMES OF CO-WORKERS
1) 2)
27.8
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
F-3: PERSONAL HISTORY STATEMENT APSC Officer
F-3: PERSONAL HISTORY STATEMENT APSC Officer
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SECTION 5: EXPERIENCE AND EMPLOYMENT continued
27.9
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE / RANK
EMAIL
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS
REASON FOR LEAVING
1) 2)
27.10
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
FROM (MM/YYYY)
TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
27.11
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE / RANK
EMAIL
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS
REASON FOR LEAVING
1) 2)
27.12
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
FROM (MM/YYYY)
TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
27.13
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE / RANK
EMAIL
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS
REASON FOR LEAVING
1) 2)
27.14
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
FROM (MM/YYYY)
TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 13 of 27 Ver. April 6, 2018
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SECTION 5: EXPERIENCE AND EMPLOYMENT
continued
27.15
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE / RANK
EMAIL
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS
REASON FOR LEAVING
1) 2)
27.16
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
FROM (MM/YYYY)
TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
27.17
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE / RANK
EMAIL
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS
REASON FOR LEAVING
1) 2)
27.18
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
FROM (MM/YYYY)
TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
27.19
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
TO (MM/YYYY)
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
EXT
JOB TITLE / RANK
EMAIL
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
NAMES OF CO-WORKERS
REASON FOR LEAVING
1) 2)
27.20
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
FROM (MM/YYYY)
TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 14 of 27 Ver. April 6, 2018
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SECTION 5: EXPERIENCE AND EMPLOYMENT continued
28. 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
29. Have you ever been fired, released from probation, or asked to resign from any place of employment? ......................................... Yes No
30. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer? ............................................... Yes No
31. Have you ever quit without giving notice? ....................................................................................................................................... Yes No
32. Have you ever resigned in lieu of termination? ............................................................................................................................... Yes No
33. 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
34. Were you ever the subject of a written complaint at work? .............................................................................................................. Yes No
35. Have you ever been counseled at work due to lateness or absences? ........................................................................................... Yes No
36. Did you ever receive an unsatisfactory performance review?.......................................................................................................... Yes No
37. Have you ever sold, released, given away, or used for your own purposes legally confidential information?................................... Yes No
38. 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? _
_ Days
If you answered “YES” to any of Questions 2841, explain (include when, where, and circumstances reference corresponding numbers).
39. 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?
40. Has your work performance ever been affected by your use of alcohol or drugs? ........................................................................... Yes No
IF YES, when? Name of employer:
41. 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
IF YES, when? Name of employer:
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 15 of 27 Ver. April 6, 2018
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SECTION 5: EXPERIENCE AND EMPLOYMENT continued
42.
Have you ever applied for any position at a law enforcement or corrections agency
(city, county, state, village/tribal, or federal)? Yes
No
If you answeredYES to Question 42, 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 27.
42.1
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
42.2
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
42.3
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 16 of 27 Ver. April 6, 2018
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SECTION 5: EXPERIENCE AND EMPLOYMENT continued
42.4
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY
DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
42.5
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY
DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
42.6
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY
DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
42.7
NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY
DATE APPLIED (MM/YYYY)
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:
STEP: Application Written Physical Ability Oral Polygraph/CVSA Background Chief’s Oral Conditional Offer
STATUS
: Hired On Eligibility List Withdrawn Disqualified List Expired
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 17 of 27 Ver. April 6, 2018
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SECTION 5: EXPERIENCE AND EMPLOYMENT continued
SECTION 6: MILITARY EXPERIENCE
You will be required to furnish your DD-214, NGB-22, or other proof to support all your military claims.
43. Are you required to register for the Selective Service? ................................................................................................................... Yes No
IF YES, have you registered? .........................................................................................................................................................
