Personal History Statement

Instructions to the Applicant

 Avoid errors by reading the directions carefully and completely before making any entries on the form. Be sure your information is accurate and in the proper sequence before you begin.

 The information you provide in this Personal History Statement including driver’s license and social security number will be used during background investigations to assist in verifying validity of the information received. We do not discriminate based on any protected class information.

 Type or neatly print, in black ink, responses to all items and questions. If a question does not apply to you, write “N/A” (not applicable) in the space provided for your response. If you cannot obtain or remember certain information, indicate so in your response.

 If you need more space for any response, use additional pages and identify the additional information by the question number.

 In most cases, photocopies of required documents are acceptable. If originals or certified copies are required it will be noted below. The following documents should be included with your application or submitted as soon as they become available:

o Completed Application (ORIGINAL REQUIRED)

o Valid Texas Driver’s License

o Social Security Card

o Birth Certificate (CERTIFIED COPY REQUIRED)

o High School Diploma / Transcripts or GED

o College Transcripts (CERTIFIED COPY REQUIRED)

o College Diploma

o T.C.O.L.E. Licenses and/or Exam Results (if applicable)

o T.C.O.L.E. Transcript (if applicable)

o Proof of Automobile Liability Insurance

o Certificates from any job-related trainings completed

o Credit History from recognized organization (Experion, TransUnion, etc.)

o Military Discharge/DD-214 (if applicable)

Disqualification

There are very few automatic bases for rejection. Deliberate misstatements or omissions can and often will result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In

1 fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent job-relevant information from their prospective employer. If discovered after applicant has been hired, these misstatements or omissions are grounds for immediate termination.

BOTTOM LINE: Be as complete, honest and specific as possible in your responses.

2 Position Applied For:

Applicant Qualification Section (Peace Officer, Jailer and Telecommunicator positions only)

Before you begin to fill out this personal history statement, if you are applying for a position as a Peace Officer, Jailer or Telecommunicator you must meet all five of these requirements to qualify for licensure. Initial next to each to indicate your understanding that you will be expected to prove these statements.

______I am a citizen of the United States of America.

______I have earned a high school diploma or a GED.

______I have never been convicted, plead guilty (nolo contendere), nor have I been on court-ordered community service/probation or deferred adjudication for a Class A misdemeanor or a felony.

______During the last ten (10) years, I have not been convicted, plead guilty (nolo contendere), been on community service/probation or deferred adjudication for a Class B misdemeanor in this state, other state, or while serving in the military.

______I have never had a military court martial that resulted in a dishonorable or bad conduct discharge.

Additional Internal Requirements

Before you begin to fill out this personal history statement, the following requirements are specific to our agency and may or may not apply to other agencies. They are applicable to new prospective employees for this agency without discrimination or exception. Initial next to each to indicate your understanding that you will be expected to prove these statements.

______I have never been indicted for / been true-billed or formally charged with Official Oppression, Perjury or any crime of Moral Turpitude.

______I have never been indicted for / been true-billed or formally charged with any violent crime above a class C misdemeanor.

______I have not been indicted for / been true-billed or formally charged with any DWI or DUI Offenses in the last 10 years.

______My driving privileges have not been suspended by any authority in the last 5 years.

______I have not had more that 3 traffic convictions (including paying tickets) in the last 3 years.

3 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 KNOWN 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. ALL EMAIL ADDRESSES HOME BUSINESS 7. If you were born outside of the United States, are you a U.S. citizen? Yes No If no, are you a resident alien who is eligible and has applied for U.S. citizenship? ...... Yes ...... No

8. BIRTH PLACE 9. BIRTHDATE 10. SOCIAL SECURITY NUMBER (CITY / COUNTY / – – STATE / COUNTRY) 11. DRIVER’S LICENSE 12. PHYSICAL DESCRIPTION

NO. STATE EXP HEIGHT WEIGHT HAIR COLOR 13. TCOLE LICENSE (IF N/A LEVEL: 14. SCARS, TATTOOS OR OTHER DISTINGUISHING MARKS: APPLICABLE) PID#. PEACE JAILER TCO

SECTION 2: RELATIVES AND REFERENCES 15. IMMEDIATE FAMILY  Provide all applicable information in the spaces below.  Mark “N/A” if a category is not applicable or if the individual is deceased.  If more space is needed, continue your response on a separate sheet.

