State of California Department of Justice
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2018)
Page 1 of 25
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 California Peace Officer, in accordance with POST Commission
Regulation 1953.
It is your responsibility to complete this form and provide all required information.
Following instructions given by the hiring department, type or neatly print in 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 supplemental information page on the last page of this form
(page 25) and identify the additional information by the question number.
Following instructions given by the hiring department, provide the completed form to your background investigator
or the agency to which you are applying. Do NOT send the form to POST.
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, the Genetic Information Nondiscrimination Act
(GINA), and the California Fair Employment and Housing Act, 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: ________________________
Commission on
Peace Officer Standards and Training (POST)
860 Stillwater Road, Suite 100
West Sacramento, CA 95605-1630
Please download PDF and save it, before filling out. Adobe Acrobat Reader is the preferred program to use.
click to sign
signature
click to edit
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 2 of 25 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 NO, are you a resident alien who is eligible and has applied for U.S. citizenship? .......................................................................... Yes No
9. BIRTH PLACE (CITY / COUNTY / STATE / COUNTRY)
10. BIRTHDATE (MM/DD/YYYY) 11. SOCIAL SECURITY NUMBER 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 25 reference corresponding numbers.
14.A Spouse / Registered Domestic Partner
Deceased N/A
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / SUITE) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
DATE OF MARRIAGE/REGISTRATION
/ (MM/YYYY)
Is there, or has there ever been, a restraining or stay-away
order in effect involving you and this individual? ....................... Yes No
14.B Former Spouse / Former Registered Domestic Partner
Deceased N/A
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / SUITE) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
DATE OF MARRIAGE/REGISTRATION DATE OF DISSOLUTON
/ (MM/YYYY) / (MM/YYYY)
Is there, or has there ever been, a restraining or stay-away
order in effect involving you and this individual? ....................... Yes No
Please download PDF and save it, before filling out.
Adobe Acrobat Reader is the preferred program to use.
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 3 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES continued
14.C Parents / Guardians / In-laws
List ALL parents/guardians/in-laws living or deceased, including biological, adoptive, foster, step-parents, etc.
14.C.1 Parent / Guardian / In-law: 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 / In-law: 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 / In-law: 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 / In-law: 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.5 Parent / Guardian / In-law: 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.6 Parent / Guardian / In-law: 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
( ) ( )
Supplemental relatives information included on page 25
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 4 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES continued
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
( ) ( )
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
( ) ( )
Supplemental relatives information included on page 25
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 Other:
NAME AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER EMAIL
( )
14.E.2 Child: Son Daughter Other:
NAME AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER EMAIL
( )
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 5 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES continued
14.E.3 Child: Son Daughter Other:
NAME AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER EMAIL
( )
14.E.4 Child: Son Daughter Other:
NAME AGE CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
CONTACT NUMBER EMAIL
( )
Supplemental relatives information included on page 25
15. LIST OF REFERENCES
List 7-10 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 WORK 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 WORK 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 WORK 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 WORK 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?
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 6 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES continued
15.5
NAME OF REFERENCE HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK 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 WORK 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?
15.7
NAME OF REFERENCE HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK 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 WORK 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 WORK 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 WORK 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?
Supplemental references information included on page 25
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 7 of 25 Initial 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 in Section 3.
If more space is needed, continue your response on page 25.