Yes No
IF NO, explain:
44. Have you ever attempted to enlist or served in the military? ........................................................................................................ Yes No
45. If you answered “YES” to Question 44, include the following service information:
BRANCH OF SERVICE FROM (MM/YYYY) TO (MM/YYYY)
TYPE OF DISCHARGE
Entry Level Honorable General OTH (Other than Honorable) Bad Conduct Dishonorable
Separation Code (14) 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 (MM/DD/YY):
47. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s mast,
office hours, article 15, company punishment, counseling statement)? ........................................................................................
Yes No
48. Were you ever denied a security clearance, or had a clearance revoked, suspended, or downgraded? ...................................... Yes No
49. Have you ever taken military property without permission for personal use, to sell, or to give away? ........................................... Yes No
If you answered “YES” to any of Questions 4749, explain (include dates and circumstances).
SECTION 7: FINANCIAL
50. INCOME AND EXPENSES
For each of the following questions (50A, B, C), fill in the amounts to the nearest dollar.
For Question 50C: 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 obligations you may have.
A) From your employer(s), what is your take-home monthly income?..............................................................
$
per month
B) Do you have other sources of income? (IF YES, fill in amount and explain.) ..................... Yes No $ per month
Explain:
C) How much do you spend each month? .......................................................................................................
$
per month
51. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)? ......................................................................................... Yes No
52. Have any of your bills ever been turned over to a collection agency? .......................................................................................... Yes No
53. Have you ever had purchased goods repossessed? .................................................................................................................... Yes No
54. Have your wages or Alaska permanent fund dividend ever been garnished? ............................................................................... Yes No
55. Have you ever been delinquent on income or other tax payments? ............................................................................................. Yes No
56. Have you ever failed to file income tax or cheated/lied on an income tax form? ........................................................................... Yes No
Page 18 of 27 Ver. April 6, 2018
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F-3: PERSONAL HISTORY STATEMENT APSC Officer
SECTION 7: FINANCIAL continued
57. Have you ever had an employment bond refused? ...................................................................................................................... Yes No
58. Have you ever avoided paying any lawful debt by moving away? ................................................................................................ Yes No
59. Have you ever defaulted on (failed to pay) a loan or failed to pay any citation/ticket? .................................................................. 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 (including insufficient fund checks or on a closed account) in a one-year period? .... Yes No
If you answered “YES” to any of Questions 5163, explain (include when, where, and why reference corresponding numbers).
Disclosure of Arrests and Convictions
This section requires you to report detentions, arrests, and convictions, including diversion programs, suspended imposition of sentences, and
offenses that may have been pardoned or expunged. As an officer applicant, you are required to disclose this information.
If more space is needed, continue your response on page 27.
64. Have you EVER been detained by law enforcement for investigation, arrested, indicted, charged, or convicted of any
misdemeanor or felony offense in this state or any other legal jurisdiction (including offenses in the Uniform Code
of Military Justice)? ...................................................................................................................................................................... Yes
No
IF YES, explain each incident:
64.1
CHARGE
A
RRE
STING OR DETAINING AGENCY
APPROX DATE (MM/YYYY)
EXPLANATION AND DISPOSITION
64.2
CHARGE A
RRE
STING OR DETAINING AGENCY
APPROX DATE (MM/YYYY)
EXPLANATION AND DISPOSITION
SECTION 8: LEGAL
Page 19 of 27 Ver. April 6, 2018
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F-3: PERSONAL HISTORY STATEMENT APSC Officer
64.3
CHARGE ARRESTING OR DETAINING AGENCY
APPROX DATE (MM/YYYY)
EXPLANATION AND DISPOSITION
65. Have you ever been placed on court probation or parole? ........................................................................................................... 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
70. Have you ever been the respondent of an emergency protective order/restraining order/stalking/stay-away order? .................... Yes No
SECTION 8: LEGAL continued
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 been required to repay any welfare payments, unemployment compensation, Alaska permanent fund
dividend, or other state or federal assistance? ............................................................................................................................. Yes
No
74. Have you ever filed a false insurance or workers’ compensation claim? ...................................................................................... Yes No
If you answered “YES” to any of Questions 6574, explain (include court case or document, dates, and circumstances reference corresponding
numbers).
