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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

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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.

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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

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 29–41, 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 (1–4) 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:

PERSONAL HISTORY STATEMENT – Peace Officer

POST 2-251 (Rev 2/2018)

Page 22 of 25 Initial this page to indicate that you have provided complete and accurate information: _____

_______________________________________________________________________________________________________

SECTION 8: LEGAL continued

82. Have you EVER engaged in any of the activities listed below involving drugs, narcotics or illegal substances, including marijuana and/or prescription

drugs without a prescription? Yes No If YES, indicate which activities (mark all that apply):

Sold Manufactured Purchased Furnished Cultivated Carried or Held for Another

IF ANY ITEM IS CHECKED, give details including drug(s) involved, over what time period(s), and circumstances.

83. During the past five years, have you associated with friends, acquaintances, housemates, or family members who

have illegally used drugs or narcotics, and/or illegally used prescription medications? .................................................................. Yes No

IF YES, explain:

Supplemental drug information included on Page 25

, or POST basic course. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.

SECTION 9: MOTOR VEHICLE INFORMATION

84. Current Driver’s License:

STATE OF ISSUE LICENSE NUMBER EXPIRATION DATE (MM/DD/YYYY) NAME UNDER WHICH LICENSE WAS GRANTED

/ /

85. List other states where you have been licensed to operate a motor vehicle:

STATE OF ISSUE LICENSE NUMBER (IF KNOWN) TYPE OF LICENSE NAME UNDER WHICH LICENSE WAS GRANTED

86. Have you ever been refused a driver’s license by any state? ........................................................................................................ Yes No

IF YES, explain (include when, where, and circumstances):

87. Has your driver’s license ever been suspended or revoked? ........................................................................................................ Yes No

IF YES, explain (include when, where, and circumstances):

_______________________________________________________________________________________________________

PERSONAL HISTORY STATEMENT – Peace Officer

POST 2-251 (Rev 2/2018)

Page 23 of 25 Initial this page to indicate that you have provided complete and accurate information: _____

______________________________________________________________________________________________________

SECTION 9: MOTOR VEHICLE INFORMATION continued

88. List your current liability insurance on your vehicle(s).

88.1

TYPE OF COVERAGE VEHICLE MAKE YEAR (YYYY) VEHICLE LICENSE

Insured Bonded Cash Deposit

INSURANCE COMPANY POLICY NUMBER EXPIRATION DATE (MM/DD/YYYY)

/ /

ADDRESS (NUMBER/STREET) CITY STATE ZIP CONTACT NUMBER

( )

88.2

TYPE OF COVERAGE VEHICLE MAKE YEAR (YYYY) VEHICLE LICENSE

Insured Bonded Cash Deposit

INSURANCE COMPANY POLICY NUMBER EXPIRATION DATE (MM/DD/YYYY)

/ /

ADDRESS (NUMBER/STREET) CITY STATE ZIP CONTACT NUMBER

( )

88.3

TYPE OF COVERAGE VEHICLE MAKE YEAR (YYYY) VEHICLE LICENSE

Insured Bonded Cash Deposit

INSURANCE COMPANY POLICY NUMBER EXPIRATION DATE (MM/DD/YYYY)

/ /

ADDRESS (NUMBER/STREET) CITY STATE ZIP CONTACT NUMBER

( )

89. Have you received any traffic citations, excluding parking citations, within the past seven years. Yes No If YES, give details below.

89.1

NATURE OF VIOLATION LOCATION (STREET) CITY STATE

DATE VIOLATION OCCURRED ACTION TAKEN

Month: Year: Not Guilty Fined Traffic School Dismissed

89.2

NATURE OF VIOLATION LOCATION (STREET) CITY STATE

DATE VIOLATION OCCURRED ACTION TAKEN

Month: Year: Not Guilty Fined Traffic School Dismissed

89.3

NATURE OF VIOLATION LOCATION (STREET) CITY STATE

DATE VIOLATION OCCURRED ACTION TAKEN

Month: Year: Not Guilty Fined Traffic School Dismissed

90. Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following (check all that apply):

Failed to Appear Failed to Complete Traffic School Failed to Pay the Required Fine

IF CHECKED, explain circumstances:

91. Have you been involved as the driver in a motor vehicle accident within the past seven years? .................................................. Yes No

IF YES, give details below.

91.1

DATE OF ACCIDENT (MM/YYYY) LOCATION (STREET) CITY STATE

POLICE REPORT LAW ENFORCEMENT AGENCY AT FAULT? WAS THE ACCIDENT?

Yes No Yes No Injury Non-injury

91.2

DATE OF ACCIDENT (MM/YYYY) LOCATION (STREET) CITY STATE

POLICE REPORT LAW ENFORCEMENT AGENCY AT FAULT? WAS THE ACCIDENT?

Yes No Yes No Injury Non-injury

PERSONAL HISTORY STATEMENT – Peace Officer

POST 2-251 (Rev 2/2018)

Page 24 of 25 Initial this page to indicate that you have provided complete and accurate information: _____

_______________________________________________________________________________________________________

SECTION 9: MOTOR VEHICLE INFORMATION continued

91.3

DATE OF ACCIDENT (MM/YYYY) LOCATION (STREET) CITY STATE

POLICE REPORT LAW ENFORCEMENT AGENCY AT FAULT? WAS THE ACCIDENT?

Yes No Yes No Injury Non-injury

92. Have you ever driven a vehicle without auto insurance, as required by law? ................................................................................ Yes No

IF YES, GIVE REASON FROM (MM/YYYY) TO (MM/YYYY)

/ /

93. Have you ever been refused automobile liability insurance or a bond, or had them cancelled? ..................................................... Yes No

IF YES, GIVE REASON

DATE (MM/YYYY)

INSURANCE COMPANY

Supplemental motor vehicle information included on page 25

SECTION 10: OTHER TOPICS

94. Have you ever been refused a permit to carry a concealed weapon? ............................................................................................. Yes No

95. Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other group

that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,

gender, sexual preference, or disability?......................................................................................................................................... Yes No

96. Other than in self-defense, have you ever used force or violence against another person with whom you have had a dating,

romantic or intimate relationship with, or who resided in the same household as you? ................................................................... Yes No

97. Since the age of 15, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act? ........... Yes No

98. Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise, street gang,

or any other group that advocates violence against individuals because of their race, religion, political affiliation, ethnic

origin, nationality, gender, sexual preference, or disability? ............................................................................................................ Yes No

If you answered “YES” to any of Questions 94–98, give details including dates and circumstances – reference corresponding numbers).

SECTION 11: CERTIFICATION

99. I hereby certify that I have personally completed and initialed each page of this form and any attached supplemental page(s), and that all

statements made are true and complete to the best of my knowledge and belief. I understand that any misstatement of material fact may

subject me to disqualification; or, if I have been appointed, may disqualify me from continued employment.

Signature in Full:  Date:

Use the following page to continue your responses, if/as appropriate. Be sure to review all responses carefully and

provide additional information, as necessary. Reference corresponding question/item numbers.

PERSONAL HISTORY STATEMENT – Peace Officer

POST 2-251 (Rev 02/2018)

Page 25 of 25 Initial this page to indicate that you have provided complete and accurate information: _____

SUPPLEMENTAL INFORMATION

• Use this space to provide information that does not fit elsewhere on this form (e.g., additional family members, schools, residences, employers,

explanations to questions, etc.). Reference the corresponding questions and/or specific items.

• You may print copies of this page as needed. If you are filling in this page online, text will flow to additional pages automatically.

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Completed 13 July 2021

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