Fillable Sworn Personal History Statement MAURY COUNTY SHERIFF'S DEPARTMENT (Maury County Government)

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Sworn Personal History Statement MAURY COUNTY SHERIFF'S DEPARTMENT (Maury County Government)

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Page 1 of 35
MAURY COUNTY SHERIFF'S DEPARTMENT
Sworn Personal History Statement
If you have any questions, or need to make notification of changes, please contact:
Criminal Investigation Division
Det/Sgt Keith Wrather
Terri Coppes
(931) 380-5725
Applicant’s Full Name: ___________________________ Phone Number: _______________
PLEASE READ VERY CAREFULLY
Thank you for applying with the Maury County Sheriff's Department, an Equal Opportunity
Employer. We want to make each applicant aware that this process traditionally takes four (4) to six (6)
months to complete, and we ask that you be very patient with our process and us. Attached is your Personal
History Statement and the related forms. Please note on the Applicant Agreement Form that your
Personal History Statement, including all attachments, are due to the Criminal Investigation Division (1301
Lawson White Drive, Columbia Tn) no later than 3:00 pm on .
You must provide complete and current information including zip codes, email addresses and
telephone numbers with area codes. Also, it is your responsibility to update the detective, within forty-eight
(48) hours, of any change of information you provided on the Personal History Statement. Such changes of
information would include, but are not limited to the following: changes of name, telephone numbers,
addresses, work history, information regarding arrests or any interaction with a Law Enforcement Officer, etc.
You should also notify this office of any extended absence from home, such as military leave or vacation, and
any interaction with law enforcement or legal issues civil or criminal.
Failure to comply with any instructions given to you may result in immediate disqualification from the
hiring process. It is to your advantage to BE ABSOLUTELY TRUTHFUL in answering all questions on your
PHS and during all interviews.
Page 2 of 35
T
able of Contents
A
greement Form……………………………………..3
Certification and Release………………………...4 - 6
Audio/Video Recording Release…………………….7
Domestic Violence Acknowledgement……………...7
Important Instructions……………………………….8
Section 1: Personal Data……………………..…9 - 13
Section 2: Arrests………………………..…….13 - 15
Section 3: Personal Questionnaire…………….15 - 19
Section 4: Education & Training………….…….….20
Section 5: Employment……………………….20 - 25
Section 6: Military Service………………...….25 - 30
Section 7: Traffic Records….............................31 - 32
Section 8: Financial……………………...........33 - 34
Section 9: Personal References……….………34 - 35
Section 10: Experience Summary…………….……35
Page 3 of 35
APPLICANT AGREEMENT FORM
I, the undersigned applicant for a Deputy Sheriff or Correctional Officer position with the Maury County
Sheriff's Department, hereby agree to the following:
I understand the Maury County Sheriff's Department, Criminal Investigation Division must receive
my completed Personal History Statement, on the date of my Civil Service Interview. Failure to
meet this deadline will subject me to disqualification, and I may not reapply for six months.
I further understand that all of the requested information on the Personal History Statement must and
will be provided by me. Further, I understand that marking N/A to indicate it is non-applicable will
complete any requested information, which does not apply to me. I acknowledge and understand that
the entire form must be completed and that it is unacceptable to submit a Personal History Statement
with unanswered (blank or incomplete responses). I understand that incomplete forms will not be
processed any further, and I may not reapply for six months.
I understand that I will be required to comply with any written or oral request, order, or directive
communicated to me by any individual recognized as a representative of the Maury County Sheriff's
Department, Criminal Investigation Division, as it applies to my application for employment with
said Department. I hereby acknowledge that I will be required to provide requested
information or documentation within a specified time period, and that the failure to do so may result
in my immediate disqualification as an applicant, and that I may not reapply for six months.
I hereby acknowledge that I have read and fully understand each of the statements contained herein above,
and further, that I had the opportunity to ask for clarification of each of the statements and that my signature
was not placed hereon until I fully understood each statement.
Applicant Name
Applicant Signature
Date
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signature
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Page 4 of 35
APPLICANT CERTIFICATION AND RELEASE
Read each of the following statements carefully. If you do not understand one of
the statements, ask for an
explanation prior to signing. Failure to abide by the following statements may
subject you to immediate
disqualification.
I agree to immediately notify the Criminal Investigation Division if I have any interaction or
contact with
any Law Enforcement Official. This includes but is not limited to: reports that are
matter of
record, citations, traffic stops, tickets, arrests, interviews, requests for information etc.
I agree to have the U. S. Internal Revenue Service furnish the Sheriff copies of my income tax returns at
any time during my processing as an applicant, and my probation period.
I agree to submit to a polygraph/ CVSA, should it become necessary, at the direction of
the Sheriff
or Detective in Charge, at any time during my processing as a
deputy applicant and during my
probationary period.
