Fillable PERSONAL HISTORY QUESTIONNAIRE (City of Oakland)

Fill Online, Printable, Fillable, Blank PERSONAL HISTORY QUESTIONNAIRE (City of Oakland) Form

Use Fill to complete blank online CITY OF OAKLAND (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PERSONAL HISTORY QUESTIONNAIRE (City of Oakland)

On average this form takes 283 minutes to complete

The PERSONAL HISTORY QUESTIONNAIRE (City of Oakland) form is 32 pages long and contains:

  • 0 signatures
  • 20 check-boxes
  • 1123 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FPD Form 70 11/17
FAIRFIELD POLICE DEPARTMENT
5230 PLEASANT AVENUE
FAIRFIELD, OH 45014
513-867-6015
PERSONAL HISTORY QUESTIONNAIRE
INSTRUCTIONS
This Personal History Questionnaire is intended for the use of the Fairfield Police Department. You must be
truthful and complete all answers requested on these forms. Non-disclosure of a material fact must be viewed
by the police department as intentionally withheld by you. All information contained herein will be subject to
verification, i.e., source documentation, polygraph or computer voice stress analysis, and screening
procedures. Information contained herein may be subject to public disclosure under the Ohio Open Records
Law. It is the policy of the Fairfield Police Department that the information contained herein will be treated
confidentially and will only be disclosed to those with an authorized need to know the information, or upon
specific request under R. C. 149.43.
The responses to questions contained in the questionnaire must be typed or printed, in your own hand, legibly
in black ink only. Each individual question must be answered. There can be no blanks. If a question does not
apply to your particular circumstances, insert "DNA" in that blank. When answering questions that require
dates, insert the full date. Partial month-year responses are unacceptable. You must provide complete
address information when requested. Partial address responses are unacceptable.
WARNING
Applicants are cautioned to answer every question truthfully and without evasion. Both the Ohio Revised Code
and Administrative Rules of the City of Fairfield provide penalties for making false statement of material fact,
or for practicing any fraud or deception in obtaining or attempting to obtain employment. Such penalties
include rejection for appointment or discharge after appointment and/or prosecution under Ohio Revised
Code Section 2921.13.
THE FOLLOWING PAGE, TITLED “AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT”,
MUST BE SIGNED AND DATED IN PERSON, AT THE TIME OF SUBMISSION OF THIS BACKGROUND PACKET.
FPD Form 70 11/17
AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT
TO WHOM IT MAY CONCERN: I am an applicant for employment with the Fairfield Police Department. The department needs to thoroughly investigate my
employment background and personal history to evaluate my qualifications to hold the position for which I applied. It is in the public's interest that all relevant
information concerning my personal and employment history be disclosed to the Fairfield Police Department
I hereby authorize any representative of the Fairfield Police Department bearing this release to obtain any information in your files pertaining to my employment and
I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof,
concerning myself, by and to any duly authorized agent of the Fairfield Police Department, whether said records are of a public, private, or confidential nature. The
intent of this authorization is to give my consent for full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and
free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the
Fairfield Police Department to consider in determining my suitability for employment. It is my specific intent to provide access to personnel information, however,
personal or confidential it may appear to be.
I consent to your release of any and all public and private information that you may have concerning me, my work history, my background and reputation, my military
service records, educational records, my financial status, my criminal history record including any arrest records, whether or not convicted, any information contained
in investigatory files, efficiency ratings, complaints or grievances, filed by or against me, either criminal or civil, in which I presently have, or have had an interest,
attendance records, polygraph or other truth verification examinations, and any internal affairs investigations and discipline, including any files which are deemed to
be confidential and/or sealed, notwithstanding any other agreements that I may have signed.
I hereby release you, your organization, and all others from liability or damages that may result from furnishing the information requested, including any liability or
damage pursuant to any state or federal laws. I hereby release you, as the custodian of such records, including officers, employees, or related personnel, both
individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of
compliance with this authorization and request to release information, or any attempt to comply with it. I direct you to release such information upon request of the
representative of the Fairfield Police Department regardless of any agreement I may have made with you previously to the contrary. The Fairfield Police Department
will discontinue processing my application if you refuse to disclose the information requested.
