Job description
Okanogan County Civil Service Commission
123 5th Avenue N. #139, Okanogan, WA 98840
Phone: (509) 422-7196 Civil Service Webpage
Commissioners
Lee Pilkinton - Bertha Wandler - Celeste Pugsley
Secretary: Vicky Poole Email: vpoole@co.okanogan.wa.us
CIVIL SERVICE APPLICATION CHECK LIST
Lateral Deputy Sheriff & Lateral or Entry Corrections Officer OR 911 Dispatcher OR
Control Room Operator & Records Clerk OR Jail Cook
Prior to forwarding your application packet to Okanogan County Civil Service
Commission, please review the Check List below. Check off each item carefully, sign
and return with the application packet. Not to be used for Entry-Level Deputy.
ALL APPLICANTS /POSITIONS
Letter of Interest
Personal History Application – 3 copies (Original + 2 Copies)
Copy of High School Diploma / GED
Copy of Driver’s License
DD214 Military Form (if applicable)
All Training completion certificates
CONTROL ROOM OPERATOR / RECORDS CLERK & CORRECTIONS (Additional)
Typing test (obtained from WorkSource OR Online equivalent)
JAIL COOK (Additional)
Food Handler Card
Name of the Co. Employee who referred you
Signature Date Email
FULL FIRST: MIDDLE: LAST: LAST 5 OF SSN: DATE:
LEGAL
NAME
PERSONAL HISTORY STATEMENT
PHS INSTRUCTIONS
1. Familiarize yourself with this form and carefully read all instructions. You may find it helpful to review this
form multiple times.
2. You may find it helpful to print out this form so that you can make handwritten notes on it. This will serve as a
rough draft before you enter your responses. Your final draft may not be handwritten!
3. Save this form on your computer. Be sure to save the final, completed version as well.
4. Carefully enter the information asked – you must answer every single inquiry to the best of your ability. If an
item does not apply to you, enter “NA” (Not Applicable). If you cannot remember or obtain with
reasonable diligence, please indicate so in your response by referencing the question number and
explanation in the “additional space” section starting on page 28.
6. Once completed fully to your satisfaction, save the file in a secure manner. You may save this file only as a
.pdf or .jpg. If you are using a Mac computer, you may need to download a Microsoft word compatible program to
fill out this form or use a different computer. Once saved, sign in to your account on the PST website and upload
this saved file to the PST website per instructions provided there.
7. Public Safety Testing WILL NOT be able to make any modifications to your form once you submit it. Please
ensure that the form is completed to your full satisfaction before you upload!
The information you provide in this Personal History Statement (PHS) will be used in the investigation into your
background to assist in determining your suitability for a public safety position that you have applied for.
Please fill out the ENTIRE questionnaire completely, accurately and truthfully.
Keep in mind that:
1. The entire completion of this form is mandatory.
2. All statements are subject to verification.
3. Deliberate inaccuracies or omissions may bar or remove you from further testing and employment.
4. All time periods in your background must be accounted for.
5. Deliberate untruthfulness, omissions or misrepresentation of information constitutes grounds for
disqualification from further testing or employment. You are encouraged to be completely truthful, detailed
and accurate completing this form and throughout all phases of the background investigation process.
It is to your advantage to respond fully and factually. Any perceived negative factor in your background will be
evaluated in light of the circumstances and facts surrounding its occurrence, and its degree of relevance to the job
you are applying for. For example, being fired from a job or having an arrest record is not in itself necessarily
grounds for disqualification. During the investigation, the investigator will inquire into the facts surrounding such an
occurrence. An evaluation will then be made of the relevance of these facts to the requirements of the job.
If a question does not apply to you, write “N/A” (not applicable) in the space provided for your answer. If you need
with the question number. Follow carefully and completely subsection instructions, particularly in subsection 14
(References) and subsection 25 (Job Experience). If you have any questions about completing this form, please
call Public Safety Testing at 425.776.9615, or email info@publicsafetytesting.com
Disclosure of Medically-Related Information
In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring process applicants are not
expected or required to reveal any medical or other disability-related information about themselves in response to
questions on this form, or to any other inquiry made prior to receiving a conditional offer of employment.
This form adapted with permission from the California Commission on Peace Officer Standards & Training (POST)
SECTION 1: PERSONAL
1. YOUR FULL NAME 1. YOUR FULL NAME 1. YOUR FULL NAME
LAST FIRST MIDDLE
2. OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOW N BY
3. ADDRESS WHERE YOU RESIDE
NUMBER / STREET APT / UNIT
CITY STATE ZIP
4. MAILING ADDRESS, IF DIFFERENT FROM ABOVE
5. CONTACT NUMBERS
HOME ( ) WORK ( ) EXT OTHER ( ) CELL FAX PAGER
6. PRIMARY EMAIL ADDRESSES
PERSONAL BUSINESS
7. LIST ALL EMAIL ADDRESSES USED IN THE LAST 5 YEARS.
8. If you were born outside of the United States, are you a U.S. citizen? Yes No N/A
If no, are you a resident alien who is eligible and has applied for U.S. citizenship? Yes No N/A
9. BIRTH PLACE (CITY / COUNTY / STATE / COUNTRY) 10. BIRTHDATE 11. SOCIAL SECURITY NUMBER
– –
12. DRIVER’S LICENSE 13. PHYSICAL DESCRIPTION
NO. STATE EXP HEIGHT WEIGHT HAIR COLOR EYE COLOR
SECTION 2: RELATIVES AND REFERENCES
14. IMMEDIATE FAMILY
Provide all applicable information in the spaces below.
Mark “N/A” if a category is not applicable or if the individual is deceased.
If more space is needed, continue your response on page 28.
N/A A. Father
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
N/A B. Step-father
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
SECTION 2: RELATIVES AND REFERENCES continued
14. IMMEDIATE FAMILY continued
N/A C. Mother
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
N/A D. Step-mother
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
N/A E. Spouse / Registered Domestic Partner
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
YEARS OF MARRIAGE
Is there, or has there been, a restraining or stay-away order in effect for this individual? Yes No
N/A F. Father-in-law
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
N/A G. Mother-in-law
NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
SECTION 2: RELATIVES AND REFERENCES continued
14. IMMEDIATE FAMILY continued
N/A H. Former Spouse(s) / Former Registered Domestic Partner(s)
1) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
YEAR OF DISSOLUTION
Is there, or has there been, a restraining or stay-away order in effect for this individual? Yes No
2) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL
( ) ( )
YEAR OF DISSOLUTION
Is there, or has there been, a restraining or stay-away order in effect for this individual? Yes No
N/A I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc.
1) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F ( )
UNDER AGE 18 WORK PHONE CELL PHONE EMAIL
( ) ( )
2) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F ( )
UNDER AGE 18 WORK PHONE CELL PHONE EMAIL
( ) ( )
3) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F ( )
UNDER AGE 18 WORK PHONE CELL PHONE EMAIL
( ) ( )
4) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F ( )
UNDER AGE 18 WORK PHONE CELL PHONE EMAIL
( ) ( )
5) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F ( )
UNDER AGE 18 WORK PHONE CELL PHONE EMAIL
( ) ( )
6) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F ( )
UNDER AGE 18 WORK PHONE CELL PHONE EMAIL
( ) ( )
SECTION 2: RELATIVES AND REFERENCES continued
14. IMMEDIATE FAMILY (Section J. Children) continued
N/A J. Children
List all of your 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 or guardian, if other than you.
1) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F
CONTACT NUMBER EMAIL
( )
2) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F
CONTACT NUMBER EMAIL
( )
3) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F
CONTACT NUMBER EMAIL
( )
4) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F
CONTACT NUMBER EMAIL
( )
5) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F
CONTACT NUMBER EMAIL
( )
6) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP M
F
CONTACT NUMBER EMAIL
( )
15. REFERENCES
List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives,
employers/supervisors or housemates/roommates, or other individuals listed elsewhere.
A) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
B) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
C) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
D) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
E) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
F) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
15. REFERENCES
List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives,
employers/supervisors or housemates/roommates, or other individuals listed elsewhere.
G) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
H) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
I) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
J) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP
( )
WORK PHONE CELL PHONE EMAIL OCCUPATION
( ) ( )
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) HOW LONG HAVE YOU KNOWN THIS PERSON?
SECTION 3: EDUCATION
NOTE: You will eventually be required to furnish transcripts or other proof to support all of your educational claims.
16. Check applicable: High School Diploma from an accredited U.S. institution GED
17. List high schools attended:
A) NAME DATE FROM DATE TO DID YOU GRADUATE?
Yes
No
CITY STATE
B) NAME FROM TO DID YOU GRADUATE?
Yes
CITY STATE No
18. List all colleges or universities attended:
A) NAME FROM TO TOTAL UNITS EARNED MAJOR/TYPE OF
DEGREE EARNED
CITY STATE
B) NAME FROM TO TOTAL UNITS EARNED MAJOR/TYPE OF
DEGREE EARNED
CITY STATE
C) NAM E FROM TO TOTAL UNITS EARNED MAJOR/TYPE OF
DEGREE EARNED
CITY STATE
19. List any trade, vocational, or business schools/institutes attended:
A) NAME FROM TO DID YOU COMPLETE
THE COURSE?
Yes
TYPE OF SCHOOL OR TRAINING CITY STATE
No
B) NAME FROM TO DID YOU COMPLETE
THE COURSE?
Yes
TYPE OF SCHOOL OR TRAINING CITY STATE
No
C) NAME FROM TO DID YOU COMPLETE
THE COURSE?
Yes
TYPE OF SCHOOL OR TRAINING CITY STATE
No
20. Have you ever attended a Basic Law Enforcement, Corrections, Telecommunication, or Fire Service Academy? ................................... Yes No
If yes, provide the following information:
A) ACADEMY NAME FROM TO DID YOU GRADUATE?
Y N
LOCATION (CITY / STATE) NAME OF TRAINING OFFICER / ACADEMY COORDINATOR CONTACT NUMBER
( )
B) ACADEMY NAME FROM TO DID YOU GRADUATE?
Y N
LOCATION (CITY / STATE) NAME OF TRAINING OFFICER / ACADEMY COORDINATOR CONTACT NUMBER
( )
SECTION 3: EDUCATION continued
21. Have you ever been placed on academic discipline, suspended, or expelled from any high school, college/university, academy,
business or trade school? ............................................................................................................................................................. Yes No
If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution. Include
when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
SECTION 4: RESIDENCE
22. LIST OF RESIDENCES
List all residences during the last ten years or since age 15. Provide complete addresses (include markers such as Street, Drive, Road, East, West,
etc., and unit or apartment number). Do not use P.O. 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 on page 28.
A) ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT) DATE FROM TO
Present
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you live:
B) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you lived:
Reason for moving:
C) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you lived:
Reason for moving:
SECTION 4: RESIDENCE continued
22. LIST OF RESIDENCES continued
D) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you lived:
Reason for moving:
E) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you lived:
Reason for moving:
F) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you lived:
Reason for moving:
G) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO
CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER
( )
CITY STATE ZIP EMAIL
Names of those with whom you lived:
Reason for moving:
SECTION 4: RESIDENCE continued
23. Provide contact information for all housemates listed in Question 22 with whom you have resided during the past 10 years, or since the age of 15. DO
NOT list anyone for whom you have already provided contact information. If more space is needed, continue your response on page 28.
A) NAME CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY) EMAIL
B) NAME CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY) EMAIL
C) NAME CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY) EMAIL
D) NAME CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY) EMAIL
E) NAME CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY) EMAIL
F) NAME CONTACT NUMBER
( )
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP
NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY) EMAIL
24. Have you ever been evicted or asked to leave a residence?............................................................................................................... Yes No
25. Have you ever left a residence owing rent? ..................................................................................................................................... Yes No
If you answered yes to Questions 24 and/or 25, explain (include when, where and circumstances):
SECTION 5: EXPERIENCE AND EMPLOYMENT
26. JOB EXPERIENCE
List ALL jobs you have had, including part-time, temporary, self-employment and volunteer. (Begin with your most current. If more space is
needed continue your response on page 28.)
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.
List your current (or most recent) supervisor for each job.
List two (2) coworkers that would best know you and your work habits, productivity, behavior, etc.
A) NAME OF EMPLOYER OR MILITARY UNIT DATE FROM DATE TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP SUPERVISOR CONTACT NUMBER EXT
( )
JOB TITLE SUPERVISOR EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
IF YES, EXPLAIN: REASON FOR WANTING TO LEAVE
Would there be a problem if we
contact your current employer?
Yes No
B) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
C) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
D) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
E) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
F) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
G) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
H) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
I) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
J) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
K) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) A ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
L) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
M) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
N) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
O) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
P) PERIOD OF UNEMPLOYMENT FROM TO
Check applicable: Student Between jobs Leave of absence Travel Other
Q) NAME OF EMPLOYER OR MILITARY UNIT FROM TO
ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR
CITY STATE ZIP CONTACT NUMBER EXT
( )
JOB TITLE EMAIL
DUTIES / ASSIGNMENTS
F-T P-T Temp
Self-employed Volunteer
NAMES OF CO-WORKERS CONTACT NUMBER EMAIL
1) ( )
NAME CONTACT NUMBER EMAIL
2) ( )
REASON FOR LEAVING
27. 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
28. Have you ever been fired, released from probation, or asked to resign from any place of employment? ........................................ Yes No
29. Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer? .............................................. Yes No
30. Have you ever quit without giving proper notice? ........................................................................................................................... Yes No
31. Have you ever resigned in lieu of termination? .............................................................................................................................. Yes No
32. 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
33. Were you ever the subject of a written complaint at work? ............................................................................................................ Yes No
34. Have you ever been counseled at work due to lateness or absences? .......................................................................................... Yes No
35. Did you ever receive an unsatisfactory performance review? ........................................................................................................ Yes No
36. Have you ever been named as a defendant in a previously adjudicated work-related civil lawsuit (regardless of outcome)? ......... Yes No
37. Is there a work-related civil lawsuit pending in which you have been named as a defendant? ....................................................... Yes No
38. Do you have reason to believe a work-related lawsuit may be filed in the future in which you may be named as a defendant? ..... Yes No
39. Have you ever sold, released, or given away legally confidential information? ............................................................................... Yes No
40. Have you ever called in sick when you were neither sick nor caring for a sick family member? ....................................................... Yes No
If YES, how many sick days have you used in the past five years which were not due to illness?
40a.Have you ever viewed pornographic material at your workplace? .................................................................................................... Yes No
40b.Have you ever engaged in sexual activity at work in violation of your employer’s policy? ................................................................. Yes No
I f you answered YES to any of Questions 27-40b, explain (include when, where & circumstances; indicate corresponding number):
41. 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?
42. Has your work performance ever been affected by your use of alcohol or drugs? .......................................................................... Yes No
WHEN? NAME OF EMPLOYER
43. 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
WHEN? NAME OF EMPLOYER
44. Have you ever applied to any other law enforcement, fire service, or public safety-type agency (city, county, state or federal)? ..... Yes No
If yes, list EVERY agency you have applied to and have advanced BEYOND an oral board (e.g., initial background investigation, etc.),
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 28.
A) NAME OF AGENCY DATE APPLIED
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:
STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer
STATUS: Hired On List Withdrawn Disqualified Other/Explain:
B) NAME OF AGENCY DATE APPLIED
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:
STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer
STATUS: Hired On List Withdrawn Disqualified Other/Explain:
C) NAME OF AGENCY DATE APPLIED
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:
STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer
STATUS: Hired On List Withdrawn Disqualified Other/Explain:
45. List ALL public safety agencies that you have applied to in which you have NOT progressed past the written exam, physical ability test and/or oral board.
All that is needed for these agencies is the agency name and approximate date of testing.
AGENCY NAME APPROXIMATE DATE CHECK All THE BOXES BELOW THAT APPLY TO ANY
(Month/Year) ORAL BOARD INVITATION YOU HAVE RECEIVED FROM
OF TEST THIS AGENCY
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
Did Not Attend Pass Fail Results Unknown
SECTION 6: MILITARY EXPERIENCE
46. Are you required to register for the Selective Service? .................................................................................................................. Yes No
If yes, have you registered? .......................................................................................................................................................... Yes No
If no, explain:
47. BRANCH OF SERVICE 48. DATES OF SERVICE
From To
49. TYPE OF DISCHARGE: E n t r y Level Honorable General OTH (Other than Honorable) Bad Conduct Dishonorable
Re-entry Code (1–4) if applicable – refer to your DD-214:
50. Are you currently participating in one of the following? Military Reserve
If checked, date obligation ends:
National Guard
51. 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
52. Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded? ......................................... Yes No
If you answered yes to Questions 51 and/or 52, explain (include dates and circumstances):
SECTION 7: FINANCIAL
53. INCOME AND EXPENSES
For each of the following questions fill in the amounts to the nearest dollar.
A) From your employer(s), what is your take-home monthly income?.............................................................................. .................$.. . . . . .. .. .. .. ... ... per month
B) Do you have income other than from your salary or wages (including spouse’s income)? ................................................................. Yes No
If yes, fill in amount: .................................................................................................................................................... .................$.. . . . . .. .. .. .. ... ... per month
Explain:
C) How much do you spend each month? ............................................................................................................ ...............$. . . . . .. .. .. .. .. .. per month
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 obligation(s) you may have.
54. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)?............................................................................................... Yes No
55. Have any of your bills ever been turned over to a collection agency?................................................................................................. Yes No
56. Have you ever had purchased goods repossessed? .......................................................................................................................... Yes No
57. Have your wages ever been garnished? ............................................................................................................................................ Yes No
58. Have you ever been delinquent on income or other tax payments? ................................................................................................... Yes No
59. Have you ever failed to file income tax or cheated/lied on an income tax form? ................................................................................. Yes No
60. Have you ever had an employment bond refused? ............................................................................................................................ Yes No
61. Have you ever avoided paying any lawful debt by moving away? ....................................................................................................... Yes No
62. Have you ever defaulted on (failed to pay) a loan? ............................................................................................................................ Yes No
63. Have you ever borrowed money to pay for a gambling debt? ............................................................................................................. Yes No
If yes, do you currently have any outstanding debts as a result of gambling? .................................................................................... Yes No
64. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)? .............. Yes No
65. Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)? ..................... Yes No
66. Have you written three or more bad checks in a one-year period? ..................................................................................................... Yes No
If you answered YES to any of Questions 54–66, explain (include when, where, and why; indicate corresponding number):
SECTION 8: LEGAL
Disclosure of Arrests and Convictions
Please disclose any of the following which occurred on or after your 15th birthday, even if the records were sealed, expunged,
dismissed or pardoned:
ALL detentions or arrests, whether they resulted in a conviction or not
ALL convictions
ALL diversion programs that were not successfully completed
If more space is needed, continue on page 28.
67. Either as an adult or a juvenile, have you EVER been detained for investigation, held on suspicion,
questioned, fingerprinted, arrested, indicted, criminally charged, or convicted of any misdemeanor or
felony offense in this state or in any other legal jurisdiction (including offenses punishable under
the Uniform Code of Military Justice)? .............................................................................................................................. Yes No
A) APPROXIMATE DATE ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
B) APPROXIMATE DATE ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
C) APPROXIMATE DATE ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
D) APPROXIMATE DATE ARRESTING OR DETAINING AGENCY
CHARGE
DISPOSITION OR PENALTY
68. Have you ever been placed on court probation as an adult?........................................................................................................... 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 non-work related civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity,
support, etc.) as either a plaintiff or defendant? .............................................................................................................................. 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 filed a false insurance or workers’ compensation claim? ......................................................................................... Yes No
77. Other than those listed in Question #67 above, will your name appear in any police record system or police report
as a VICTIM, WITNESS or SUSPECT? (Do not include when acting in the capacity of paid employment, such as an
EMT or store loss prevention officer). Yes No
78. Are you currently, or have you ever within the past seven years, received unemployment benefits while also receiving other sources of income?
Yes No
_____________________________________________________________________________________________________________
If you answered yes to any of Questions 68–78, explain (include court case or document, dates, and circumstances; indicate corresponding number):
79. UNDETECTED ACTS – PART 1
Within the past seven (7) years OR at any time after you were first employed in law enforcement or the fire service, have you ever
committed any of the following misdemeanors? NOTE: You may not withhold any information regarding you 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.
A) Annoying / obscene phone calls or text messages; cyber bullying ................................................................................................... Yes No
B) Battery (use of force or violence upon another) ............................................................................................................................... Yes No
C) Brandishing a weapon (any type of weapon) ................................................................................................................................... Yes No
D) Carrying a concealed weapon without a permit ................................................................................................................................ Yes No
E) Contributing to the delinquency of a minor; providing alcohol to minors ........................................................................................... Yes No
F) Defrauding an innkeeper (not paying for food or room at a hotel/motel) ........................................................................................... Yes No
G) Driving under the influence of alcohol and/or drugs ......................................................................................................................... Yes No
H) Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) ....................................................... Yes No
I) Hit & run collision (no injuries) ......................................................................................................................................................... Yes No
J) Any hunting and/or fishing violations …… ........................................................................................................................................ Yes No
K) Illegal gambling; including online gambling ...................................................................................................................................... Yes No
L) Impersonating a peace officer (pretending to be a police officer) ..................................................................................................... Yes No
M) Indecent exposure (including flashing or mooning); sex within public view ....................................................................................... Yes No
N) Joyriding (using a car or other vehicle without owner’s permission) ................................................................................................. Yes No
O) Petty theft (value up to $400, including shoplifting/switching price tags) ........................................................................................... Yes No
P) Possession of alcohol as a minor ..................................................................................................................................................... Yes No
Q) Possession of falsified or altered identification, including use of another person’s ID (for any reason) ............................................. Yes No
R) Possession of stolen property (including vehicles) ........................................................................................................................... Yes No
S) Prostitution or soliciting a prostitute .................................................................................................................................................. Yes No
T) Resisting arrest (including running from the police) .......................................................................................................................... Yes No
U) Trespassing ..................................................................................................................................................................................... Yes No
V) Vandalism (including “tagging,” malicious mischief and/or property damage) ................................................................................... Yes No
W) Intentionally writing a bad check ...................................................................................................................................................... Yes No
X) Filing a false police report ................................................................................................................................................................ Yes No
Y) Any other act amounting to a misdemeanor within the past seven years .......................................................................................... Yes No
Z) Cruelty to animals .............................................................................................................................................................................. Yes No
AA) Street racing ..................................................................................................................................................................................... Yes No
If you answered yes to any item(s) in Question 79, fully explain circumstances, including date(s), names of individuals involved, and
resolution. Indicate the corresponding letter (79-A, etc.) for each explanation.
80. UNDETECTED ACTS – PART 2
At any time in your life have you ever committed any of the following? 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.
A) Arson (intentionally destroying property by setting a fire) ................................................................................................................. Yes No
B) Assault with a deadly weapon .......................................................................................................................................................... Yes No
C) Theft of a vehicle and/or vehicle parts .............................................................................................................................................. Yes No
D) Burglary (entering a structure or vehicle to commit theft or other crime) ........................................................................................... Yes No
E) Child molestation (performing unlawful acts with a child) ................................................................................................................. Yes No
F) Accessing and/or possessing child pornography .............................................................................................................................. Yes No
G) Elder abuse/neglect ......................................................................................................................................................................... Yes No
H) Embezzlement (theft of money or other valuables entrusted to you) ................................................................................................ Yes No
I) Felony drunk driving (involving injuries) ........................................................................................................................................... Yes No
J) Forcible rape or other act of unlawful intercourse ............................................................................................................................. Yes No
K) Forgery (falsifying any type of document, check certificate, license, currency, etc.).......................................................................... Yes No
L) Hit & run (with injuries) ..................................................................................................................................................................... Yes No
M) Hate crime ....................................................................................................................................................................................... Yes No
N) Insurance fraud ................................................................................................................................................................................ Yes No
O) Grand theft (value of over $400, or any firearm) ............................................................................................................................... Yes No
P) Murder, homicide, or attempted murder ........................................................................................................................................... Yes No
Q) Perjury (lying under oath) ................................................................................................................................................................. Yes No
R) Possession of an explosive/destructive device ................................................................................................................................. Yes No
S) Robbery (theft from another person using a weapon, force, or fear) ................................................................................................. Yes No
T) Stalking ............................................................................................................................................................................................ Yes No
U) Blackmail or extortion....................................................................................................................................................................... Yes No
V) Any other act amounting to a felony ................................................................................................................................................. Yes No
W. Copyright infringement (including illegally downloading or copying software, audio files, movies, digital files, etc) ............................ Yes No
If you answered YES to any item(s) in Question 80, fully explain circumstances, including date(s), names of individuals involved,
and resolution. Indicate the corresponding letter (80-A, etc.) for each explanation.
Questions 81 and 82 ask about your current and past recreational drug use. This covers the use of any drug, including the unauthorized
use of prescription drugs or over-the-counter drugs. Your answers should include, but not be limited to, your use of
any of the following drugs:
– Amphetamines / Methamphetamines – Glue – Mescaline
(Uppers, Speed, Crank, etc.)
– Hallucinogens – Morphine
– Barbiturates (Downers) (Peyote, LSD, Mushrooms)
– PCP / Angel Dust
– Cocaine / Crack Cocaine – Hashish / Hashish Oil
– Quaaludes
– Designer Drugs – Heroin / Opium
– Steroids
(Ecstasy, Synthetic Heroin, etc.)
– Marijuana – Tetrahydrocannabinol (THC)
– GHB (Date Rape Drug) - Prescription drugs used for
- Prescription drug(s) not prescribed to you recreation purposes
81. Within the past six months, have you used any drug(s) as indicated above? ................................................. Yes No
If yes, give details, including drug(s) used and circumstances:
82. Prior to the past six months (check all that apply):
I have never used, or experimented with, any drug recreationally.
I have tried or used one or more drugs, but only under limited circumstances (for example, experimentation, at parties,
concerts, special events, etc.).
If checked, give details including drug(s) used, most recent date used, and circumstances.
83. Have you ever engaged in any of the activities listed below for drugs, prescription drugs, narcotics or illegal substances, including marijuana
(check all that apply)?
Sold Purchased Cultivated
Manufactured Furnished / Shared Carried or held for another
Present when illegal drugs were Loaned money to someone Traded/Bartered
being used else to purchase illegal drugs
If you checked any items above, give details including drug(s) involved, over what time period(s), and circumstances.
SECTION 9: MOTOR VEHICLE OPERATION
84. CURRENT DRIVER’S LICENSE NUMBER STATE OF ISSUE EXPIRATION DATE NAME UNDER WHICH LICENSE WAS GRANTED
85. LIST OTHER STATES WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE:
State of issue Type of license Name under which license was granted and license number, if known
86. Have you ever been refused a driver’s license by any state? ...................................................................................................... Yes No
If yes, explain (include when, where, and circumstances):
87. Has your driver’s license ever been suspended or revoked? ...................................................................................................... Yes No
If yes, explain (include when, where, and circumstances):
88. List your current liability insurance on your vehicle(s):
A) TYPE OF COVERAGE VEHICLE MAKE YEAR VEHICLE LICENSE
Insured Bonded Cash Deposit
INSURANCE COMPANY POLICY NUMBER EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP CONTACT NUMBER
( )
B) TYPE OF COVERAGE VEHICLE MAKE YEAR VEHICLE LICENSE
Insured Bonded Cash Deposit
INSURANCE COMPANY POLICY NUMBER EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP CONTACT NUMBER
( )
C) TYPE OF COVERAGE VEHICLE MAKE YEAR VEHICLE LICENSE
Insured Bonded Cash Deposit
INSURANCE COMPANY POLICY NUMBER EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP CONTACT NUMBER
( )
D) TYPE OF COVERAGE VEHICLE MAKE YEAR VEHICLE LICENSE
Insured Bonded Cash Deposit
INSURANCE COMPANY POLICY NUMBER EXPIRES
ADDRESS (NUMBER / STREET CITY STATE ZIP CONTACT NUMBER
( )
89. List all traffic citations, excluding parking citations, you have received within the past ten years. List the citation or infraction AS ORIGINALLY ISSUED. If
the citation/infraction was reduced to a lesser violation for whatever reason, please explain in #93 below.
A) NATURE OF VIOLATION LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED ACTION TAKEN
Month Year Not Guilty Fined Traffic School Dismissed
B) NATURE OF VIOLATION LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED ACTION TAKEN
Month Year Not Guilty Fined Traffic School Dismissed
C) NATURE OF VIOLATION LOCATION (STREET) CITY STATE
DATE VIOLATION OCCURRED ACTION TAKEN
Month Year Not Guilty Fined Traffic School Dismissed
D) Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following? (Check all that apply.)
Failed to appear Failed to complete traffic school Failed to pay the required fine
If checked, explain circumstances:
90. Have you been involved as the driver in a motor vehicle accident/collision within the past ten years? ....................................... Yes No
If yes, give details.
A) DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
.
POLICE REPORT LAW ENFORCEMENT AGENCY
INJURY NON-INJURY
YES NO
B) DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
POLICE REPORT LAW ENFORCEMENT AGENCY
INJURY NON-INJURY YES NO
C) DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
POLICE REPORT LAW ENFORCEMENT AGENCY
YES NO
INJURY NON-INJURY
91. Have you ever driven a vehicle without auto insurance, as required by law? ............................................................................. Yes No
IF YES, GIVE REASON:
DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
Month Year
92. Have you ever been refused automobile liability insurance or a bond, or had either of them cancelled? .................................... Yes No
IF YES, GIVE REASON: INSURANCE COMPANY
DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP
Month Year
93. Use this space for additional information you would like to include regarding your driving record.
SECTION 10: OTHER TOPICS
94. Have you ever been refused a permit to carry a concealed weapon? ........................................................................................ Yes No
95. Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other group
that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,
gender, sexual preference, or disability? ................................................................................................................................... Yes No
96. Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise,
street gang, or any other group that advocates violence against individuals because of their race, religion,
political affiliation, ethnic origin, nationality, gender, sexual preference, or disability? ................................................................ Yes No
97. Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or other
violent act? ................................................................................................................................................................................ Yes No
98. Have you ever hit or physically overpowered a spouse or romantic partner? ............................................................................. Yes No
99. Have you ever been involved in a domestic violence act with a relative, spouse, significant other, romantic partner or domestic
partner, including but not limited to, an act of violence, threats, infliction of emotional distress and/or property damage? ............ Yes No
100. Do you know of any reason that would disqualify you from being appointed to this job or prevent you from performing
the essential duties of the job:...................................................................................................................................................... Yes No
101. Have you ever engaged in sexual abuse inside a prison, jail, juvenile facility, lockup or any other institution where
there are inmates being held? ..................................................................................................................................................... Yes No
102. Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force,
implied threats of force or coercion or if the victim did not or was unable to consent? .................................................................. Yes No
103. Have you ever been civilly or administratively adjudicated to have engaged in the activities listed in questions 101 or 102? ...... Yes No
If you answered YES to any of Questions 94–103, give details including dates and circumstances; indicate corresponding number.
SECTION 11: CERTIFICATION
CERTIFICATION
I hereby swear or affirm that there are no willful misrepresentations or omissions in, or falsifications of, the
statements and answers in this Personal History Statement. I herby certify that I have personally
completed each page of this form and any supplemental pages(s) attached, and that all statements made
are true and complete to the best of my knowledge and belief. I am aware that should an investigation
disclose such misrepresentations, omissions, or falsifications in any documents I submit, or statements I
make as part of the application, testing and/or hiring process, my application will be rejected and I will be
disqualified from applying for any future position with the agency or agencies to which I have applied to.
If, after my acceptance for employment, subsequent investigation should disclose misrepresentation,
omission, or falsification, it will be just cause for my immediate dismissal. I understand that this is a
continuing investigation and agree to notify the hiring agency of any information that may reflect any
changes or additions in this Personal History Statement.
BY ENTERING YOUR FULL LEGAL NAME HERE, YOU ACKNOWLEDGE AND AGREE TO THE
ABOVE CERTIFICATION: Name: Date:
THE FOLLOWING SIGNATURE SECTION IS TO BE COMPLETED AT A LATER DATE IN THE PRESENCE OF A WITNESS/BACKGROUND INVESTIGATOR:
SIGNATURE IN FULL DATE
WITNESS/BACKGROUND INVESTIGATOR: DATE
ADDITIONAL SPACE
Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g., additional family members, schools,
residences, employers, explanations to questions, etc.)
Identify the corresponding question and specific item being referenced.
ADDITIONAL SPACE
Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g., additional family members, schools,
residences, employers, explanations to questions, etc.)
Identify the corresponding question and specific item being referenced.
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