16. CHECK APPLICABLE MM/YYYY MM/YYYY MM/YYYY
High School Diploma: /
High School Equivalency Test:
/ California High School Proficiency Certificate: /
17. LIST HIGH SCHOOL(S) ATTENDED
17.1
NAME OF HIGH SCHOOL FROM (MM/YYYY) TO (MM/YYYY)
/ /
CITY STATE
17.2
NAME OF HIGH SCHOOL FROM (MM/YYYY) TO (MM/YYYY)
/ /
CITY STATE
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) DEGREE EARNED
YES NO TYPE:
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) DEGREE EARNED
YES NO TYPE:
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) DEGREE EARNED
YES NO TYPE:
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
Supplemental education information included on page 25
LIST ALL POST BASIC COURSES ATTENDED
20. Have you ever taken a PC832 (Arrest and/or Firearms) Course? .................................................................................................... Yes No
IF YES, provide the following information:
A. COURSE PRESENTER NAME LOCATION (CITY / STATE)
B. COURSE COMPLETION COMPLETION DATE (MM/YYYY)
Did you successfully complete the course? .................................................................. Yes No /
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 8 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
SECTION 3: EDUCATION continued
21. Have you ever attended a POST Basic Course/Academy: Regular, Modular, Specialized Investigators’, Reserve, or Dispatcher? Yes No
IF YES, provide the following information:
21.1
NAME OF COURSE PRESENTER/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 COURSE PRESENTER/ACADEMY FROM (MM/YYYY) TO (MM/YYYY) DID YOU PASS/GRADUATE?
/ / Yes No
LOCATION (CITY, STATE) NAME OF TRAINING OFFICER / ACADEMY COORDINATOR CONTACT NUMBER
( )
Supplemental POST basic course information included on Page 25
22. Have you ever been subject to any disciplinary action, including academic probation, civil fine, suspension, or expulsion
from any high school(s), college/university, business, trade school, or POST 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
POST basic course academy. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
23. Since the age of 18, have you cheated on an exam, or assisted another person in cheating on an exam, or participated in
cheating on any POST exam? ......................................................................................................................................................... Yes No
IF YES, explain circumstances.
SECTION 4: RESIDENCE HISTORY
24. 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/dormitory). 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 25.
24.1
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:
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 9 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 4: RESIDENCE HISTORY continued
24.2
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:
24.3
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:
24.4
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:
24.5
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:
Supplemental residence information included on page 25
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 10 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 4: RESIDENCE HISTORY continued
25. LIST OF HOUSEMATES
Provide contact information for all housemates listed in Question 24 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 25.
25.1
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
25.2
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
25.3
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
25.4
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
25.5
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
Supplemental housemate information included on page
25
26. Have you ever been evicted or asked to leave a residence? .......................................................................................................... Yes No
27. Have you ever left a residence owing rent, utilities, or other household expenses? ........................................................................ Yes No
If you answered “YES” to Questions 26 and/or 27, explain (include when, where, and circumstances):
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 11 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______
______
SECTION 5: EXPERIENCE AND EMPLOYMENT
28. JOB EXPERIENCE
List ALL jobs you have had, including part-time, temporary, self-employment, and volunteer. (Begin with your current or most recent.)
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.
If more space is needed, continue your response on page 25.
28.1
NAME OF CURRENT EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR WANTING TO LEAVE
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
Would there be a problem if we contact your current employer? .................................................................................................. Yes No
IF YES, explain:
28.2
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
28.3
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR LEAVING
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
28.4
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 12 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
28.5
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR LEAVING
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
28.6
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
28.7
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR LEAVING
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
28.8
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
28.9
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR LEAVING
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 13 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
28.10
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
28.11
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR LEAVING
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
28.12
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
28.13
NAME OF EMPLOYER OR MILITARY UNIT FROM (MM/YYYY) TO (MM/YYYY)
/ /
ADDRESS (NUMBER / STREET / SUITE / OR BASE) CONTACT NUMBER EXT
( )
CITY STATE ZIP EMAIL
JOB TITLE / RANK TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
FT PT Temp Self-employed Volunteer
DUTIES / ASSIGNMENTS REASON FOR LEAVING
SUPERVISOR CONTACT NUMBER EXT. EMAIL
( )
NAMES OF CO-WORKERS CONTACT NUMBER EXT. EMAIL
1) ( )
2) ( )
28.14
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE) FROM (MM/YYYY) TO (MM/YYYY)
Student Between jobs Leave of absence Travel Other:
/ /
Supplemental employment information included on Page 25
29. 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
30. Have you ever been fired, released from probation, or asked to resign from any place of employment? ......................................... Yes No
31. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer? ............................................... Yes No
32. Have you ever quit without giving proper notice? ............................................................................................................................ Yes No
33. Have you ever resigned in lieu of termination? ................................................................................................................................ Yes No
34. 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
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 14 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
35. Were you ever the subject of a written complaint at work that resulted in disciplinary action against you? ...................................... Yes No
36. Have you ever been counseled at work due to lateness or absences? ............................................................................................ Yes No
37. Did you ever receive an unsatisfactory performance review? .......................................................................................................... Yes No
38. Have you ever sold, released, or given away legally confidential information? ................................................................................ Yes No
39. 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
40. While working (i.e. on duty), have you ever engaged in sexual intercourse or the unwarranted touching of the intimate body
parts of another person? (NOTE: Do not include lawful contact such as pat searches in law enforcement duties and/or training.) .. Yes No
41. While working (i.e. on duty), have you ever sent photographs of yourself or others, showing nudity or depicting sexual acts,
to co-workers or other persons without prior authorization and/or consent? (NOTE: Do not include lawful exchange of
investigative content and/or evidence pursuant to official law enforcement investigations.) ............................................................. Yes No
If you answered “YES” to any of Questions 2941, explain (include when, where, and circumstances reference corresponding numbers).
Supplemental employment information included on Page 25
42. 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?
43. Has your work performance ever been affected by your use of alcohol or drugs? ........................................................................... Yes No
IF YES, when? Name of employer:
44. 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:
45. Have you ever applied for any position at this or any other law enforcement agency (city, county, state, or federal)? .................... Yes No
If you answered “YES to Question 45, 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.
45.1
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 15 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
45.2
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
45.3
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
45.4
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
45.5
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 16 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
45.6
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
45.7
NAME OF LAW ENFORCEMENT 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 Withdrew Disqualified List Expired Other (explain)
Supplemental employment information is included on Page 25
SECTION 6: MILITARY EXPERIENCE
46. Are you required to register for the Selective Service?.................................................................................................................... Yes No
IF YES, have you registered? ......................................................................................................................................................... Yes No
IF NO, explain:
47. Have you ever served in the military? .......................................................................................................................................... Yes No
48. If you answered “YES” to Question 47, 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
Re-entry Code (14) if applicable refer to your DD-214:
49. Are you currently participating in one of the following?
Military Reserve National Guard IF CHECKED, date obligation ends (MM/DD/YY):
50. 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
51. Were you ever denied a security clearance, or had a clearance revoked, suspended, or downgraded? ...................................... Yes No
52. 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 50-52, explain (include dates and circumstances).
Supplemental military information included on Page 25
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 17 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 7: FINANCIAL
53. INCOME AND EXPENSES
For each of the following questions (53A and B), fill in the amounts to the nearest dollar.
For Question 53A: Provide your total monthly disposable income. Include money from investments, rental income, alimony, side businesses, etc.
For Question 53B: 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) What is your total monthly disposable income? ..........................................................................................
$ per month
B) How much do you spend each month? .......................................................................................................
$ per month
54. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)? ......................................................................................... Yes No
55. Have any of your bills ever been turned over to a collection agency? .......................................................................................... Yes No
56. Have you ever had purchased goods repossessed? .................................................................................................................... Yes No
57. Have your wages ever been garnished? ...................................................................................................................................... Yes No
58. Have you ever been delinquent on income or other tax payments? ............................................................................................. Yes No
59. Have you ever failed to file income tax or cheated/lied on an income tax form? ........................................................................... Yes No
60. Have you ever had an employment bond refused? ...................................................................................................................... Yes No
61. Have you ever avoided paying any lawful debt by moving away? ................................................................................................ Yes No
62. Have you ever defaulted on (failed to pay) a loan? ...................................................................................................................... Yes No
63. 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
64. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)? ........ Yes No
65. Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)? ............... Yes No
66. Have you written three or more bad checks in a one-year period? ............................................................................................... Yes No
If you answered “YES” to any of Questions 54-66, explain (include when, where, and why reference corresponding numbers).