Involvement in Criminal Acts Part 1
75.
Have you committed any of the following acts at any time in your life?
You MUST include any acts committed at any time after you were first employed in law enforcement, including as a reserve officer, Police
Explorer/Police Cadet.
NOTE: You may NOT withhold any information regarding your involvement in any of the following acts, even if federal or state law
relieved you from reporting the detention, arrest, or conviction that arose from it.
75.1
Animal abuse and/or neglect ................................................................................................................................................. Yes No
75.2
Annoying, obscene, or harassing contacts by telephone or other electronic communication device; including “sexting”
or sending/receiving/sharing personally intimate photos of self or others ................................................................................. Yes
No
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 20 of 27 Ver. April 6, 2018
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SECTION 8: LEGAL continued
75.3
Assault or Battery (use of force or violence upon another or placing another in fear) ................................................................ Yes No
75.4
Brandishing a weapon or discharging a firearm in violation of city, state, or federal laws .......................................................... Yes No
75.5
Carrying a concealed weapon without a permit ........................................................................................................................ Yes No
75.6
Contributing to the delinquency of a minor ............................................................................................................................. Yes No
75.7
Defrauding an innkeeper or theft of services (not paying for food, a room at a hotel/motel or campground, or taxi service) ... Yes No
75.8
Driving or operating a vehicle under the influence of alcohol and/or drugs ............................................................................. Yes No
75.9
Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) ............................................... Yes No
75.10
Filing a false police report ...................................................................................................................................................... Yes No
75.11
Hit & run collision (no injuries) .................................................................................................................................................. Yes No
75.12
Illegal gambling ........................................................................................................................................................................ Yes No
75.13
Illegal hunting and/or fishing (for example, without a license, out of season) ............................................................................ Yes No
75.14
Impersonating a peace officer (pretending to be a police officer) ............................................................................................. Yes No
75.15
Indecent exposure and/or lewd or obscene conduct ................................................................................................................ Yes No
75.16
Intentionally writing a bad check .............................................................................................................................................. Yes No
75.17
Joyriding (using a car or other vehicle without owner’s permission) ......................................................................................... Yes No
75.18
Peeping (including, but not limited to, looking through a window or opening with the intent to invade someone’s privacy) ........ Yes No
75.19
Petty theft (value up to $250, including shoplifting/switching price tags) .................................................................................. Yes No
75.20
Possession or consumption of alcohol as a minor .................................................................................................................... Yes No
75.21
Possession of falsified or altered identification, including use of another person’s ID (for any reason) ...................................... Yes No
75.22
Possession of stolen property (including, but not limited to, vehicles, credit/debit cards, etc.) ................................................... Yes No
75.23
Prostitution or solicitation of prostitution (including, but not limited to, patronizing illegal massage parlors; include legalized
prostitution, whether inside the U.S. or not) .............................................................................................................................. Yes
No
75.24
Reckless driving ....................................................................................................................................................................... Yes No
75.25
Resisting arrest and/or delaying or obstructing an officer (including, but not limited to, running from the police) ....................... Yes No
75.26
Trespassing ............................................................................................................................................................................. Yes No
75.27
Vandalism (including, but not limited to, “tagging,” malicious mischief, and/or property damage) .............................................. Yes No
75.28
Any other act amounting to a misdemeanor ............................................................................................................................. Yes No
If you answered “YES” to ANY of the item(s) in Question 75, fully explain circumstances, including dates, names of individuals involved,
and resolution. Reference the corresponding number (e.g., 75.5) for each explanation.
If more space is
needed, continue your response on page 27.
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 21 of 27 Ver. April 6, 2018
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SECTION 8: LEGAL continued
Involvement in Criminal Acts Part 2
76. At any time in your life, have you EVER committed any of the following acts?
NOTE: You may NOT withhold any information regarding your involvement in any of the following acts, even if federal or state law
relieved you from reporting the detention, arrest, or conviction that arose from it.