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. Mother NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP ( )

4 WORK PHONE CELL PHONE EMAIL ( ) ( )

SECTION 2: RELATIVES AND REFERENCES continued 15. IMMEDIATE FAMILY continued

N/A C. 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 ( ) ( ) 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 / 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 ( ) ( )

5 SECTION 2: RELATIVES AND REFERENCES continued 15. IMMEDIATE FAMILY continued

N/A H. Former Spouse(s) / Former 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

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

M HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

( ) F WORK PHONE CELL PHONE EMAIL UNDER 18 ( ) ( ) 2) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

M HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

( ) F WORK PHONE CELL PHONE EMAIL UNDER 18 ( ) ( ) 3) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

M HOME PHONE WORK ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

( ) F WORK PHONE CELL PHONE EMAIL UNDER 18 ( ) ( )

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)

M CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

F CONTACT NUMBER EMAIL ( ) 2) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

M CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

F CONTACT NUMBER EMAIL ( )

SECTION 2: RELATIVES AND REFERENCES continued 15. IMMEDIATE FAMILY continued

J. Children continued 3) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

M CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

6 F CONTACT NUMBER EMAIL

( )

4) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

M CHILD’S AGE ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP

F CONTACT NUMBER EMAIL ( ) 16. REFERENCES: List 3-4 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, 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 ( ) ( ) HOW DO YOU KNOW THIS PERSON? (FOR HOW LONG HAVE YOU KNOWN THIS PERSON? EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) 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 ( ) ( ) HOW DO YOU KNOW THIS PERSON? (FOR HOW LONG HAVE YOU KNOWN THIS PERSON? EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND,

CO- WORKER) 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 ( ) ( ) HOW DO YOU KNOW THIS PERSON? (FOR HOW LONG HAVE YOU KNOWN THIS PERSON? EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER) 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 ( ) ( ) HOW DO YOU KNOW THIS PERSON? (FOR HOW LONG HAVE YOU KNOWN THIS PERSON? EXAMPLE: FRIEND, TEACHER, FAMILY FRIEND, CO- WORKER)

7 SECTION 3: EDUCATION

NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.

17. Check applicable: High School Diploma from an accredited U.S. institution GED

18. List high schools attended: A) NAME FROM TO DID YOU GRADUATE? CITY STATE Yes No B) NAME FROM TO DID YOU GRADUATE? CITY STATE Yes No

19. List all colleges or universities attended: A) NAME FROM TO TOTAL UNITS TYPE OF EARNED DEGREE EARNED CITY STATE

B) NAME FROM TO TOTAL UNITS TYPE OF EARNED DEGREE EARNED CITY STATE

C) NAME FROM TO TOTAL UNITS TYPE OF EARNED DEGREE EARNED CITY STATE

20. List any trade, vocational, or any other schools/institutes attended: A) NAME FROM TO DID YOU COMPLETE THE COURSE? TYPE OF SCHOOL OR CITY STATE TRAINING

B) NAME FROM TO DID YOU COMPLETE THE COURSE? TYPE OF SCHOOL OR CITY STATE TRAINING

C) NAME FROM TO DID YOU COMPLETE THE COURSE? TYPE OF SCHOOL OR CITY STATE TRAINING

21. Were you ever suspended, expelled or placed on academic probation at any school? Yes No If yes, describe in detail below.

SECTION 4: RESIDENCES 22. LIST OF RESIDENCES  List all residences during the last ten years or since age 17, starting with the most recent. Provide complete addresses, 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 barrack-mates unless you shared individual quarters.  If you need additional space, attach additional sheets. A) ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT) FROM TO Present

8 CITY ST ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER: ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER ( ) CITY ST ZIP EMAIL

Names of those with whom you live: B) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO

CITY ST ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER: ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER ( ) CITY ST ZIP EMAIL

Names of those with whom you lived:

Reason for moving: C) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO

CITY ST ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER: ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER ( ) CITY ST ZIP EMAIL

Names of those with whom you lived:

Reason for moving: D) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO

CITY ST ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER: ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER ( ) CITY ST ZIP EMAIL

Names of those with whom you lived:

Reason for moving:

23. Provide contact information for all housemates listed in Question 22 who are over 16 years old with whom you have resided during the past 10 years, or since the age of 16. DO NOT list anyone for whom you have already provided contact information. If more space is needed, attach additional pages. A) NAME CONTACT NUMBER ( ) CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, EMAIL HOUSEMATE ONLY)

B) NAME CONTACT NUMBER ( ) CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP

9 NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, EMAIL HOUSEMATE ONLY)

C) NAME CONTACT NUMBER ( ) CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, EMAIL HOUSEMATE ONLY)

D) NAME CONTACT NUMBER ( ) CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, EMAIL HOUSEMATE ONLY)

E) NAME CONTACT NUMBER ( ) CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT CITY STATE ZIP

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, EMAIL HOUSEMATE ONLY)

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/or unpaid work. (Begin with your most current; continue until the age of 17 if possible. If more space is needed continue your response on additional pages.)  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.

A) NAME OF CURRENT EMPLOYER OR MILITARY UNIT FROM TO

ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR

CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / ASSIGNMENTS F-T P-T Temp

Self-employed Volunteer

NAMES OF CO-WORKERS X REASON TO LEAVE 1) 2) Would there be a problem if we IF YES, EXPLAIN: contact your current employer? Yes No

B) PERIOD OF UNEMPLOYMENT FROM TO Check applicable: Student Between jobs Leave of absence Travel Other 10 C) NAME OF EMPLOYER OR MILITARY UNIT FROM TO

ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR

CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / ASSIGNMENTS F-T P-T Temp Self-employed Volunteer

NAMES OF CO-WORKERS X REASON FOR LEAVING 1) 2)

D) PERIOD OF UNEMPLOYMENT FROM TO Check applicable: Student Between jobs Leave of absence Travel Other

11 12 SECTION 5: EXPERIENCE AND EMPLOYMENT continued 26. JOB EXPERIENCE continued

E) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1) F) PERIOD OF FROM TO UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other

G) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1) H) PERIOD OF FROM TO UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other

I) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1)

13 SECTION 5: EXPERIENCE AND EMPLOYMENT continued 26. JOB EXPERIENCE continued

J) PERIOD OF FROM TO UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other K) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1) L) PERIOD OF FROM TO UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other M) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1) N) PERIOD OF FROM TO UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other O) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

14 NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1) P) PERIOD OF FROM TO UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other

SECTION 5: EXPERIENCE AND EMPLOYMENT continued 26. JOB EXPERIENCE continued

Q) NAME OF FROM TO EMPLOYER OR MILITARY UNIT ADDRESS (NUMBER / SUPERVISOR STREET OR BASE) CITY ST ZIP CONTACT NUMBER EXT ( ) JOB TITLE EMAIL

DUTIES / F-T P-T Temp ASSIGNMENTS Self-employed Volunteer

NAMES OF CO- X REASON FOR LEAVING WORKERS 2) 1) 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 ever you ever been fired, unable to complete a probationary period, or asked to resign from any place of employment? .... Yes No

29. Have you ever quit without giving proper notice? ...... Yes No

30. Have you ever resigned in lieu of termination? ...... Yes No

31. 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

32. Were you ever the subject of a written complaint at work? ...... Yes No

33. Have you ever been counseled at work due to lateness or absences? ...... Yes No

34. Did you ever receive an unsatisfactory performance review? ...... Yes No

35. Have you ever sold, released, or given away legally confidential information? ...... Yes No

36. 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? If you answered yes to any of Questions 27–37, explain (include when, where and circumstances; indicate corresponding number):

37. In the past three years, have you missed days or been late to work due to drug and/or alcohol consumption? Yes No If yes, how often? 38. Has your work performance ever been affected by your use of alcohol and/or drugs? Yes No

WHEN? NAME OF EMPLOYER

39. 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

15 WHEN? NAME OF EMPLOYER

16 SECTION 5: EXPERIENCE AND EMPLOYMENT continued

40. Have you ever applied to any other law enforcement agency (city, county, state or federal)?...... Yes No  If yes, list EVERY agency you have applied to, starting with the most recent (give complete and accurate addresses).  All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for each agency.  If more space is needed, continue your response on additional pages. A) NAME OF AGENCY DATE APPLIED

ADDRESS BACKGROUND INVESTIGATOR’S NAME (IF KNOWN) (NUMBER / STREET) CITY STATE ZIP CONTACT NUMBER EXT ( ) POSITION APPLIED EMAIL FOR Check each step in the process that you completed, and your status: STEPS: Application Written Physical agility Oral Polygraph Background Chief’s oral Conditional job offer STATUS: Hired On List Withdrawn Disqualified B) NAME OF AGENCY DATE APPLIED

ADDRESS BACKGROUND INVESTIGATOR’S NAME (IF KNOWN) (NUMBER / STREET) CITY STATE ZIP CONTACT NUMBER EXT ( ) POSITION APPLIED EMAIL FOR Check each step in the process that you completed, and your status: STEPS: Application Written Physical agility Oral Polygraph Background Chief’s oral Conditional job offer STATUS: Hired On List Withdrawn Disqualified C) NAME OF AGENCY DATE APPLIED

ADDRESS BACKGROUND INVESTIGATOR’S NAME (IF KNOWN) (NUMBER / STREET) CITY STATE ZIP CONTACT NUMBER EXT ( ) POSITION APPLIED EMAIL FOR Check each step in the process that you completed, and your status: STEPS: Application Written Physical agility Oral Polygraph Background Chief’s oral Conditional job offer STATUS: Hired On List Withdrawn Disqualified

17 SECTION 6: MILITARY EXPERIENCE 41. ALMOST ALL MALE U.S. CITIZENS, AND MALE IMMIGRANTS, WHO ARE 18 THROUGH 25, ARE REQUIRED TO REGISTER WITH SELECTIVE SERVICE. Are you required to register for the Selective Service? ...... Yes No If yes, have you registered? ...... Yes No If you have not registered, explain: Have you served in any branch of the military? ...... Yes No If yes continue with question #42; If no, skip to question #48. 42. BRANCH OF SERVICE 43. DATES OF SERVICE FROM TO 44. TYPE OF Entry Level Honorable General OTH (Other than Honorable) Bad Conduct Dishonorable DISCHARGE: Re-entry Code (1–4) if applicable – refer to your DD-214: 45. Are you currently participating in one of the following? If checked, date obligation ends: Military Reserve National Guard 46. 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

47. Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded? ...... Yes No

IF YOU ANSWERED YES TO QUESTIONS 46 AND/OR 47, EXPLAIN (INCLUDE DATES AND CIRCUMSTANCES):

SECTION 7: FINANCIAL 48. 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? ...... 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. 49. Have you ever avoided paying any lawful debt by moving away?...... Yes No

50. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)?...... Yes No

SECTION 8: LEGAL Disclosure of Arrests and Convictions As an applicant for a Peace Officer, Jailer or Telecommunicator position, you are required to disclose any of the following, even if the records were sealed, expunged, dismissed or pardoned:  ALL detentions or arrests, whether they resulted in a conviction or not  ALL convictions and deferred adjudications  ALL accusations of family violence, even Class C Misdemeanors of a family violence nature  ALL diversion programs that were not successfully completed If more space is needed, continue on additional pages.

51.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

18 If yes, explain each incident. 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

52. HAVE YOU EVER BEEN PLACED ON COURT PROBATION AS AN ADULT?...... Yes No

53. 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

SECTION 8: LEGAL continued 54. Have you ever been a party in a civil lawsuit?...... Yes No

55. Have the police ever been called to your home for any reason?...... Yes No

56. HAVE YOU OR YOUR SPOUSE/PARTNER ever BEEN REFERRED TO CHILD PROTECTIVE SERVICES?...... Yes No

57. Have you ever been the subject of an emergency protective order/restraining order/stay-away order?...... Yes No

58. Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or other state or federal assistance?...... Yes No

59. Have you ever filed a false insurance or workers’ compensation claim?...... Yes No

IF YOU ANSWERED YES TO ANY OF QUESTIONS 52-59, EXPLAIN (INCLUDE COURT CASE OR DOCUMENT, DATES, AND CIRCUMSTANCES; INDICATE CORRESPONDING NUMBER):

Questions 60 and 61 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:

19 – 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, Synthetic Marijuana – Tetrahydrocannabinal (THC) – GHB, Roofies (Date Rape Drug) – Prescriptions drugs (not yours)

60. 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:

61. Prior to the past six months (check all that apply): I HAVE NEVER USED ANY DRUG RECREATIONALLY.

I HAVE TRIED OR USED ONE OR MORE DRUGS. If checked, give details including drug(s) used, most recent date used, frequency of use, and circumstances.

SECTION 8: LEGAL continued

62. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including marijuana or synthetic marijuana?

SOLD PURCHASED CULTIVATED

MANUFACTURED FURNISHED CARRIED OR HELD FOR ANOTHER

If you checked any items above, give details including drug(s) involved, over what time period(s), frequency of use, and circumstances.

SECTION 9: MOTOR VEHICLE OPERATION 63. CURRENT DRIVER’S LICENSE STATE OF EXPIRATION NAME UNDER WHICH LICENSE WAS GRANTED NUMBER ISSUE DATE

64. 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

20 65. HAVE YOU EVER BEEN REFUSED A DRIVER’S LICENSE BY ANY STATE?...... Yes No If yes, explain (include when, where, and circumstances):

66. HAS YOUR DRIVER’S LICENSE EVER BEEN SUSPENDED OR REVOKED?...... Yes No If yes, explain (include when, where, and circumstances):

SECTION 9: MOTOR VEHICLE OPERATION continued

67. List your currently owned vehicle(s): A) TYPE OF VEHICLE VEHICLE MAKE YEAR VEHICLE LICENSE Car/Truck/Wheeled-vehicle Boat/Watercraft Aircraft B) TYPE OF COVERAGE VEHICLE MAKE YEAR VEHICLE LICENSE Car/Truck/Wheeled-vehicle Boat/Watercraft Aircraft C)TYPE OF COVERAGE VEHICLE MAKE YEAR VEHICLE LICENSE Car/Truck/Wheeled-vehicle Boat/Watercraft Aircraft

68. List all traffic citations, excluding parking citations, you have received within the past ten (10) years: 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) NATURE OF VIOLATION LOCATION (STREET) CITY STATE DATE VIOLATION OCCURRED ACTION TAKEN Month Year Not Guilty Fined Traffic School Dismissed

E) 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

21 If checked, explain circumstances:

69. Have you been involved as the driver in a motor vehicle accident within the past ten (10) years?...... Yes No If yes, give details. A) DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP

POLICE REPORT LAW ENFORCEMENT AGENCY INJURY YES NO NON-INJURY B) DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP

POLICE REPORT LAW ENFORCEMENT AGENCY INJURY YES NO NON-INJURY C) DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP

POLICE REPORT LAW ENFORCEMENT AGENCY INJURY YES NO NON-INJURY

SECTION 9: MOTOR VEHICLE OPERATION continued

70. 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 71. Have you ever been refused automobile insurance or had it cancelled?...... Yes No

IF YES, GIVE REASON: INSURANCE COMPANY

DATE LOCATION (NUMBER / STREET / APT) CITY STATE ZIP Month Year

Use this space for additional information you would like to include regarding your driving record.

SECTION 10: OTHER TOPICS

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

73. 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 identity, or disability?...... Yes No 74. 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 identity, or disability?...... Yes No 75. Since the age of 17, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act?...... Yes No

22 If you answered yes to any of Questions 72–75, give details including dates and circumstances; indicate corresponding number.

23 SECTION 10: OTHER TOPICS continued

76. Identify any special licenses or skills you hold that may be relevant to your employment. (e.g. pilot, radio operator, etc.)

77. List any foreign or secondary languages you know and your level of fluency: Language Understand Speak Read Write A) B) C) 78. List any clubs or organizations you belong to relevant to the position you have applied for.

SECTION 11: CERTIFICATION

79. I hereby certify that I have personally completed each page of this form and any supplemental page(s) attached, and that all statements made are true and complete to the best of my knowledge and belief. I understand that any misstatement of material fact may subject me to disqualification; or, if I have been appointed, may disqualify me from continued employment. I further understand that ALL employees of the Sheriff’s Office (including civilian employees) are considered “essential employees” and may be called upon to respond and report for work during any emergency event when the Administration determines the employee’s services are needed.

SIGNATURE IN FULL DATE

24 PERSONAL HISTORY STATEMENT

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I, (print full name)______do hereby authorize a review of full disclosure of all records concerning myself to any duly authorized agent of the County of Victoria, whether the said records are of a Criminal, Public, Private, or Confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of the records held by any Law Enforcement Agency, authorization to release any record maintained by them, but not limited to Records of Arrest and or conviction, or those relating to traffic violations, records of the U.S. Army, U.S. Air Force, U.S. Navy, U.S. Marine Corps, or the U. S. Coast Guard; educational institutions; and financial statements and records wherever filed; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me that the records and recollections of attorneys at law, or of other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the County of Victoria. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information.

MOTOR VEHCILE RECORD ACKNOWLEDGEMENT: I understand that by signing this form I am giving a representative of the County of Victoria my authorization to obtain a copy of my motor vehicle record or to use a copy provided by me.

A photocopy, a facsimile or an electronically transmitted copy of this release form will be valid as an original thereof, even though said photocopy, facsimile or an electronically transmitted copy does not contain an original writing of my signature.

Signature of Applicant Date

Address/City/State/Zip:

Phone: Social Security No.: Driver’s License No.:

STATE OF TEXAS COUNTY OF

This instrument was acknowledged before me on by . (date) Printed name of Applicant

SEAL Signature of Notary

My Commission Expires:

25 WAIVER OF LIABILITY EMPLOYMENT HISTORY RELEASE

Name (Last, First, Middle): ______

Social Security Number: ______

Agency Requesting Records: Victoria County Sheriff’s Office, Victoria County, Texas

I understand that a report is submitted to the Commission each time I resign or am terminated from employment or appointment with a law enforcement agency.

I understand the report must include an explanation of the circumstances of my resignation or termination.

I understand the chief administrator of each law enforcement agency with which I apply for employment may request the contents of each report that pertains to resignation or termination due to substantiated incidents of excessive force or violations of law other than traffic offenses.

I understand the Commission is not liable for civil damages for providing information contained in a report concerning the circumstances cited above, when a written request, on agency letterhead, from a chief administrator and this release is presented to the Commission; and

I understand a law enforcement agency, chief administrator of a law enforcement agency or other law enforcement official is not liable for civil damages for a report made by that agency or person if the report is made in good faith.

I expressly waive my right to hold the Commission, law enforcement agency, chief administrator of the law enforcement agency, or other law enforcement official liable for civil damages for the contents of reports concerning my resignation or termination as a peace officer, reserve law enforcement officer, county jailer, or public security officer which are on file with the Commission, if the law enforcement agency, chief administrator of the law enforcement agency, or other law enforcement official made the report in good faith; and

I expressly waive my right to hold the Commission, law enforcement agency, chief administrator of a law enforcement agency, or other law enforcement official liable for civil damages for any action based on information contained in my reports concerning the circumstance of my resignation or termination from prior employment or appointment with a law enforcement agency.

I have read and understand the foregoing statements. I hereby authorize the Commission to release all reports concerning my resignation or termination pertaining to circumstances cited above as a peace officer, reserve law enforcement officer, county jailer, or public security officer which are on file with the Commission to the department named above.

Signature of Licensee Date

Sworn to and subscribed before me, this

the day of

Notary public in and for, State of Texas My Commission expires Printed Name of Notary

Notary Seal or Stamp Signature of Notary

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