I certify that there are no misrepresentations, omissions, or falsifications in the foregoing
statements
and answers, and that the entries made or attached by me are true, complete, and
correct to the best of
my knowledge and belief and are made in good faith.
I further agree and consent in advance to being immediately disqualified and/or discharged if any of
the above information contains any misrepresentations or falsifications or if any material
information has been omitted.
I further agree that should I change my address or place of employment, I will notify the
Criminal Investigation Division of the Maury County Sheriff's Department within 48 hours. Should I fail
to do this, it may subject me to disqualification as an applicant. Also, I shall report any interaction with
law enforcement or legal issues criminal or civil by applicant or immediate family during application
period or during the training process.
Applicant Name
Applicant Signature
Date
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Page 5 of 35
**THIS PAGE MUST BE NOTARIZED**
I hereby certify that all statements made in this application or attached to it are true and correct
to the best of my knowledge. I am aware that withholding pertinent information or information
found to be materially (grossly) inaccurate may be cause for refusing further consideration of my
application, or will constitute grounds for my termination if I am employed. I understand this is
not to be considered as an indication of probable obligation upon the department to make an
appointment, but a part of the selection process only. I understand that failure on my part to
comply with any instructions given or to notify the Maury County Sheriff's Department of a
change of address within 48 hours may subject my file to being closed.
Name of Applicant
Signature of Applicant
NOTARY ACKNOWLEDGEMENT
State of
County of
Personally appeared before me, the undersigned, Notary Public for said County and State,
To me known (or proved to me on the basis of
satisfactory evidence) to be the person who executed the within instrument for the purposes therein
contained.
Witness my hand, at Office this day of , 20
Notary Public
My Commission Expires
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Page 6 of 35
**THIS PAGE MUST BE NOTARIZED**
Release From Liability:
I respectfully request and authorize you to furnish the Maury County Sheriff's Department any
and all information that you have concerning me, my employment record, school and academic
record (to include any disciplinary action), reputation, financial and credit status, criminal
record, and my traffic record. Such information will include but will not be limited to: hospital,
medical, physical, mental, military, police and court records, police reports including juvenile
records, polygraph/CVSA examination reports, background investigative material and reports.
This information is to be used to assist the Maury County Sheriff's Department in determining
my qualifications and fitness for the position I am seeking. I hereby release you, your
organization, or others from any liability or damage which may result from furnishing the
information requested.
Name of Applicant
Signature of Applicant
NOTARY ACKNOWLEDGEMENT
State of
County of
Personally appeared before me, the undersigned, Notary Public for said County and State,
To me known (or proved to me on the basis of
satisfactory evidence) to be the person who executed the within instrument for the purposes therein
contained.
Witness my hand, at Office this day of , 20
Notary Public
My Commission Expires
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Page 7 of 35
AUDIO/VIDEO RECORDING RELEASE
I understand that I may be audio and/or video recorded during the background investigation and/or
civil service testing process. I agree and consent, without compensation, to being audio and/or video
recorded and to the use of any audio and/or video recordings containing my image, likeness, and/or
voice, for the purpose of determining my suitability and/or eligibility for employment.
APPLICANT’S SIGNATURE____________________________ DATE______________________
WITNESS’ SIGNATURE________________________________DATE_____________________
DOMESTIC ABUSE ACKNOWLEDGEMENT
WHAT QUALIFIES AS DOMESTIC ABUSE?
(1) "Abuse" means inflicting, or attempting to inflict, physical injury on an adult or minor by other than
accidental means, placing an adult or minor in fear of physical harm, physical restraint, malicious damage
to the personal property of the abused party, including inflicting, or attempting to inflict, physical injury on
any animal owned, possessed, leased, kept, or held by an adult or minor, or placing an adult or minor in
fear of physical harm to any animal owned, possessed, leased, kept, or held by the adult or minor.
WHO IS A DOMESTIC ABUSE VICTIM?
(5) "Domestic abuse victim" means any person who falls within the following categories:
(A) Adults or minors who are current or former spouses;
(B) Adults or minors who live together or who have lived together;
(C) Adults or minors who are dating or who have dated or who have or had a sexual
relationship, [as used herein "dating" and "dated" do not include fraternization between
two (2) individuals in a business or social context];
(D) Adults or minors related by blood or adoption;
(E) Adults or minors who are related or were formerly related by marriage; or
(F) Adult or minor children of a person in a relationship that is described in subdivisions (5)
(A)-(E); (TCA 36-3-601)
You must immediately report to the Criminal Investigation Division within 48 hours any
Domestic Violence incident that you or your immediate family member is involved in as a
suspect, victim or witness.
APPLICANT’S SIGNATURE____________________________ DATE______________________
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Page 8 of 35
IMPORTANT INSTRUCTIONS
Type an answer to every question. If a question does not apply to you, indicate so with
N/A. If you are not sure if a question applies to you, contact the Criminal Investigation
Division.
If you answered ‘yes’ to a question that requires a detailed explanation, use the continuation
sheet located at the end of each section.
List complete addresses, and telephone numbers (to include numerical, street, city, state,
zip code and area codes).
Prior to submitting this form, signature pages 4 and 5 must be signed and notarized.
All signatures must be affixed in the presence of a Notary Public.
Do not misstate or omit any material facts since the statements made herein are subject
to verification. Failure to follow any instructions may subject you to disqualification.
If you have military experience:
Page 27 is to be completed and notarized by all those who have enlisted in any of the
Armed Forces of the United States (whether currently serving or have prior experience).
Page 29 – Military Records Request Form 180
Complete Section I
Section II - the years the undeleted Report of Separation is requested for, and
Section III - signature of requestor, date of request, daytime phone number, and email address.
The information furnished on this form is to be utilized for the purpose of enabling the Maury
County Sheriff's Department to determine the applicant’s qualifications.
Page 9 of 35
Section 1: Personal Data
1. Last Name: ____________________First Name: _________________Middle Name: ___________
2. Social Security Number: __________-______-______________
3. Driver License Number: _____________________________State:_________________
4. Is this a valid “Class D” driver license? Yes No
5. Home Address: ____________________________________City: ____________________________
State: ___________________Zip: __________County: ______________________________
6. Mailing Address: (if different than home address)__________________________________________
City: __________________________________State:_________________
Zip: ______________County: __________________________
7. Home Phone: _______________ Cell Phone: __________________ Work Phone: ________________
8. Email:____________________________________________________________________
9. Date of Birth: ________________City & State of Birth: _______________________________
10. Sex: Male Female Age: ___ Eye Color: ________ Hair Color: _____________
11. Height: __________ Weight: _________ Race: (as listed on birth certificate) ___________________.
12. Scars, tattoos, and/or distinguishing marks or features: ____________________________________.
13. U.S. Citizen? Yes No If yes, Native Born or Naturalized ?
14. If naturalized, give date, place and court of naturalization. Attach copy of naturalization documentation.
_______________________________________________________________________________________
15. List any other names, aliases, nicknames, or maiden names that you have been known by
________________________________________________________________________________.
16. Yes No Have you ever used a different Social Security number?
If yes, explain: _________________________________________________________________
Page 10 of 35
17. Yes No Have you ever used a date of birth or a name different from your birth certificate?
If yes, explain: _________________________________________________________________
18. Yes No Have you ever intentionally altered your name, address, or date of birth on any official
document, certificate or license?
If yes, explain: _________________________________________________________________
19. List all residences (complete addresses) within the last 10 years. If apartment, include name and
address of apartment complex or landlord below your address. Note: include all military residences.
From
Mo/Yr
Full Address (include city, state, zip code)
20. Marital Status: Married Separated Widowed Single Divorced
How many times have you been married? ______ If divorced, provide copies of all divorce decrees.
21. Current Spouse:
Last Name: ____________________First Name: _________________Middle Name: _________
Maiden Name: ____________________________Phone:______________________________
Social Security Number: ______________________________
Driver License Number: _____________________________State:_________________
Home Address: _______________________________Email:_____________________________
City: __________________________________State:__________________Zip:______________
Date Married: ____________________City/State where performed:__________________________
Spouse’s Employer: ___________________________________Occupation:____________________________
Employer’s Address: ____________________________________Employer’s Phone: __________________
Page 11 of 35
22. Ex-Spouse or Separated Spouse: (If more than one, use continuation of answer table at the end of this
section)
Last Name: ____________________First Name: _______________Middle Name: ______________
Maiden Name: _____________________________ Phone: ______________________________
Social Security Number: ______________________________
Driver License Number: _____________________________State:_________________
Home Address: _______________________________Email (if known):____________________
City: __________________________________State:__________________Zip:______________
Date Married: ____________________City/State where performed: __________________________
Spouse’s Employer: ____________________________________Occupation:___________________________
Employer’s Address: ______________________________________Employer’s Phone: __________________
23. List all children below, including step, foster and adopted children.
Name Sex
Date of
Birth
Have
Custody?
Current Address/Email for children 18 and over
24. Yes No Are you required to pay child support? If yes, explain in detail and include monthly
payment amount.
_________________________________________________________________________________________
25. Yes No Have you ever had wages garnished or attached for non-payment of child support? If yes,
explain in detail. ___________________________________________________________
26. List all parents below.
Father: If deceased, Date of Death________________
Last Name: ____________________First Name: _________________Middle Name: _________
Page 12 of 35
Date of Birth: ____________ Phone: ______________Email:_____________________________
Home Address: _________________________________________________________________
City: __________________________________State:__________________Zip:______________
Mother: If deceased, Date of Death_________________
Last Name: ____________________First Name: _________________Middle Name: _________
Maiden Name:__________________________________________________________________
Date of Birth: ____________ Phone: ______________Email:_____________________________
Home Address: _________________________________________________________________
City: __________________________________State:__________________Zip:______________
If you have Step Parents, please add their information in the continuation of answer table at the end of this
section.
27. List all siblings-step, half, natural and adopted:
Full Name
Date of
Birth
Phone Current Address and Email Line of work
28. Question Removed - Proceed to # 29
Full Name
Date of
Birth
Phone Current Address and Email Line of work
Page 13 of 35
29. List all current and former domestic partners, girlfriends or boyfriends within the last 5 years:
Full Name
Date of
Birth
Phone Current Address and Email Line of work
Page
Number
Question
Number
Section 1 Continuation of Answer
Section 2: Arrests
IMPORTANT! If you answer yes to any of the questions below, provide a full explanation in the continuation
of answer table at the end of this section.
30. Yes No Have you ever been arrested for a criminal offense, felony, misdemeanor, misdemeanor
Page 14 of 35
arrest citation, or had any charges expunged? Even if the charge was expunged, you must
tell us in order to avoid disqualification for failing to disclose, including offenses that
occurred as a juvenile. If expunged, attach a copy of the expungement order.
31. Yes No Have you ever been convicted, pled guilty, or entered a plea of nolo contendere for a
criminal offense, felony, misdemeanor, or misdemeanor arrest citation? Include offenses
that occurred as a juvenile.
32. Yes No Have you ever been placed on or received pretrial diversion, or community corrections
for any charge?
33. Yes No Are there any criminal or civil case pending against you or your immediate family at this
time?
34. Yes No Have you ever received and/or been convicted of a traffic offense, including parking
violations? Conviction also means the payment of fines.
35. Yes No Have you ever been involved in any civil court action?
36. Yes No Have you ever been served with a criminal summons?
37. Yes No Have you ever had a civil order placed against you? To include an order of protection,
restraining order, injunction against harassment.
38. Yes No Have you ever been fingerprinted for any reason other than this hiring process?
39. Yes No Have you ever taken a polygraph or CVSA examination other than for this hiring
process?
40. Yes No Have the police ever been called to your residence for any reason? If yes, explain and
include who called the police.
41. Yes No Have the police ever been called to or summoned to an incident where you were present
or had participated? If yes, explain and include who called the police.
42. Yes No Are there any incidents in which you have been contacted or interviewed by a police
officer? If yes, list all such matters, even if not formally charged, no court appearance
was required, found not guilty, or matter settled by payment or fine. Do not include traffic
tickets.
43. Yes No Have you ever been in a physical confrontation or altercation with anyone, including your
spouse, ex-spouse, children, relatives, girl/boyfriend, or parents? To include pushing,
shoving, etc.
44. Yes No Has your spouse, ex-spouse, children, relatives, girl/boyfriend or parents ever called the
police on you for any reason?
45. Yes No Has your spouse, ex-spouse, children, relatives, girl/boyfriend or parents ever accused
Page 15 of 35
you of battery in a report or discussion with anyone else?
46. Yes No Has anyone ever claimed that you have beaten, abused, mistreated, or sexually assaulted
a child, no matter the relationship or non-relationship of the child to you?
47. Yes No Have you ever abused or mistreated an animal or has anyone ever claimed that you have
abused or mistreated an animal?
48. Yes No Have you ever been the victim of a crime?
Page
Number
Question
Number
Section 2 Continuation of Answer
Section 3: Personal Questionnaire
IMPORTANT! If you answer yes to any of the questions below, provide a full explanation in the continuation
of answer table at the end of this section. Particularly describe the dates, circumstances, and frequency. If
associated with any organization, also include nature and extent of the association, including office or position
held. If associations have been with individuals who are members of these organizations, then list the
individuals and the organizations with which they were or are affiliated.
49. Yes No Are you now or have you ever been a member of any organization, association,
movement, group, or combination of persons which advocates the overthrow of our
constitutional form of government, or which has adopted the policy of advocating or
approving the commission of acts of force or violence to deny other persons their rights
under the law or the Constitution of the United States by unlawful or unconstitutional
means?
50. Yes No Are you now or have you ever been affiliated or associated with any organization of the
type described in question 49, as an agent, official or employee?
51. Yes No Have you ever associated with any individuals, including relatives, who you know or
Page 16 of 35
have reason to believe are or have been members of any organizations described in
question 49?
52. Yes No Have you ever been engaged in any of the following activities of any organization of the
type described previously in question 49: contribution(s) to, attendance of or participation
in any organization, social, or other activities of said organizations or any projects
sponsored by them: the sale, gift, or distribution of any written, printed, or other matter,
prepared, reproduced, or published, by them or any of their agents or instrumentalities?