76.1
Arson (intentionally destroying property by setting a fire) ......................................................................................................... Yes No
76.2
Felony Assault (struck or threatened to strike someone with an instrument likely to cause great bodily
injury or death, or caused a person injury by using a dangerous instrument) ...........................................................................
Yes No
76.3
Blackmail or extortion ............................................................................................................................................................ Yes No
76.4
Burglary (entering a structure or vehicle to commit theft or other crime) .................................................................................. Yes No
76.5
Child molestation (performing unlawful acts with a child, inappropriate touching of a child) ..................................................... Yes No
76.6
Elder abuse and/or neglect (physical and/or financial) ............................................................................................................. Yes No
76.7
Embezzlement (theft of money or other valuables entrusted to you) ........................................................................................ Yes No
76.8
Felony drunk driving ................................................................................................................................................................ Yes No
76.9
Rape (including sexual contact, penetration without consent, or statutory rape) .................................................................... Yes No
76.10
Forgery (falsifying any type of document, check certificate, license, currency, etc.) ............................................................... Yes No
76.11
Fraudulent use of a credit, ATM, debit, and/or check card ..................................................................................................... Yes No
76.12
Theft (value of over $250, or any firearm) ................................................................................................................................ Yes No
76.13
Hit & run (with injuries) ............................................................................................................................................................ Yes No
76.14
Hate crime ............................................................................................................................................................................. Yes No
76.15
Illegal sex acts ........................................................................................................................................................................ Yes No
76.16
Insurance fraud ..................................................................................................................................................................... Yes No
76.17
Murder, homicide, manslaughter, or attempted murder ......................................................................................................... Yes No
76.18
Perjury (lying under oath) ........................................................................................................................................................ Yes No
76.19
Possession of an explosive/destructive device ...................................................................................................................... Yes No
76.20
Robbery (theft from another person using a weapon, force, or fear) ........................................................................................ Yes No
76.21
Stalking ................................................................................................................................................................................... Yes No
76.22
Theft of a vehicle and/or vehicle parts ..................................................................................................................................... Yes No
76.23
Viewing and/or possessing child pornography (including distributing or creating) .................................................................. Yes No
76.24
Bigamy or Polygamy, married to more than one person at the same time ................................................................................ Yes No
76.25
Any other act amounting to a felony ...................................................................................................................................... Yes No
F-3: PERSONAL HISTORY STATEMENT APSC Officer
Page 22 of 27 Ver. April 6, 2018
Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL continued
If you answered “YES” to ANY of the item(s) in Question 76, fully explain circumstances, including dates, names of individuals involved,
and resolution. Reference the corresponding number (e.g., 76.3) for each explanation.
If more space is needed, continue your response on page 27.
IF YES, give details including drug(s) used, most recent date used, and circumstances:
Illegal Use of Drugs
For the purpose of responding to the following questions, “illegal drugs” include the unauthorized or illegal use of prescription medications
or over-the-counter drugs; the illegal use of “controlled substances,” and includes the illegal use of any substance for the purpose of getting “high.”
Your responses should include but not be limited to your use of any of the following:
Amphetamines / Methamphetamines (Uppers, Speed, Crank, etc)
Barbiturates (Downers)
Cocaine / Crack Cocaine
Designer Drugs (Ecstasy, Synthetic Heroin, Spice, etc.)
GHB (Date Rape Drug)
Hallucinogens (Peyote, LSD, Mushrooms)
Hashish / Hashish Oil
Heroin / Opium
Marijuana (with or without a prescription)
Mescaline
Morphine
PCP / Angel Dust
Quaaludes
Steroids
Tetrahydrocannabinal (THC)
Glue, paint, or any substance containing toluene
77.
Within the past twelve months, have you used any drug(s) indicated above or any other illegal substances? ........................... Yes No
78.
Prior to the past twelve months:
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 YOU CHECKED BOX 2, give details including drug(s) used, most recent date used, and circumstances: