CHECK THE POSITION YOU ARE APPLYING FOR:
POLICE OFFICER CERTIFIED OFFICER NON-SWORN POSITION (Please specify: ______________________________________________________
Instructions to the Applicant:
1. Your application must be TYPED or printed legibly in BLACK INK.
2. You are responsible for obtaining correct and complete addresses. If you are not sure of an address, personally verify before making that
entry on the history statement. ALL ADDRESSES MUST BE COMPLETE WITH ZIP CODES.
3. All time periods in your background must be accounted for.
4. You are responsible for furnishing any changes and/or updating your application as needed, such as address changes or telephone
changes in writing.
5. 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. ALL questions on this application MUST be answered IN FULL before it will be accepted for processing. Failure to
complete the application does not exclude applicant from being hired. Any delay in providing this information will have a negative impact
on your consideration for employment. Intentional omissions or falsifications will result in immediate disqualification.
6. If you need more space for any response, use the supplemental information page on the last page of this form (Page 30) and identify the
additional information by the question number.
7. Below is the list of required documents needed to process your application. Please submit copies of all applicable documents with your
completed Personal History Statement. Do not submit originals. Copies of the requested documents will not be returned to you.
Valid driver’s license
Social Security Card
Certified (Department of Health) Birth Certificate
High school diploma or GED certificate (GED must be accompanied by the test scores)
College degree or transcript from every university attended (sealed originals in envelope) if no degree was
achieved.
Military DD Form 214
Original Naturalization Certificate, if applicable (No photo copy, applicant will provide this at the time of the initial
Interview).
Marriage License/Divorce decree
Court Orders (legal separations, adoptions, name changes, and bankruptcy petition/discharge.)
A current copy (past 6 months) of your credit report.
TO THE APPLICANT- IMPORTANT NOTICE!
Employees are exposed to confidential and law enforcement sensitive information. You will be the subject of a complete
background investigation consisting of family, personal, employment, financial, driving and criminal history. A thorough
background investigation is required to properly evaluate the suitability of applicants for employment with the agency. These
instructions are provided as a guide to assist you in properly completing your Personal History Statement. IT IS ESSENTIAL
THAT THE INFORMATION IS ACCURATE IN ALL RESPECTS, SO PLEASE READ ALL INSTRUCTIONS CAREFULLY
BEFORE PROCEEDING. All applicants will be administered a polygraph examination prior to acceptance for employment by
the Manassas City Police Department to determine the truthfulness of the information furnished.
ANY MISSTATEMENT, MISREPRESENTATION, FALSIFICATION OF FACT, OR OMISSION OF ANY INFORMATION
REQUESTED IN THIS APPLICATION OR IN THE HIRING PROCESS WILL PERMANENTLY DISQUALIFY YOU FROM
EMPLOYMENT WITH THE MANASSAS CITY POLICE DEPARTMENT.
I hereby certify that I have read, understood and agree to the foregoing information and conditions, AS WELL AS THE
INSTRUCTIONS that follow, and further, certify that all of my statements and responses contained herein are, to the best of
my knowledge and belief, true, complete, correct and made in good faith. I understand that knowing and/or a willful false
statement in this Personal History Statement constitutes grounds for immediate disqualification from the hiring process or
termination after I have been employed. I understand that I must pass a polygraph examination and a physical examination
to be considered for employment.”
_________________________________________ ________________________________________________
Signature of Applicant Date
PRINT OR TYPE FULL NAME (FIRST, MIDDLE, LAST)
CITY OF MANASSAS POLICE DEPARTMENT
Applicant Personal History Statement
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Report To:
Manassas City Police Department
Recruitment / Applicant Investigation Division
9518 Fairview Avenue
Manassas, Virginia 20110
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
click to sign
signature
click to edit
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 07/2018)
Page 2 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
TABLE OF CONTENTS
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 3 of 31 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
Have you ever gone by or used a different name? .............................................................................................................................. Yes No
Has your name ever been changed by court order? ........................................................................................................................... Yes No
Please list all names you have used or been known by (include maiden name and nicknames:
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, by naturalization? If by naturalization, please include the COURT and CERTIFICATE/PETITION numbers on the Supplemental Information
Page (page 30). Please also include PARENT(S’) applicable certification numbers and Alien registration numbers. .......................... Yes No
9. BIRTH PLACE (CITY / COUNTY / STATE / NATIVE 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:
14.1 Have you ever used a date or place of birth other than what is listed on your birth certificate? Yes No
14.2 Have you ever intentionally altered your name, date of birth, address, or place of birth on any official document? Yes No
14.3 Have you ever lied about your name, age, address, or place of birth on any official document? Yes No
14.4 Have you ever obtained a fraudulent identification or “fake ID”? Yes No
14.5 Have you ever used a different social security number? Yes No
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 4 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES
15. 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 30 reference corresponding numbers.
15.A Spouse / Registered Domestic Partner / Engaged Partner
Deceased
N/A
NAME
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
HOME PHONE
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
CELL PHONE DATE OF BIRTH
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
15.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
CELL PHONE DATE OF BIRTH
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
Supplemental relatives information included on page 30
15.C Parents / Guardians / In-laws
List ALL parents/guardians/in-laws living or deceased, including biological, adoptive, foster, step-parents, etc.
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 5 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES (Continued)
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.D Brothers / Sisters
N/A
List ALL LIVING siblings, including half-siblings, step-siblings, foster-siblings, etc.
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
15.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
CELL PHONE DATE OF BIRTH
EMAIL
Supplemental relatives information included on page 30
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 6 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES (Continued)
15.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.
15.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
15.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
15.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
15.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 30
SECTION 2: RELATIVES AND REFERENCES QUESTIONS
15. F.1 Has your spouse, significant other, or family member ever called the police on you? YES NO
15. F.2 Has your spouse, significant other, or family member ever claimed you assaulted him/her? YES NO
15. F.3 YES NO
15. F.4 Has anyone, including your spouse, significant other, or family member, ever claimed that you
mistreated, beat, abused, or sexually molested your child or any other child? YES NO
Have any members of your immediate family ever been arrested?
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 7 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES CONTINUED
16. LIST OF REFERENCES
Provide the data requested below for 3-5 references, not related by blood or marriage, not former employers and not mentioned elsewhere in this
form, who are responsible adults of reputable standing in their community, and have known you well for at least three (3) years. These references
may include, but are not limited to: former school teachers, counselors, property owners, members of the clergy, and business people.
16.1
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?
16.2
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?
16.3
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?
16.4
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?
16.5
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?
16.6
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?
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 8 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 2: RELATIVES AND REFERENCES CONTINUED
16. LIST OF REFERENCES
Provide the data requested below for 3-5 references, not related by blood or marriage, not former employers and not mentioned elsewhere in this
form, who are responsible adults of reputable standing in their community, and have known you well for at least three (3) years. These references
may include, but are not limited to: former school teachers, counselors, property owners, members of the clergy, and business people.
16.6
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?
16.7
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?
16.8
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?
16.9
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?
16.10
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 30
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 9 of 31 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 30.
17A. CHECK APPLICABLE
MM/YYYY
MM/YYYY
High School Diploma:
High School Equivalency Test:
17B. 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
18.4 Have you ever misrepresented your educational level? Yes No
18.5 Were your degrees obtained fraudulently? Yes No
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 30
LIST ALL POST BASIC COURSES ATTENDED
20. Have you ever taken a firearms proficiency 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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 10 of 31 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 30
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 30.
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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 11 of 31 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 30
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 12 of 31 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 30.
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
30
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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 13 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
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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 30.
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/ SALARY
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)
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/SALARY
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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 14 of 31 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 /SALARY
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 / SALARY
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 / SALARY
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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 15 of 31 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 / SALARY
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 / SALARY
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 30
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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 16 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
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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
Have stolen anything or assisted someone in stealing from an employer? ...................................................................................... Yes No
39. Have you ever called in sick when you were neither sick nor caring for a sick family member? ....................................................... Yes No
Have you ever called in sick when you were too intoxicated or “hung over” to come into work? ...................................................... 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 while working (i.e. on duty)? (NOTE: Do not include lawful contact such as pat searches in law
enforcement duties and/or training.) ................................................................................................................................................ Yes No
While working (i.e. on duty), have you ever drank any alcoholic beverage or used any illegal drug? ............................................... 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 30
42. Have you ever been intoxicated or under the influence of drugs on any job? .................................................................................. Yes No
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:
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 17 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT (Continued)
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 answeredYES 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 30.
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)
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)
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 18 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 5: EXPERIENCE AND EMPLOYMENT (CONTINUED)
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)
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)
45.8
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 30
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 19 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
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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:
47a. Have you ever served in the military? .......................................................................................................................................... Yes No
47b. Have you ever been denied entry into the armed service for any reason? ................................................................................... Yes No
48. If you answered “YES” to Question 47a, 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:
Highest Rank Attained: Position:
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
Were you ever picked up by the military police for any reason? ................................................................................................... Yes No
If you answered “YES” to any of Questions 50-52, explain (include dates and circumstances).
Supplemental military information included on Page 30
, or POST basic course. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
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 of have any judgements or liens against you? ..................... Yes No
56. Have you ever had purchased goods repossessed? .................................................................................................................... Yes No
57. Have your wages ever been garnished? ...................................................................................................................................... Yes No
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 20 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
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SECTION 7: FINANCIAL (Continued)
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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 21 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
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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 police department 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 30.
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 30
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. a. Have you ever filed a false insurance or workers’ compensation claim? ................................................................................... Yes No
b. Have you ever cheated your employer out of anything? ........................................................................................................... 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 30.
PERSONAL HISTORY STATEMENT
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 22 of 31 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 since the age of eighteen (18)? (You do NOT have to report any acts committed prior to age 15.)
NOTE: Please list all times you committed the act even if you were not caught.
POLICE OFFICER APPLICANT: 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/hiding merchandise) ................................................... 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
POLICE DEPARTMENT APPLICANT
(REV. 01/2019)
Page 23 of 31 Initial this page to indicate that you have provided complete and accurate information: _____
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SECTION 8: LEGAL continued
Involvement in Criminal Acts Part 1 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
78.29
Have you ever been a lookout while someone else committed these acts? .............................................................................. 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 30.
Supplemental legal information included on Page 30 ,
Involvement in Criminal Acts Part 2
79. At any time in your life, have you EVER committed any of the following acts? NOTE: Please list all times you committed the act even if you were
not caught.
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