For and in consideration of the Fairfield Police Department's acceptance and processing my application for employment, I agree to hold the City of Fairfield, the
Fairfield Civil Service Commission, and Fairfield Police Department, their agents and employees harmless from any and all claims and liability associated with my
application for employment or in any way connected with the decision whether or not to employee me with the Fairfield Police Department. I understand that
should information of a serious criminal nature surface as a result of this investigation, the information will be turned over to the proper authorities.
I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those
rights with the understanding that information furnished will be used by the Fairfield Police Department in conjunction with employment procedures.
A photocopy or facsimile copy of this release will be valid as an original thereof, even though said photocopy or facsimile copy does not contain an original writing of
my signature.
This waiver is valid for a period of one year from the date of my signature. Should there be any question as to the validity of this release, you may contact me at the
address listed on this form.
I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form.
I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims, damages, losses and
expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request.
I am informed that, with limited exception, the reports, documents, and other information in written form, learned about me will be subject to public disclosure
under R.C. 149.43, the Ohio Open Records law.
Full Name (Printed) ___________________________________________________________
SSN _______________________________________________________________________
Address ____________________________________________________________________
____________________________________________________________________
Telephone __________________________________________________________________
FPD Form 70 11/17
SECTION 1 – PERSONAL AND FAMILY HISTORY
APPLICANT’S NAME
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
DATE OF BIRTH
ADDRESS (NUMBER, STREET, APARTMENT)
CITY
COUNTY
STATE
ZIP
BY WHAT OTHER NAMES HAVE YOU BEEN KNOWN (MAIDEN NAME, FORMER MARRIED NAMES, ALIASES, NICKNAMES, ETC.)
PHONE NUMBER
OHIO DRIVER’S LICENSE NO.
TYPE
EXPIRATION DATE
OUT OF STATE DRIVER’S LICENSE NO.
TYPE/STATE
EXPIRATION DATE
PRESENT MARITAL STATUS
CITY, COUNTY, STATE – PRESENT MARRIAGE PERFORMED
DATE PRESENT MARRIAGE PERFORMED
LIST ANY IDENTIFYING SCARS, TATTOOS, BIRTHMARKS ETC. THAT YOU HAVE
NAME OF CURRENT SPOUSE (LAST, FIRST, MIDDLE)
MAIDEN NAME (SPOUSE – IF APPLICABLE)
SPOUSE’S SOCIAL SECURITY NUMBER
DATE OF BIRTH (SPOUSE)
BIRTH PLACE OF SPOUSE
NAME OF SPOUSE’S EMPLOYER
PHONE NUMBER
FATHER
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
FATHER’S NAME (LAST, FIRST, MIDDLE)
FATHER’S DATE OF BIRTH
IF DECEASED, DATE OF DEATH
FATHER’S ADDRESS
PHONE NUMBER
MOTHER
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
MOTHER’S NAME (LAST, FIRST, MIDDLE)
MOTHER’S DATE OF BIRTH
IF DECEASED, DATE OF DEATH
MOTHER’S ADDRESS
PHONE NUMBER
CHILDREN:
o SON
o DAUGHTER
LAST NAME FIRST MIDDLE
DATE OF BIRTH
PLACE OF BIRTH (CITY, STATE)
ADDRESS (IF DIFFERENT FROM YOUR’S)
RELATIONSHIP TO YOU
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
RELATIONSHIP TO SPOUSE
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
NAME OF OTHER NATURAL PARENT (IF APPLICABLE)
o SON
o DAUGHTER
LAST NAME FIRST MIDDLE
DATE OF BIRTH
PLACE OF BIRTH (CITY, STATE)
ADDRESS (IF DIFFERENT FROM YOUR’S)
RELATIONSHIP TO YOU
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
RELATIONSHIP TO SPOUSE
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
NAME OF OTHER NATURAL PARENT (IF APPLICABLE)
1
BIRTH CERTIFICATE NUMBER
FPD Form 70 11/17
PERSONAL AND FAMILY HISTORY CONTINUED
o SON
o DAUGHTER
LAST NAME FIRST MIDDLE
DATE OF BIRTH
PLACE OF BIRTH (CITY, STATE)
ADDRESS (IF DIFFERENT FROM YOUR’S)
RELATIONSHIP TO YOU
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
RELATIONSHIP TO SPOUSE
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
NAME OF OTHER NATURAL PARENT (IF APPLICABLE)
o SON
o DAUGHTER
LAST NAME FIRST MIDDLE
DATE OF BIRTH
PLACE OF BIRTH (CITY, STATE)
ADDRESS (IF DIFFERENT FROM YOUR’S)
RELATIONSHIP TO YOU
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
RELATIONSHIP TO SPOUSE
o NATURAL
o FOSTER
o STEP
o ADOPTIVE
NAME OF OTHER NATURAL PARENT (IF APPLICABLE)
LIST YOUR RELATIVES IN THE FOLLOWING ORDER:
1. BROTHERS 2. SISTERS 3. STEP BROTHERS 4. STEP SISTERS 5. FATHER-IN-LAW
6.MOTHER-IN-LAW 7. SISTERS-IN-LAW 8 BROTHERS-IN-LAW
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
2
FPD Form 70 11/17
PERSONAL AND FAMILY HISTORY CONTINUED
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
RELATIONSHIP
LAST NAME FIRST MIDDLE
AGE
PHONE NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
Yes No
1. Are you now supporting all dependents that you are required to support? If No, explain in detail
on continuation sheets.
Yes No
2. Are you paying child support or alimony? $ __________ (amount) per month if applicable
Yes No
3. Is the amount you pay in child support/alimony in compliance with the court order or an order
from a support enforcement agency? If No, explain in detail on continuation sheets.
Yes No
4. Have you ever been sued for alimony payments, child support, nonpayment of debt, or fraud? If
Yes, explain in detail below:
COURT
CASE NUMBER
DATE OF DISPOSITION
COURT
CASE NUMBER
DATE OF DISPOSITION
COURT
CASE NUMBER
DATE OF DISPOSITION
Yes No
5. Have you ever been convicted or accused of, or engaged in, physical, emotional, or sexual abuse
of a family or household member? If Yes, explain in detail on continuation sheets.
Yes No
6. Have you ever violated a protection or temporary restraining order? If Yes, explain in detail
on continuation sheets.
Previous Marriages – If previously married, provide the following:
DATE MARRIED
WHERE MARRIED (CITY, STATE)
NAME OF EX-SPOUSE (MAIDEN NAME)
IF DIVORCED (CITY, STATE)
DATE FINALIZED
DATE MARRIED
WHERE MARRIED (CITY, STATE)
NAME OF EX-SPOUSE (MAIDEN NAME)
IF DIVORCED (CITY, STATE)
DATE FINALIZED
Yes No
Are you a U.S. Citizen?
Yes No
Are you a permanent resident alien? If yes, give port of entry to U.S. and date:
PORT OF ENTRY
DATE
3
FPD Form 70 11/17
SECTION 2 – PREVIOUS RESIDENCES RECORD
List last 9 addresses, excluding current address. List most recent, next most recent, etc. Include all military addresses,
listing the nearest city in proximity to the base if you resided on base. If renting or leasing include the agent or
management company to whom you paid rent.
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
FROM (MONTH – YEAR TO (MONTH-YEAR)
WITH WHOM DID YOU LIVE? LAST, FIRST, MIDDLE
RELATIONSHIP
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP)
PROPERTY MANAGER PHONE (IF APPLICABLE)
4
FPD Form 70 11/17
SECTION 3 – Employment History
Yes No
1. May we contact your current employer? If NO, explain why on continuation page and be prepared
to submit copies of performance evaluations or other documentation. If presently unemployed,
indicate so in first box.
Yes No
2. Have you ever received any disciplinary action from any job? If YES, explain on continuation sheets.
Yes No
3. Have you ever been discharged or asked to resign from any job? If YES, make sure job is listed below.
Yes No
4. Have you ever been discharged or asked to resign from a criminal justice occupation?
Begin with your most recent job and list your complete work history in chronological order. Include in sequence all part time jobs,
periods of unemployment and military service. When listing military service, substitute for the name and address of immediate
supervisor, the name, address, and rank of the last commissioned officer who was your immediate commissioned superior, and
substitute for the name and address of co-worker, the name and address of a non-commissioned officer with whom you served.
When listing periods of unemployment, indicate dates in space provided. In the box designated as “Name of Employer” write in
unemployed. In the block designated as “Reason for Leaving “, indicate from what source you received income during that period of
unemployment. Address information must be complete – street, apartment or suite, City, State, and zip code. If more than eleven
places of employment, add additional to continuation sheet.
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
5
FPD Form 70 11/17
Employment History Continued
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
6
FPD Form 70 11/17
Employment History Continued
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
FROM (MONTH – YEAR TO (MONTH-YEAR)
NAME OF EMPLOYER
JOB TITLE
PART TIME OR FULL TIME
Part Time
Full Time
ADDRESS OF EMPLOYER (NUMBER, STREET, CITY, STATE, ZIP)
DESCRIPTION OF DUTIES
REASON FOR LEAVING
TOTAL TIME EMPLOYED
FULL NAME OF IMMEDIATE SUPERVISOR
TELEPHONE # OF BUSINESS
SALARY (ANNUAL)
FULL NAME OF CO-WORKER
TELEPHONE # OF CO-WORKER
Yes No
5. Have you ever applied for a position with any law enforcement or other governmental agency?
NAME OF DEPARTMENT OR AGENCY AND COMPLETE ADDRESS
POSITION APPLIED FOR
DATE APPLIED
ACCEPTED
Yes
No
NAME OF DEPARTMENT OR AGENCY AND COMPLETE ADDRESS
POSITION APPLIED FOR
DATE APPLIED
ACCEPTED
Yes
No
NAME OF DEPARTMENT OR AGENCY AND COMPLETE ADDRESS
POSITION APPLIED FOR
DATE APPLIED
ACCEPTED
Yes
No
NAME OF DEPARTMENT OR AGENCY AND COMPLETE ADDRESS
POSITION APPLIED FOR
DATE APPLIED
ACCEPTED
Yes
No
NAME OF DEPARTMENT OR AGENCY AND COMPLETE ADDRESS
POSITION APPLIED FOR
DATE APPLIED
ACCEPTED
Yes
No
7
Pending
Pending
Pending
Pending
Pending
FPD Form 70 11/17
SECTION 4 – Military and Education Record
Military Record
Have you ever registered with the Selective Service?
Yes No
SELECTIVE SERVICE NUMBER
Have you ever been in a Military Service?
Yes No
Active Reserve
BRANCH OF SERVICE (ARMY, NAVY, ETC)
UNIT (TANK CORPS, ENGINEERS, MEDIC, ETC)
ACTIVE DUTY DATES (TOURS OF 90 DAYS OR MORE)
HIGHEST MILITARY RANK OR RATE HELD
TYPE OF SEPARATION
TOTAL MONTHS OF COMBAT DUTY
TOTAL MONTHS OF OVERSEAS DUTY
NAME AND ADDRESS OF GUARD / RESERVE UNIT
Yes No
Have you ever received a dishonorable discharge? If YES, explain on continuation sheets.
Yes No
Have you ever been convicted of any article of the uniform code of military justice? If YES, explain on
continuation sheets.
Educational Record
1. Have you graduated from high school?
Yes No
HIGHEST GRADE LEVEL COMPLETED
2. Do you have a General Education Development (GED) certificate?
Yes No
3. Have you graduated from college?
Yes No
4. Have you attended any post high school educational institutions?
Yes No
List each high school, trade, part time, night school, business college, and university that you have attended. Start with
the most recent school.
NAME OF SCHOOL
LOCATION OF SCHOOL (CITY AND STATE)
FROM DATE – TO DATE
GRADUATE
Yes No
DEGREES OR # OF UNITS
NAME OF SCHOOL
LOCATION OF SCHOOL (CITY AND STATE)
FROM DATE – TO DATE
GRADUATE
Yes No
DEGREES OR # OF UNITS
NAME OF SCHOOL
LOCATION OF SCHOOL (CITY AND STATE)
FROM DATE – TO DATE
GRADUATE
Yes No
DEGREES OR # OF UNITS
8
FPD Form 70 11/17
SECTION 5 – Traffic Record
Yes No
1. Have you ever been arrested for operating a motor vehicle under the influence of alcohol or
drugs, as an adult or juvenile? If YES, explain on continuation sheets.
2. List all moving violations you have received.
DATE
OFFENSE
CONVICTED
YES NO
LOCATION OR CITING AGENCY
AGE AT TIME OF VIOLATION
DATE
OFFENSE
CONVICTED
YES NO
LOCATION OR CITING AGENCY
AGE AT TIME OF VIOLATION
DATE
OFFENSE
CONVICTED
YES NO
LOCATION OR CITING AGENCY
AGE AT TIME OF VIOLATION
DATE
OFFENSE
CONVICTED
YES NO
LOCATION OR CITING AGENCY
AGE AT TIME OF VIOLATION
DATE
OFFENSE
CONVICTED
YES NO
LOCATION OR CITING AGENCY
AGE AT TIME OF VIOLATION
DATE
OFFENSE
CONVICTED
YES NO
LOCATION OR CITING AGENCY
AGE AT TIME OF VIOLATION
3. List traffic accidents you have been involved in.
DATE
LOCATION
CITED
YES NO
AGENCY OF TRAFFIC CITATION
DATE
LOCATION
CITED
YES NO
AGENCY OF TRAFFIC CITATION
DATE
LOCATION
CITED
YES NO
AGENCY OF TRAFFIC CITATION
DATE
LOCATION
CITED
YES NO
AGENCY OF TRAFFIC CITATION
DATE
LOCATION
CITED
YES NO
AGENCY OF TRAFFIC CITATION
Yes No
4. Do you have automobile insurance? If NO, explain on continuation page.
INSURANCE AGENCY
POLICY NUMBER
PHONE NUMBER
Yes No
5. Has your driver’s license ever been revoked or suspended? If YES, explain on continuation page.
9
FPD Form 70 11/17
Section 5 - Traffic Record Continued
6. List all out of state driver’s licenses you have held and whether they are currently valid.
STATE
LICENSE NUMBER
VALID
YES NO
DATES VALID (IF NOT CURRENT)
STATE
LICENSE NUMBER
VALID
YES NO
DATES VALID (IF NOT CURRENT)
STATE
LICENSE NUMBER
VALID
YES NO
DATES VALID (IF NOT CURRENT)
STATE
LICENSE NUMBER
VALID
YES NO
DATES VALID (IF NOT CURRENT)
Yes No
7. Have you ever been convicted of vehicular homicide or vehicular manslaughter? If YES, explain
on continuation page.
SECTION 6 – General Information Inquiry
Yes No
1. Have you ever stolen anything from your employer? If YES, list items in detail below.
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
Yes No
2. Other than from your employer, have you ever stolen anything? If YES, list items in detail below.
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
DATE
ITEM
VALUE
FROM WHOM
AGE AT TIME
10
FPD Form 70 11/17
Section 6 - General Information Inquiry Continued
Yes No
3. Have you ever received Welfare, Workers Compensation, Unemployment Compensation, or
other public assistance illegally, or above the amount you were entitled?