53. Yes No Have you ever done anything to harm, insult, or frighten another person because of that
person’s race, color, national origin, gender, gender identity, sexual orientation, age,
religion, creed or disability?
54. Yes No Have you ever been delinquent in paying any of your debts or taxes?
55. Yes No Have you ever been bonded?
56. Yes No Have you ever been refused by a bonding company?
57. Yes No Have you ever had any licenses or permits issued to you? Include security guard and
private investigator license, but exclude driver license.
58. Yes No Have you ever been refused a license or permit?
59. Yes No Have you ever applied for a permit to carry a concealed weapon?
If yes, what state? ________________________Was permit granted? Yes No
Reason for Permit: ___________________________________________________
60. Yes No Have you ever been denied a permit to carry a concealed weapon?
61. Yes No To your knowledge, have you ever been the subject of any criminal or civil rights
investigation?
62. Yes No Have you ever driven a motor vehicle when you thought you had drank too much of any
alcoholic beverage or used drugs?
63. Yes No Have you ever been stopped, questioned, or arrested for driving while intoxicated,
driving while impaired, or driving under the influence of alcohol or any controlled
substance, whether you were arrested or not?
64. Yes No Do you routinely consume alcoholic beverages or use drugs? If so, explain the
circumstances, and the setting – include the type of drink or drugs used, and how much
used in an average week.
65. Yes No Have you been intoxicated within the last year? If yes, indicate how many times. When
was the last time you drank any alcoholic beverage or used any type of drug (other than a
drug prescribed by a physician)? List type of alcoholic beverage and/or drug used and
date.
Page 17 of 35
66. Yes No Does your personality change when you have been drinking or using drugs?
67. Yes No Has there been a period in your life when you thought you abused alcoholic beverages or
drugs?
68. Yes No Have you ever had any contact with any law enforcement officer because you had been
drinking?
69. Yes No Have you ever been in a fight or argument with anyone while you had been drinking?
70. Yes No Have you ever used drugs or drank alcoholic beverages while on the job anywhere?
71. Yes No Have you ever called in sick because you were too hung over or drunk to go to work?
72. Yes No Have you ever done anything while under the influence of alcohol or drugs that you
would not have done if you had been sober?
73. Yes No Have you ever used a prescription medication that was prescribed for someone else?
74. Yes No Have you ever used illegal drugs? If yes, use the continuation sheet to list what types
you have used; how many times you have used them, and when was the last time that you
used them.
75. Yes No Have you ever sold or participated in the sale of any kind of narcotic, dangerous drug, or
marijuana? This includes but is not limited to: marijuana, cocaine, crack cocaine, anabolic
steroids, ecstasy, LSD. If yes, use the continuation sheet to explain in detail to include the
last time you sold, kind of drug, and how many times.
76. Yes No Have you ever bought any kind of narcotic, dangerous drug, or marijuana? This includes
but is not limited to: marijuana, cocaine, crack cocaine, anabolic steroids, ecstasy, LSD.
77. Yes No Did you ever deliver, pick up, send, hide, keep or in any other way handle any narcotic,
dangerous drug, or marijuana that belonged to you or someone else? This includes but is
not limited to: marijuana, cocaine, crack cocaine, anabolic steroids, ecstasy, LSD.
78. Yes No Have you ever been involved in an argument or fight because of a narcotic, dangerous
drug, or marijuana? This includes but is not limited to: marijuana, cocaine, crack cocaine,
anabolic steroids, ecstasy, LSD.
79. Yes No Have you ever been present when someone else was selling, or buying a narcotic,
dangerous drug, or marijuana? This includes but is not limited to: marijuana, cocaine,
crack cocaine, anabolic steroids, ecstasy, LSD.
80. Yes No Have you ever used, bought, sold or given away any prescription drugs not lawfully
prescribed to you.
81. Yes No Have you ever purchased alcoholic beverages for a minor?
Page 18 of 35
82. Yes No As an adult, have you ever stolen money? If yes, use continuation sheet to explain.
Include the amount of money and the circumstances.
83. Yes No As an adult, have you ever shoplifted anything at any time in your life?
84. Yes No As an adult, have you ever switched price tags or labels on any merchandise at any
time in your life?
85. Yes No Did you ever buy anything that you suspected or knew was stolen?
86. Yes No Have you ever stolen a gun or weapon of any kind?
87. Yes No Did you ever steal or help someone else steal any kind of vehicle?
88. Yes No Did you ever ride in a vehicle you suspected or knew to be stolen?
89. Yes No Have you ever unlawfully forced entry into any room, building, or residence of any kind
in your life?
90. Yes No Were you ever with someone else who unlawfully forced entry into any room, building,
or residence of any kind in your life?
91. Yes No Have you ever robbed anyone or were you ever with someone else who robbed
someone?
92. Yes No Have you ever snatched a purse or were you ever with someone who snatched a purse?
93. Yes No Have you ever been involved in a fight?
94. Yes No Have you ever been involved in or witnessed any kind of murder or any other type of
killing?
95. Yes No Have you ever been involved in or been accused of any type of forced sexual act?
96. Yes No Have you ever forced anyone to have sexual intercourse with you?
97. Yes No Have you ever forced anyone to kiss, touch, or to have any other type of sexual contact with
you?
98. Yes No Have you intentionally ever viewed, downloaded or possessed materials containing
sexually explicit pictures of minors?
99. Yes No Have you any racial, ethnic, religious, sexual or other prejudices that will affect your job
performance?
100. Yes No Have you ever committed or been involved in any illegal activity involving animals?
Page 19 of 35
101. Yes No Have you ever committed or been involved in the violation of any firearm law or
regulation?
102. Yes No Have you ever committed or been involved in vandalism, fraud, forgery, harassment,
arson, bigamy, bribery, extortion, prostitution, theft, illegal numbers, unlawful gambling,
trespassing, false alarms, embezzlement, illegal eavesdropping, or impersonation of a law
enforcement officer?
103. Yes No Have you ever been on parole or probation for any reason?
104. Yes No Have you ever been the subject of a disciplinary investigation at work, at a volunteer or
other unpaid position, in the military, or in school?
105. Yes No Have you ever committed a crime for which you were not caught?
106. Yes No Is there anything in your past that someone could use to blackmail you?
107. Yes No Are there any incidents in your life not mentioned herein which may reflect upon your
suitability to perform the duties which you may be called upon to take or which might
require further explanation?
Page
Number
Question
Number
Section 3 Continuation of Answer
Page 20 of 35
Section 4: Education & Training
108. High School Name: __________________________________Phone: ___________________________
Address: ____________________________________________________ Year graduated: ___________
109. List all postsecondary education. List the most current first. You must submit an official college transcript
at this time (not a copy). Must be in a sealed envelope from the institution.
Name of School and Location
Dates Attended
(From – To)
Credit Hours
Earned & GPA
Degree/Major
110. List other schools or training (military, specialized schools, trade, technical, vocational, business)
Name of School and Location
Dates Attended
(From – To)
Degree/Certificate
Received
Course of Study
Section 5: Employment
111. List every period of employment, or period of unemployment for the last 10 years. Begin with present
employment. Account for all time periods. Include all part-time, temporary, and/or seasonal employment,
periods of unemployment, and school attendance. Please list complete addresses and telephone numbers with
area code.
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Page 21 of 35
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary:
_____________________________ Duties:
________________________________________________________________________________ Start
Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Page 22 of 35
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Page 23 of 35
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
Employer: _____________________________________________________________________________
Address: ___________________________________________________ Phone: _____________________
Supervisor’s Name: ___________________________________ Supervisor’s Phone: __________________
Supervisor’s Email: ______________________________________________________________________
Co-Worker’s Name: _________________________________ Co-Worker’s Phone: ___________________
Co-Worker’s Email: _____________________________________________________________________
Job Title: ___________________________________________ Salary: _____________________________
Duties: ________________________________________________________________________________
Start Date: _________________________________ End Date: ___________________________________
Reason Left: __________________________________________________ Was Notice Given? Yes No
Did You Ever Receive Any Disciplinary Action? Yes No
IMPORTANT! If you answer yes to any of the questions below, please fully explain on the continuation of
answer table at the end of this section.
112. Yes No Have you ever applied for employment with any law enforcement, criminal justice, or
governmental agency to include the Maury County Sheriff's Department? If yes, use the
continuation table at the end of this section to provide the name of the agency, complete
address, position applied for and approximate date applied.
113. Yes No Have you ever been disqualified by any law enforcement, criminal justice, or
governmental agency including MCSD? If yes, use the continuation table at the end of
this section to provide the name of the agency, complete address, position applied for,
approximate date applied and reason for disqualification.
114. Yes No Have you ever been discharged, asked to resign, laid-off, or subjected to disciplinary
action while in any position (except military)?
115. Yes No Have you ever resigned (quit) after being informed that your employer intended to
discharge (fire) you for any reason?
116. Yes No Have you ever been discharged from any position for failing a probationary period?
117. Yes No Have you ever resigned while under investigation or resigned in lieu of being terminated
for any reason?
118. Yes No Have you ever received unemployment compensation?
119. Yes No Have you ever quit any job without giving notice?
120. Yes No Have you ever been refused a job?
121. Yes No Are there any places where you once worked that would refuse to rehire you?
Page 24 of 35
122. Yes No Have you ever been disciplined, reprimanded, or counseled at any job for any reason?
123. Yes No Have you ever been interviewed by an employer’s internal affairs, quality control, loss
prevention, or other disciplinary unit?
124. Yes No Have you ever been warned, counseled, disciplined, or otherwise spoken to about
comments you made regarding someone’s race, gender, religion, nationality, or sexual
orientation?
125. Yes No Have you ever sexually harassed another employee?
126. Yes No Have you ever called in sick to work when you were not sick?
127. Yes No Have you ever clocked someone else in or had someone else clock you in in violation of
the employer’s rules?
128. Yes No Have you ever used a company vehicle for personal use in violation of the employer’s
rules?
129. Yes No Have you ever intentionally violated any employer’s rules but not been caught?
130. Yes No Have you ever used your position for personal gain in any way?
131. Yes No Have you ever stolen money or anything else from any employer?
132. Yes No Have you ever been accused of stealing any money or anything else from any employer,
whether you did it or not?
133. Yes No Have you ever had any system or plan for stealing from an employer?
134. Yes No Will your current position be in jeopardy if contacted by the Maury County Sheriff's
Department?
135. Yes No At this time do you agree to allow the Maury County Sheriff's Department to contact
any and/all present employers? If no, explain in detail on continuation of answer table
at the end of this section.
Page
Number
Question
Number
Section 5 Continuation of Answer
Page 25 of 35
Section 6: Military Service
If you have never served in any branch of the US Armed Forces, skip to Section 7.
136. In which branch of the US Armed Forces have you served? ______________________________________
You must provide a DD Form 214 (Discharge) for each period of non-continuous service.
137. Yes No Are you currently on active duty? If yes, provide the information below.
Branch
Date Entered
Length of Commitment
Date of Actual or Estimated Separation
Grade/Rank
Current M.O.S.
Supervisor Unit Mailing Address
138. Yes No Are you currently in the Reserves, National Guard, ROTC or Coast Guard? If yes, provide
the information below.
Branch
Date Entered
Length of Commitment
Date of Actual or Estimated Separation
Grade/Rank
Current M.O.S.
Supervisor Unit Mailing Address
139. List all military service. Use continuation table at the end of this section if necessary.
Dates of Service
Branch of Service
Page 26 of 35
Complete Unit Address
M.O.S.
Highest Rank
Type of Discharge
Reason for Discharge
Disciplinary Action
Dates of Service
Branch of Service
Complete Unit Address
M.O.S.
Highest Rank
Type of Discharge
Reason for Discharge
Disciplinary Action
IMPORTANT! If you answer yes to any of the questions below, provide a full explanation in the continuation
of answer table at the end of this section.
140. Yes No Have you ever served in the armed forces of another nation?
141. Yes No Have you ever been denied entrance or re-entrance to any of the US Armed Forces for any
reason?
142. Yes No Have you been charged, detained, or arrested on a military installation for any reason? If
yes, use continuation sheet to explain in detail (include dates, places, law enforcing
authority or type, type of court or court martial, unit where action occurred, charge and
action taken in each incident) and attach a copy of all reports.
143. Yes No While in military service, were you ever arrested and/or convicted for any offense, a
defendant in a trial, or have you been subject to any disciplinary or corrective action? If
yes, use the continuation table at the end of this section to explain in detail (include dates,
places, law enforcing authority or type, type of court or court martial, unit where action
occurred, charge and action taken in each incident) and attach a copy of all reports.
Page
Number
Question
Number
Section 6 Continuation of Answer
Page 27 of 35
MILITARY RECORDS
To: The National Personnel Records Center
I respectfully request and authorize the National Personnel Records Center, and other
custodian of my military record to release to the Maury County Sheriff's Department any
and all information or photocopies that you have concerning my military personnel records to
include medical records and any record of disciplinary action and/or court martial. This
should also include an undeleted photocopy of my Report of Separation, DD214.
SIGNATURE MUST BE NOTARIZED
Name of Applicant
Signature of Applicant
Address (Numerical, Street, City, State, Zip Code)
NOTARY ACKNOWLEDGEMENT
State of
County of
Personally appeared before me, the undersigned, Notary Public for said County and State,
, to me known (or proved to me on the basis
of satisfactory evidence) to be the person who executed the within instrument for the
purposes therein contained.
Witness my hand, at Office this day of _ , 20
Notary Public
My Commission Expires
Page 28 of 35
https://www.archives.gov/files/sf180-request-pertaining-to-military-records-exp-april2018-1.pdf /
ww.archives.gov/files/sf180-request-pertaining-to-military-records-exp-april2018-1.pdf
Page 29 of 35
Page 30 of 35
Page 31 of 35
Section 7: Traffic Records
IMPORTANT!
If you answer yes to any of the questions below, provide a full explanation in the
continuation of answer table at the end of this section.
144. In what state do you currently have a driver license? ____________________________
145. Yes No Are there any other states where you have been or are currently licensed to operate a motor
vehicle? If yes, use continuation sheet to list each state and driver license number.
146. Yes No Has your driver license ever been suspended, revoked, or cancelled in any state?
147. Yes No Has any registration for any vehicle owned by you ever been cancelled, refused, suspended,
or revoked for any reason?
148. Yes No Are there any traffic charges pending against you at this time?
149. Yes No Have you ever used registration plates on your vehicle when those plates were registered to
another vehicle?
150. Yes No Have you ever used another person’s driver license or allowed another person to use your
driver license for any reason?
151. Yes No Have you ever been involved in a hit and run accident?
152. Yes No Have you ever been involved in a motor vehicle accident? If yes, list all traffic accidents in
which you were a driver below.
Date Location
Did Police
Investigate?
If Yes, Which
Police Agency?
Was Anyone
Injured?
Were you
at Fault?
153. Yes No Have you ever lied to any insurance company about any traffic incident?
154. Yes No Have you ever had automobile insurance withdrawn, revoked, cancelled, or have you been
refused automobile insurance? If yes, use continuation table at the end of this section to
explain in detail. Include name and address of insurance carrier, dates of occurrences and
reason.
155. List the name and address of the insurance company with whom you previously and/or currently have
automobile insurance. Tennessee law requires that you have at least liability insurance on all motor vehicles.
Page 32 of 35
Insurance Company Address
156. List all traffic citations you have received. Exclude parking citations.
Date
Agency/City/State
Charge
Disposition
Page
Number
Question
Number
Section 7 Continuation of Answer
Page 33 of 35
Section 8: Financial
157. The management of personal finances is relevant to an individual’s qualifications for the position of
Deputy Sheriff. The amount of indebtedness in itself will not be used in evaluating your
qualifications, but rather the behavior exhibited in meeting your financial obligations. Give the name
and address of the individuals, companies, or others, to whom you are indebted and the extent of the
debt, include housing, vehicles, student loans, credit cards, etc. Additionally, include any loans on
which you are a co-signer. List any and all garnishments and indicate their status. Be complete and
accurate in completing this information.
Name/Address
Type of Debt
(Loan, credit card,
mortgage, etc.)
Amount
Outstanding
Late
Payments
Yes/No
158. What is the estimated balance of your financial indebtedness as of this date? ______________________
IMPORTANT! If you answer yes to any of the questions below, provide a full explanation in the
continuation of answer table at the end of this section.
159. Yes No Have you ever filed for or declared bankruptcy?
160. Yes No Have any judgements ever been filed against you?
161. Yes No Are you currently more than 30 days behind payment to any creditor?
162. Yes No Have you ever had any delinquent federal or state income tax?
163. Yes No Do you have any outstanding student loans?
164. Yes No Have you had any liens placed against you?
165. Yes No Have you ever had your wages attached or garnished?
166. Yes No Have any of your debts been turned over for collection?
Page 34 of 35
167. Yes No Have you ever had anything repossessed?
168. Yes No Have you ever been named as a party in a civil matter?
169. Yes No Have you ever been evicted?
170. Yes No Have you ever broken a lease agreement?
Page
Number
Question
Number
Section 8 Continuation of Answer
Section 9: Personal References
171. List at least 5 persons NOT related by blood or marriage. Do not list employers or supervisors
(current or former). List individuals who have known you for at least 3 or more years.
Name
Complete Address
Email Address Phone Number
Page 35 of 35
172. List at least 3 next door neighbors of your current address. If you have lived there less than 6 months,
list the neighbors from your previous address. If you do not know your neighbor’s name, indicate so
and provide address.
Name
Complete Address
E-Mail Address Phone Number
Section 10: Experience Summary
Summarize your experience, training, knowledge, skills and abilities, which, in your opinion, establishes
your fitness for service with the Maury County Sheriff's Department. Include experience in criminal justice
agencies. Include special awards. Attach additional pages if needed.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
IMPORTANT! If you answered yes to any question on this PHS, did you explain your answer in the appropriate area?
Reminder that the following documents MUST be submitted at the time of application:
*Birth Certificate
*Photo Copy of Drivers License
*Photo Copy of Social Security Card
*High School Diploma or GED
*Official College Transcripts (if applicable)
*Trade School Diploma / Certificate
*Military Discharge, long form DD214 (if you served in the military)
*P.O.S.T. Certification (if you are an existing police officer)
*Police Academy Certificate (Post and Academy Certificates are 2 separate documents)
*PSID # (only if you have had previous Police or Fire training in Tennessee will you have this)
*Completed TLETA Application (attached)
*Completed POST Application (attached)
SOCIAL MEDIA
Do you use social media? Yes No
If yes, please list all sites or apps and your username(s)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please provide all email addresses, past and present that have been used by you
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Sworn Personal History Statement MAURY COUNTY SHERIFF'S DEPARTMENT (Maury County Government)

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Completed 14 February 2021

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