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Personal History Statement Police Officer Applicant Personal History Statement Applicant:_______________________________________ Last Name, First Name Middle Primary Phone (cell): (_____) _____ - ________________ Secondary Phone (home/other): (_____) _____- _______ Check one Email Addresses (List All): List ALL, active or not Social Media: (Facebook/Twitter/Instagram/Reddit/Tumblr or anything else not listed) JSS243 02/2017 1 Table of Contents SECTION PAGE # A. Instructions 3 B. Applicant Identification 4 C. Residences 5-7 D. Employment History 8-19 E. Military Record 20 F. Educational History 21-22 G. Marital and Family Information 23-24 H. Financial History 25-26 I. Driving History 27-30 J. Litigation’s 30 K. Arrests and Detentions 31 L. Narcotic Usage 32-36 M. Criminal History 37-48 N. Application with Other Law Enforcement Entities 49 O. References 50-51 P. Club/Group or Association Memberships 52 Q. Neighbors 53 R. Narrative and Agreement 54 JSS243 02/2017 2 INSTRUCTIONS READ THESE INSTRUCTIONS CAREFULLY BEFORE PROCEEDING!! These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is essential that the information be accurate in all respects. It will be used as the basis for a background investigation that will determine your eligibility for employment. 1. Your Personal History Statement must be filled out by you, personally. Answer all questions to the best of your ability. 2. If a question is not applicable to you, enter N/A in the space provided. 3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is correct and in proper sequence before you begin. 4. You are responsible for obtaining correct information and addresses. If you are not sure of any address, check it by personal verification. Your local library may have a directory service or copies of local telephone directories. 5. If there is insufficient space on the form for you to include all information required, attach extra sheets to the Personal History Statement. Be sure to reference the relevant section before you continue your answer. 6. Please attach a recent photograph of yourself within the last 90 days to the last page of this document. 7. Some of the questions asked in this personal history statement will be verified by a polygraph examination at a later date. To avoid problems on your polygraph examination, please DO NOT falsify, misrepresent, lie about facts, leave out, and neglect to mention or purposely withhold any information about your background; no matter how insignificant you believe it is. Little lies or minor omissions will have the same effect on the polygraph results as more serious lies or omissions. Be completely open and truthful. 8. An accurate and complete form will help expedite your application. On the other hand, ANY OMISSIONS OR FALSIFICATIONS MAY RESULT IN DISQUALIFICATION OF YOUR APPLICATION! 9. Failure to complete this form with all information and blanks filled in can terminate your application! **I understand that the information obtained during the background investigation is confidential and the Grand Prairie Police Department will not release to me any details of these interviews or the reason(s) for rejection of employment. If the reasons for my rejection are temporary in nature whereby I may be accepted at a later date, I understand I may be notified. Applicant’s signature:____________________________________________ Print Name:____________________________________________________ JSS243 02/2017 3 APPLICANT IDENTIFICATION Information provided in this section is for the purpose of identification and notification. NAME:_____________________________________________________________________________________________ Last First Middle ADDRESS:__________________________________________________________________________________________ Street City State Zip Code PRIMARY PHONE (______)______________________WORK PHONE (______)_________________ ADDITIONAL PHONE NUMBER; (such as spouse or emergency contact) (______)________________ DATE OF BIRTH: _______________ ARE YOU A U.S. CITIZEN: YES NO PLACE OF BIRTH: _________________________ SOCIAL SECURITY #: __________________________ DRIVER LICENSE NUMBER:____________________________STATE:_______TYPE:____ HEIGHT________ WEIGHT_______ HAIR_________ EYES_________ SEX: Male Female PANT SIZE: W____” x L _____” SHIRT SIZE: ______ Are you RIGHT HANDED or LEFT HANDED? XS - S – M – L – XL - 2XL (check one) RACE (CHECK ONE): WHITE BLACK HISPANIC AMERICAN INDIAN ASIAN / PACIFIC ISL. NICKNAME(S), MAIDEN NAME OR ANY OTHER NAMES BY WHICH YOU HAVE BEEN KNOWN: TATTOOS, OR OTHER DISTINGUISHING MARKS (List what they are and where they are located) From this point forward: EVERY “YES” ANSWER REQUIRES EXPLANATION in the areas provided. JSS243 02/2017 4 RESIDENCES List all addresses where you have lived during the past 10 years, beginning with present address. List date by month and year. Attach an extra copy of page 5 if necessary. YES NO Have you ever been evicted, threatened with eviction, or asked to move from any place you have lived? (List on back or attach a sheet) Have you ever moved to avoid paying rent that was YES NO due? If yes, when/where? YES Have you ever broken a lease and were you required to pay a fee? NO Explain on back or attach a sheet DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ JSS243 02/2017 5 RESIDENCES DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ JSS243 02/2017 6 RESIDENCES DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ DATES: FROM:________TO:_________ COMPLETE ADDRESS ___________________________________________________________________________________ Street Number Street Name City State Zip ___________________________________________________________________________________ Apt. complex Name Landlord Name-Ph.# Was a lease signed? Yes No Who was on the lease?_______________________________ JSS243 02/2017 7 EMPLOYMENT HISTORY Beginning
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