DATE RECEIVED
TYPE OF BENEFIT
AMOUNT RECEIVED
DATE RECEIVED
TYPE OF BENEFIT
AMOUNT RECEIVED
DATE RECEIVED
TYPE OF BENEFIT
AMOUNT RECEIVED
DATE RECEIVED
TYPE OF BENEFIT
AMOUNT RECEIVED
DATE RECEIVED
TYPE OF BENEFIT
AMOUNT RECEIVED
Yes No
4. Have you ever used, tried, or purchased marijuana? If YES, describe below.
LAST DATE USED
# OF TIMES USED / TRIED
DATE PURCHASED
LAST DATE USED
# OF TIMES USED / TRIED
DATE PURCHASED
LAST DATE USED
# OF TIMES USED / TRIED
DATE PURCHASED
LAST DATE USED
# OF TIMES USED / TRIED
DATE PURCHASED
LAST DATE USED
# OF TIMES USED / TRIED
DATE PURCHASED
Yes No
5. Have you ever used, tried, or purchased illegal drugs other than marijuana? If YES, describe below.
DRUG
LAST DATE USED / TRIED
# OF TIMES USED
DATE PURCHASED
# OF TIMES PURCHASED
DRUG
LAST DATE USED / TRIED
# OF TIMES USED
DATE PURCHASED
# OF TIMES PURCHASED
DRUG
LAST DATE USED / TRIED
# OF TIMES USED
DATE PURCHASED
# OF TIMES PURCHASED
DRUG
LAST DATE USED / TRIED
# OF TIMES USED
DATE PURCHASED
# OF TIMES PURCHASED
Yes No
6. Have you ever sold illegal drugs, prescriptive drugs, or marijuana? If YES, describe below.
DRUG
DATE OF SALE
QUANITIY
# OF TIMES SOLD
DRUG
DATE OF SALE
QUANITIY
# OF TIMES SOLD
DRUG
DATE OF SALE
QUANITIY
# OF TIMES SOLD
DRUG
DATE OF SALE
QUANITIY
# OF TIMES SOLD
11
FPD Form 70 11/17
Section 6 - General Information Inquiry Continued
Yes No
7. Have you ever abused alcohol, chemical agents / solvents, or prescriptive drugs (including
steroids)? If YES, describe below.
SUBSTANCE
LAST DATE USED
# OF TIMES USED
SUBSTANCE
LAST DATE USED
# OF TIMES USED
SUBSTANCE
LAST DATE USED
# OF TIMES USED
SUBSTANCE
LAST DATE USED
# OF TIMES USED
Yes No
8. As an adult or a juvenile, other than traffic offenses, have you ever committed or been convicted
of a criminal offense? If YES, list items below.
DATE
OFFENSE
LOCATION
DATE
OFFENSE
LOCATION
DATE
OFFENSE
LOCATION
DATE
OFFENSE
LOCATION
DATE
OFFENSE
LOCATION
Yes
DATE
No 9. Have you ever been convicted of carrying a concealed weapon? If YES, describe below.
LOCATION (CITY AND STATE) REASON
DATE
LOCATION (CITY AND STATE)
REASON
DATE
LOCATION (CITY AND STATE)
REASON
DATE
LOCATION (CITY AND STATE)
REASON
DATE
LOCATION (CITY AND STATE)
REASON
Yes
DATE
BOUGHT SOLD RECEIVED
No 10. Have you ever bought, sold, or received stolen property? If YES, describe below.
BOUGHT, SOLD, OR RECEIVED TYPE OF PROPERTY
VALUE
DATE
BOUGHT, SOLD, OR RECEIVED
BOUGHT SOLD RECEIVED
TYPE OF PROPERTY
VALUE
DATE
BOUGHT, SOLD, OR RECEIVED
BOUGHT SOLD RECEIVED
TYPE OF PROPERTY
VALUE
DATE
BOUGHT, SOLD, OR RECEIVED
BOUGHT SOLD RECEIVED
TYPE OF PROPERTY
VALUE
12
FPD Form 70 11/17
Section 6 - General Information Inquiry Continued
Yes No
11. Do you have any problems because of gambling? If YES, explain on continuation page.
Yes No
12. Do you have any problems controlling you temper? If YES, explain on continuation page.
Yes No
13. Is there anything in your medical or psychological history, that you are aware of, that could
disqualify you for this position? If YES, explain on continuation page.
Yes No
14. If it became necessary in the course of your police duties to take a human life, would you be
reluctant to do so, because of religious or other beliefs? (Only police officer applicants need to
answer this question.) If YES, explain on continuation page.
Yes No
15. Have you ever been placed on or served in a criminal diversion type program or applied for and
had charges / convictions sealed? If YES, explain on continuation page.
Yes No
16. Have you ever been in prison / jail due to a felony or misdemeanor conviction? If YES,
explain on continuation page.
Yes No
17. Are you presently under indictment or a defendant in any pending criminal, traffic, or civil
actions? If YES, explain on continuation page.
Yes No
18. Have you ever committed a felony for which you were never arrested? If YES, explain on
continuation page.
Yes No
19. Do you have any hatreds or prejudices towards others because of race, sex, national origin, color,
religion, or disability that would be detrimental to your functioning as a police officer? If YES, explain
on continuation page.
Yes No
20. Have you engaged in any grossly unnatural sex acts? If YES, explain on continuation page.
Yes No
21. Have you engaged in any illegal sexual activities? If YES, explain on continuation page.
Yes No 1. Are you now delinquent in any financial obligation?
Yes No 2. Do your monthly bills exceed your take-home pay?
Yes No 3. Do you, your spouse, or ex-spouses have any pending civil actions?
Yes No 4. If employed by the Police Department, do you anticipate any income other than your salary?
Yes No 5. Have you ever been garnished, filed for bankruptcy, or been declared bankrupt?
6. Indebtedness: Involving you, your spouse, or your ex-spouses for which you are liable.
TO WHOM OWED ADDRESS
DATE OCCURRED ORIGINAL AMOUNT AMOUNT DUE MONTHLY PAYMENT
SECTION 7 - Financial Record
13
FPD Form 70 11/17
SECTION 7 – Financial Record Continued
TO WHOM OWED
ADDRESS
DATE OCCURRED
ORIGINAL AMOUNT
AMOUNT DUE
MONTHLY PAYMENT
TO WHOM OWED
ADDRESS
DATE OCCURRED
ORIGINAL AMOUNT
AMOUNT DUE
MONTHLY PAYMENT
TO WHOM OWED
ADDRESS
DATE OCCURRED
ORIGINAL AMOUNT
AMOUNT DUE
MONTHLY PAYMENT
TO WHOM OWED
ADDRESS
DATE OCCURRED
ORIGINAL AMOUNT
AMOUNT DUE
MONTHLY PAYMENT
TO WHOM OWED
ADDRESS
DATE OCCURRED
ORIGINAL AMOUNT
AMOUNT DUE
MONTHLY PAYMENT
NAME OF YOUR BANK
TYPE OF ACCOUNT
CHECKING SAVINGS
LOCATION
NAME OF YOUR BANK
TYPE OF ACCOUNT
CHECKING SAVINGS
LOCATION
NAME OF YOUR BANK
TYPE OF ACCOUNT
CHECKING SAVINGS
LOCATION
YEAR, MAKE, MODEL OF YOUR PRESENT VEHICLES
LICENSE PLATE NUMBER
DATE PURCHASED
NAME OF LEGAL OWNER
YEAR, MAKE, MODEL OF YOUR PRESENT VEHICLES
LICENSE PLATE NUMBER
DATE PURCHASED
NAME OF LEGAL OWNER
14
FPD Form 70 11/17
References: Fill in the names of three adults not related to you and not former employers, who have known you for a
period of preferably more than five years.
NAME
ADDRESS
OCCUPATION OR PROFESSION
YEARS KNOWN
HOME PHONE
BUSINESS OR CELL PHONE
NAME
ADDRESS
OCCUPATION OR PROFESSION
YEARS KNOWN
HOME PHONE
BUSINESS OR CELL PHONE
NAME
ADDRESS
OCCUPATION OR PROFESSION
YEARS KNOWN
HOME PHONE
BUSINESS OR CELL PHONE
All applicants must sign the following certificate
I certify that the statements contained in this questionnaire, and any pages I have attached, are true to the best of my
knowledge. I understand that any false statements made in this questionnaire may be cause for disapproval of my
appointment or for discharge after appointment.
APPLICANT’S SIGNATURE
DATE
15
FPD Form 70 11/17
CONTINUATION PAGE
SECTION
NUMBER
PAGE
NUMBER
QUESTION
NUMBER
CONTINUATION
16
FPD Form 70 11/17
CONTINUATION PAGE
SECTION
NUMBER
PAGE
NUMBER
QUESTION
NUMBER
CONTINUATION
17
FPD Form 70 11/17
CONTINUATION PAGE
SECTION
NUMBER
PAGE
NUMBER
QUESTION
NUMBER
CONTINUATION
18
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PERSONAL HISTORY QUESTIONNAIRE (City of Oakland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 December 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document