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 18 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
SECTION 8: LEGAL
Disclosure of Arrests and Convictions
This section requires you to report detentions, arrests, and convictions, including diversion programs that were not successfully completed,
and in some cases, offenses that may have been pardoned. As a peace officer applicant, you are required to disclose this information,
unless specifically exempted by state or federal law. It is strongly recommended that you consult with an attorney before omitting
any information.
If more space is needed, continue your response on page 25.
67. 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:
67.1
CHARGE APPROX DATE (MM/YYYY) ARRESTING OR DETAINING AGENCY
/
DISPOSITION OR PENALTY
67.2
CHARGE APPROX DATE (MM/YYYY) ARRESTING OR DETAINING AGENCY
/
DISPOSITION OR PENALTY
Supplemental disclosure information included on Page 25
68. Have you ever been placed on court probation? .......................................................................................................................... Yes No
69. 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
70. Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity,
support, etc.)? ............................................................................................................................................................................. Yes No
71. Have the police ever been called to your home for any reason? .................................................................................................. Yes No
72. Have you or your spouse/partner ever been referred to Child Protective Services? ..................................................................... Yes No
73. Have you ever been the subject of an emergency protective order/restraining order/stay-away order? ........................................ Yes No
74. 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
75. Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or other state
or federal assistance? ................................................................................................................................................................. Yes No
76. Have you ever been required to repay any welfare payments, unemployment compensation, or other state or
federal assistance? ...................................................................................................................................................................... Yes No
77. Have you ever filed a false insurance or workers’ compensation claim? ...................................................................................... Yes No
If you answered “YES” to any of Questions 68-77, explain (include court case or document, dates, and circumstances reference corresponding
numbers). If more space is needed, continue your response on page 25.
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 19 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 8: LEGAL continued
Involvement in Criminal Acts Part 1
78. Have you committed any of the following acts within the past seven (7) years? (You do NOT have to report any acts committed prior to age 15.)
You MUST include any acts committed at any time after you were first employed in law enforcement, including as a 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.
78.1
Animal abuse and/or neglect ................................................................................................................................................. Yes No
78.2
Annoying, obscene, or harassing contacts by telephone or other electronic communication device ....................................... Yes No
78.3
Battery (use of force or violence upon another) ........................................................................................................................ Yes No
78.4
Brandishing a weapon (any type of weapon) ............................................................................................................................ Yes No
78.5
Carrying a concealed weapon without a permit ........................................................................................................................ Yes No
78.6
Contributing to the delinquency of a minor ............................................................................................................................. Yes No
78.7
Defrauding an innkeeper (not paying for food or room at a hotel/motel, campground, etc.) .................................................... Yes No
78.8
Driving a vehicle or operating a boat/vessel while under the influence of alcohol and/or drugs .............................................. Yes No
78.9
Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) ............................................. Yes No
78.10
Filing a false police report ...................................................................................................................................................... Yes No
78.11
Hit & run collision (no injuries) .................................................................................................................................................. Yes No
78.12
Illegal gambling ........................................................................................................................................................................ Yes No
78.13
Illegal hunting and/or fishing (for example, without a license, out of season) ............................................................................ Yes No
78.14
Impersonating a peace officer (pretending to be a police officer) ........................................................................................... Yes No
78.15
Indecent exposure and/or lewd or obscene conduct .............................................................................................................. Yes No
78.16
Intentionally writing a bad check ............................................................................................................................................ Yes No
78.17
Joyriding (using a car or other vehicle without owner’s permission) .......................................................................................... Yes No
78.18
Peeping (including, but not limited to, looking through a window or opening with the intent to invade someone’s privacy) ........ Yes No
78.19
Petty theft (value up to $950, including shoplifting/switching price tags) .................................................................................. Yes No
78.20
Possession of alcohol as a minor (under the age of 21) ........................................................................................................... Yes No
78.21
Possession of falsified or altered identification, including use of another person’s ID (for any reason) ...................................... Yes No
78.22
Possession of stolen property (including, but not limited to, vehicles, credit/debit cards, etc.) ................................................... Yes No
78.23
Prostitution or solicitation of prostitution (including, but not limited to, patronizing illegal massage parlors) ............................... Yes No
78.24
Reckless driving ....................................................................................................................................................................... Yes No
78.25
Resisting arrest and/or delaying or obstructing an officer (including, but not limited to, running from the police) ....................... Yes No
78.26
Trespassing ............................................................................................................................................................................. Yes No
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 20 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 8: LEGAL continued
78.27
Vandalism (including, but not limited to, “tagging,” malicious mischief, and/or property damage) .............................................. Yes No
78.28
Any other act amounting to a misdemeanor ............................................................................................................................. Yes No
If you answered “YES” to ANY of the item(s) in Question 78, fully explain circumstances, including dates, names of individuals involved,
and resolution. Reference the corresponding number (e.g., 78.5) for each explanation.
If more space is needed, continue your response on page 25.
Supplemental legal information included on Page 25
, or POST basic course. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
Involvement in Criminal Acts Part 2
79. 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.
79.1
Arson (intentionally destroying property by setting a fire) ....................................................................................................... Yes No
79.2
Assault with a deadly weapon (struck or threatened to strike someone with an instrument likely to cause great bodily
injury or death) ...................................................................................................................................................................... Yes No
79.3
Blackmail or extortion ............................................................................................................................................................ Yes No
79.4
Burglary (entering a structure or vehicle to commit theft or other crime) ................................................................................ Yes No
79.5
Child molestation (performing unlawful acts with a child, inappropriate touching of a child) ................................................... Yes No
79.6
Elder abuse and/or neglect (physical and/or financial) ........................................................................................................... Yes No
79.7
Embezzlement (theft of money or other valuables entrusted to you) ...................................................................................... Yes No
79.8
Felony drunk driving (involving injuries) ................................................................................................................................. Yes No
79.9
Felony illegal sex acts ............................................................................................................................................................ Yes No
79.10
Forcible rape ......................................................................................................................................................................... Yes No
79.11
Forgery (falsifying any type of document, check certificate, license, currency, etc.) ............................................................... Yes No
79.12
Fraudulent use of a credit, ATM, debit, and/or check card ..................................................................................................... Yes No
79.13
Grand theft (value of over $950, automobile, any firearm) ..................................................................................................... Yes No
79.14
Hit & run (with injuries) .......................................................................................................................................................... Yes No
79.15
Hate crime ............................................................................................................................................................................. Yes No
79.16
Insurance fraud ..................................................................................................................................................................... Yes No
79.17
Murder, homicide, attempted murder, or assault with intent to commit murder ........................................................................ Yes No
79.18
Perjury (lying under oath) ...................................................................................................................................................... Yes No
79.19
Possession of an explosive/destructive device ...................................................................................................................... Yes No
79.20
Robbery (theft from another person using a weapon, force, or fear) ...................................................................................... Yes No
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 2/2018)
Page 21 of 25 Initial this page to indicate that you have provided complete and accurate information: _____
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
SECTION 8: LEGAL continued
79.21
Stalking ................................................................................................................................................................................. Yes No
79.22
Theft of a vehicle and/or vehicle parts ................................................................................................................................... Yes No
79.23
Viewing and/or possessing child pornography ....................................................................................................................... Yes No
79.24
Any other act amounting to a felony ...................................................................................................................................... Yes No
If you answered “YES” to ANY of the item(s) in Question 79, fully explain circumstances, including dates, names of individuals involved,
and resolution. Reference the corresponding number (e.g., 79.3) for each explanation.
If more space is needed, continue your response on page 25.
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; it also includes the illegal use of any other 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, 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
80.
Within the past six months, have you used any drug(s) as indicated above? ............................................................................ Yes No
IF YES, give details including drug(s) used, most recent date used, and circumstances:
81. Prior to the past six 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: