Personal History Statement

Police Officer Applicant

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?______

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?______

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?______

JSS243 02/2017 7 EMPLOYMENT HISTORY Beginning with your current or most recent job, list all employment since the age of 16, including part-time, temporary or seasonal employment. Include all periods of unemployment. List dates by month and year. Failure to list any jobs may terminate your application. Attach extra copies of these sheets if necessary.

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 8 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 9 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 10 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 11 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 12 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 13 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 14 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 15 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 16 EMPLOYMENT HISTORY

Check appropriate job description(s): Full Part-time Temporary Seasonal

Employer:______

Complete Address:______

Phone:(______)______Job Title:______

Employed from: ______to: ______

Duties:______

Supervisor: ______Co-Worker: ______

Work schedule:______Salary: Beginning:______Ending:______

Reason for leaving: ______

Did you receive job performance evaluations? YES NO

Was notice given? YES NO

Were you fired, asked to resign or contract terminated by this employer? YES NO

If yes, state the reason for having been fired or contract terminated:______

JSS243 02/2017 17 EVERY “YES” REQUIRES EXPLANATION (use the area provided, on the back, or attach another page) EMPLOYMENT HISTORY

Have you ever been suspended, disciplined, reprimanded, terminated or asked to resign in lieu of termination from any job? YES NO Explain:______

Have you ever been suspended, disciplined, reprimanded, placed on administrative leave, or been the subject of an internal affairs complaint while employed with a law enforcement agency? YES NO Explain:______

Are you currently the subject of an internal affairs complaint or on administrative leave with a law enforcement agency? YES NO Explain (add additional pages if necessary):______

Is there any job that you have held that you are classified by that employer as YES NO “NOT ELIGIBLE FOR REHIRE”?

YES NO Have you ever filed a complaint against an employer?

YES NO Have you ever filed a lawsuit against an employer, either past or present?

YES NO Have you ever intentionally damaged an employer’s property?

JSS243 02/2017 18 EMPLOYMENT HISTORY

Have you ever violated an employer rule, regulation, or policy that would have resulted in YES NO Disciplinary action or termination had the employer been aware?

YES NO Have you ever been reprimanded for reporting late to work?

YES NO Have you ever stolen any money from a place where you worked?

If YES, state the place, date, and amount. PLACE DATE AMOUNT

Have you ever taken any materials, merchandise, uniforms, supplies, or tools from any place you YES NO work or have worked, without direct permission?

If YES, state the employer, items taken, and approx. value of the items. PLACE DATE AMOUNT

Have you ever not told a supervisor or fellow employee the truth about a work-related YES NO incident?

Use this area for additional details:

JSS243 02/2017 19 MILITARY RECORD

Are You Registered With the Draft Board: YES NO FEMALE

If yes, list Selective Service number ______(SELECTIVE SERVICE INFORMATION) 1-847-688-6888 Have you ever served with the Armed Forces: YES NO

If you have not been in the military, skip this section.

Date of Service: From ______To ______Branch ______

Military Service #: ______Rank at Discharge: ______

Location of Discharge: ______Type of Discharge: ______

Are you currently on: Active Reserve In-Active Reserve National Guard

Were you ever disciplined while in the Military? YES NO

Were you ever AWOL? YES NO

(Include Court-Martial, Captain's Masts, Company Punishment, Article 15, etc.) CHARGE AGENCY DATE DISPOSTIION

If you received a discharge other than honorable, give complete details:

JSS243 02/2017 20 EDUCATIONAL HISTORY

ELEMENTARY/MIDDLE SCHOOLS ATTENDED CITY & STATE DATES ATTENDED

GRADUATED HIGH SCHOOL ATTENDED CITY & STATE DATES ATTENDED YES NO

COLLEGES or DATES TOTAL DEGREE UNIVERSITIES CITY & STATE ATTENDED HRS MAJOR/MINOR RECEIVED

List other schools attended (academy, trade, vocational, business, etc.). Give name and address of school, dates attended, course of study, certificate and any other pertinent information.

Have you ever been suspended from any high school, college, university, business, or vocational schools?

YES NO If yes, explain:

SPECIAL QUALIFICATIONS & SKILLS: List any other special skills or qualifications you may possess. List any special licenses you hold such as pilot, radio operator, scuba, etc., showing license authority, original date of issue and date of expiration.

JSS243 02/2017 21 EDUCATIONAL HISTORY

When completing the following information you must give sufficient detailed information that can be verified. List information such as the name of the school and year involved in such activities. School Activities: Clubs/Sports/Etc.

______

Positions of Leadership: (Indicate Position/Organization/Dates held)

______

Community Activities:

Awards/Commendations or Special Recognition:

If you know a foreign language (not including ENGLISH), indicate each and your level of proficiency. (Excellent, Good, Fair) LANGUAGE READING SPEAKING UNDERSTANDING WRITING

JSS243 02/2017 22 MARITAL & FAMILY INFORMATION

Status: Single Separated Divorced Significant Other/Long Term Relationship

Married Engaged Widowed Common Law Roommate(s)

Current, if applicable:

Name of Person:______Date of Birth______

Home Address:______Home Phone:______

Name of Employer: ______Work Address: ______

Work Phone:______Work Schedule:______

If married: Date: ______Maiden Name:______

Previous marriage or additional roommate (if applicable):

Separated Divorced Widowed Annulled

Date of Marriage: ______City & State:______

Date of Order/Decree ______Court & State Where Issued______

Ex-spouse's Name: ______Maiden name______

Ex-spouse’s date of birth: ______

Present Address: ______

Phone: Home ______Work ______

Do you have more than one previous marriage? YES NO

Previous marriage or additional roommate (List additional people on back if applicable):

Separated Divorced Widowed Annulled____

Date of Marriage: ______City & State:______

Date of Order/Decree ______Court & State Where Issued______

Ex-spouse's Name: ______Maiden name______

Ex-spouse’s date of birth: ______

Present Address: ______

Phone: Home ______Work ______

JSS243 02/2017 23

MARITAL & FAMILY INFORMATION

Do you pay child support? Y/N Are you current? Y/N Amount paid?______

List all children related to you or your spouse (natural, stepchildren, adopted and foster children):

DATE SUPPORTED NAME RELATION OF BIRTH ADDRESS BY WHOM

***List all information on parents to the above children if not mentioned previously on page 23

NAME ADDRESS DATE OF BIRTH/PHONE

______

List ALL other relatives (including STEP and HALF) in the following order: Father, mother (maiden also), brothers, & sisters.

NAME ADDRESS PHONE# RELATION AGE

______

JSS243 02/2017 24 FINANCIAL

Your monthly salary? ______Your spouse’s monthly salary? ______

Other monthly income - describe:

______

Do you own any real estate? YES NO Location:______Value:______

Location:______Value:______

YES NO Do you own any bonds?

Value:______

YES NO Do you own any corporate stock?

Value:______

YES NO Do you have a bank account?

List ALL Checking Average Balance Name and Address of Bank

______

List ALL Savings Average Balance Name and Address of Bank

______

JSS243 02/2017 25 FINANCIAL

YES NO Have you ever been delinquent on payments of any loans / charge accounts?

YES NO Have you ever filed for or declared bankruptcy?

YES NO Have any of your bills ever been turned over to a collection agency?

YES NO Have you ever had purchased goods repossessed?

YES NO Have your wages ever been garnished?

YES NO Have you ever been delinquent on income or other tax payments?

YES NO Have you ever had a check returned for insufficient funds?

If yes to any of the above questions, please explain: ______

______

Please list all of your financial liabilities (charge accounts, rent, mortgage, car payments, etc.)

Reason for Debt Total Monthly Name, Address, Phone of Creditor or item Purchased Account Number Balance Payment

JSS243 02/2017 26

DRIVING HISTORY

How many citations have you received since you began driving? ______

How many MOVING citations have you received in the past three years? ______

A moving violation is any violation that is NOT a mechanical infraction. It does not include such violations as expired inspection stickers, expired vehicle registrations, defective headlamps, etc.

List ALL traffic citations you have received, excluding parking tickets. INCLUDE CITATIONS FOR WHICH YOU HAVE TAKEN DEFENSIVE DRIVING

MONTH / YEAR CHARGE CITY & STATE DISPOSITION

JSS243 02/2017 27

DRIVING HISTORY

List any traffic accidents in which you have been involved including dates and locations, city and state, and describe what happened.

YES NO Do you have any unpaid traffic or parking citations?

YES NO Have you driven a motor vehicle, since your 17th birthday, without a valid driver’s license?

YES NO Have you ever driven a vehicle without insurance?

YES NO Have you ever had your driver’s license suspended?

IF YES, COMPLETE THE FOLLOWING: DATE OF SUSPENSION TYPE OF SUSPENSION DATE LIFTED

Have you ever had you driver’s license placed on probation for receiving an excessive number YES NO of traffic violations?

YES NO Have you ever had a civil or criminal hearing for probation/suspensions, etc.?

JSS243 02/2017 28 DRIVING HISTORY

YES NO Have you ever been placed as an assigned risk for vehicle insurance?

YES NO Have you ever had your insurance revoked due to the number of traffic citations or accidents?

YES NO Have you ever knowingly driven a motor vehicle after your driver’s license was suspended or after it had been revoked?

YES NO Do you have a valid driver’s license in more than one state?

YES NO Have you ever been issued a driver’s license in another state?

If YES, list the state and license number:

YES NO Have you ever been arrested for DWI, BWI, or DUI?

If YES, give details:

YES NO Have you ever been denied a driver’s license for any reason?

YES NO Have you ever struck a vehicle and then left without leaving identification or complying with the duties upon striking an unattended motor vehicle?

If YES, give details:

Have you ever driven a vehicle while you were under the influence of alcoholic beverages? Explain YES NO

Have you ever driven a vehicle while you were under the influence of a narcotic? Explain YES NO

JSS243 02/2017 29 DRIVING HISTORY

YES NO Have you ever fled from the police (in a vehicle or on foot)?

YES NO Have you ever been involved in an accident, as a driver, after you had been drinking Alcoholic beverages?

YES NO Have you ever been turned down for auto insurance?

With what company do you carry auto insurance?

______Company Vehicle Year, Make & Model

______Company Address License Plate Number/ State

______Additional Vehicle(s): Policy Number

______Agent Name Vehicle Year, Make & Model

(______)______Agent Telephone Number License Plate Number/ State

LITIGATIONS

YES NO Have you ever been involved in any type of lawsuit? (Even as a witness).

YES NO Were you personally sued?

YES NO Have you ever sued anyone?

YES NO Has anyone ever threatened to take you to court for non-payment of a bill?

If YES to any of the above, explain each incident. (List juvenile, as well as adult occurrences).

______

JSS243 02/2017 30 ARRESTS & DETENTIONS

An arrest occurs when you have been handcuffed and taken to jail or to the police station where you are later released. Generally, it requires you to post a bond, pay a fine, or be released to a responsible party (such the case would be for releasing an intoxicated person to another without the posting of a bond). A detention is a temporary loss of freedom pending the results of a criminal investigation that may be occurring or have occurred. In being detained, one may be released with no further action taken against you or it may result in a citation and future summons to court. YES NO Have you ever been arrested by the police?

YES NO Have you ever been detained or questioned by the police (other than for traffic violation)?

YES NO Have you ever had a warrant issued for your arrest?

YES NO Have you ever been summoned into court for a criminal offense (other than for traffic)?

If YES, list all detentions and summons below, including traffic warrants. (List juvenile as well as adult occurrences). OFFENSE CHARGED POLICE AGENCY CITY, STATE DATE DISPOSITION

YES NO Have you ever been listed as a suspect, complainant or witness in a police information / offense report?

If YES, list all reports. POLICE AGENCY CITY, STATE DATE TYPE OF REPORT

JSS243 02/2017 31 NARCOTIC USAGE

Our society’s opinion and beliefs on the use of narcotics is constantly changing and in some instances leaning to more liberal thoughts. However, an ILLEGAL DRUG IS STILL AN ILLEGAL DRUG HERE IN TEXAS. It is important that the Grand Prairie Police Department be aware of your past and/or current illegal drug use. This is because if you become a peace officer you may be called to testify as a witness for the State in criminal prosecutions of persons charged with illegal drug usage. The defense can and will ask about your personal drug usage in an effort to attack or impeach your credibility. We believe in honesty and integrity, first and foremost, here at the GPPD.

An illegal use is when a drug is NOT PRESCRIBED TO YOU by a licensed medical practitioner, but ingested by YOU. It is also considered an illegal use when, having received a prescribed narcotic by a licensed medical practitioner, you fail to follow the instructions on the quantity to ingest over periods of time thus taking more than prescribed. Further, ingesting another patient’s medication that is not prescribed to you becomes illegal. An example of this type of act is where you may have a headache and another person, who has a prescription of Tylenol 3-with Codeine, gives you one to ingest for your headache.

Let’s discuss what we mean by drug usage. By usage we mean the ingestion of drugs into your system. Ingestion is defined as, but not limited to, snort, sniff, inject (needle), smoke, puff, toke, oral (by pill tab, tasting, consume or mixed with food or drink), or absorbed into the body by any means. Each separate instance of usage, regardless of quantity consumed, constitutes “one time used.”

We are also interested in identifying exactly when you used each drug. You will be given an opportunity to explain the first date that you used each drug, and the last time you used each drug.

When asked to give the maximum number of times that you used the drug, you must give the ABSOLUTE MAXIMUM NUMBER OF TIMES YOU USED THE DRUG. For instance, if you have snorted cocaine six times, and you state that you used cocaine five times, you will appear to be deceptive when questioned on a polygraph. Likewise, if you are not sure how many times you used a drug, such as marijuana, then state the absolute maximum number of times you could have used the drug.

Now please consider the following chart, explaining if you have used each of the drugs mentioned, the first time (year) you used the drug, the last time (month and year) you used the drug, the absolute maximum number of times you used the drug, and how you used the drug. If you have never used the particular drug, then check the appropriate NEVER area. Please list only drugs not prescribed to you or having been prescribed but used improperly. Prescription drugs of another person’s that you used, even though legally prescribed, should be listed.

JSS243 02/2017 32

ILLEGAL DRUG and NARCOTIC USAGE

FIRST LAST MAXIMUM HOW NEVER DRUG TIME USED TIME USED TIMES USED USED USED (Month/Year) (Month/Year)

PCP / ANGEL DUST

VYVANSE

THC / MARIJUANA / HASH

LSD

PEYOTE

MESCALINE

HEROIN

COCAINE / CRACK

QUAALUDES

DOWNERS

TRANQUILIZERS

AMPHETAMINE

METH-AMPHETAMINE / ICE

SPEED

CRANK

ADDERALL (STUDY PILL)

BIPHETAMINE

ECSTASY / XTC

PRELUDIN

DILAUDID

ROHYPNOL or GHB

JSS243 02/2017 33

ILLEGAL DRUG and NARCOTIC USAGE

FIRST LAST MAXIMUM HOW DRUG TIME USED TIME USED TIMES USED USED NEVER

XANAX/ “QUAD BARS” MUSHROOMS (PSILOCYBIN) INHALANTS- SEE BELOW

GLUE

PAINT

FREON GASOLINE PRODUCTS BUTYL NITRITE (LOCKER ROOM, RUSH, POPPERS)

STEROIDS

STEROID (STREET NAME)

HOW MANY CYCLES?

OTHERS- LIST BELOW

SALVIA (OTHER HERBS)

WHIP-ITS

BATH SALTS

ANY OTHERS NOT LISTED

JSS243 02/2017 34

ILLEGAL DRUG and NARCOTIC USAGE

In reference to any type of the illegal drugs listed below, usage covers any of the terms you might use in referring to their use, example: experimentation, tried, taking a hit, etc.

______is the maximum number of times I have ever used Marijuana in any form. The last possible date that I used Marijuana is

YES NO Would you arrest a friend or family member for a drug violation if you were a police officer?

YES NO Have you ever bought an illegal substance?

YES NO Have you ever sold any illegal substance to another person?

If YES, explain:

______

YES NO Have you ever given any illegal substance to another person?

If YES, explain:

______

YES NO Have you ever been involved, in any way, in the manufacturing of an illegal substance?

If YES, explain:

______

JSS243 02/2017 35 AN ALCOHOLIC BEVERAGE, BY DEFINITION, IS A NARCOTIC. DEPENDING UPON THE SUBJECT MATTER, IT CAN BE CONSIDERED UNLAWFUL TO POSSESS, CONSUME OR SELL. YES NO Have you ever purchased an alcoholic beverage using a fake identification card?

If YES, explain:

______

YES NO Have you ever had someone, other than your parents, purchase alcoholic beverages for you because You were too young to make the purchase?

If YES, explain:

______

YES NO Have you ever made alcoholic beverages available to a minor by purchasing or providing it yourself?

If YES, explain:

______

Have you ever been issued a citation for Minor in Possession / Consumption of Alcoholic Beverages? YES NO

DATES: ______

Have you ever been late for, or missed, work because of alcohol use? YES NO

Has alcohol ever affected your job performance? YES NO

As an adult, have you ever been convicted of DWI? YES NO

Have you ever been arrested or detained and released to a responsible party as a result of YES NO being determined too intoxicated by a law enforcement officer?

JSS243 02/2017 36 CRIMINAL HISTORY

YES NO Have you ever forced sexual contact with another person by force, word, or action?

YES NO Have you ever engaged in sexual contact while you were at a job?

YES NO Have you taken part in a riot as a rioter? (Defined: 7 or more persons causing a disruption of the public peace)

YES NO Are you aware of any problems that could prevent you from getting this job?

If YES, explain:

______

YES NO Have you committed any criminal offense classified as a Felony?

If YES, explain:

______

Have you committed any criminal offense classified as a Misdemeanor within the last YES NO seven years?

If YES, explain:

______

JSS243 02/2017 37 CRIMINAL HISTORY

Have you ever been investigated by a law enforcement agency for allegedly committing YES NO any crime, Felony or Misdemeanor?

If YES, explain:

______

Have you ever carried, either on your person or in a vehicle, any instrument that could YES NO be classified as an illegal weapon?

If YES, explain:

______

Do you know any relatives, friends or personal contacts that are or have been involved in YES NO any type of criminal activity?

If YES, identify the person, the activity and the type of relationship you have with them:

______

YES NO Have you ever been arrested?

If YES, list all arresting agencies, dates, charges and status of each: AGENCY DATE CHARGE STATUS

JSS243 02/2017 38 CRIMINAL HISTORY

YES NO Have you ever taken, under any circumstances, property that did not belong to you?

If YES, explain:

______

YES NO Have you ever been present when someone, friend or relative, committed a crime?

If YES, explain:

______

YES NO Have you ever entered a house or building (other than your own) without the owner(s) permission?

If YES, explain:

______

YES NO Have you ever entered a house or building with the intent of hurting someone or stealing any property?

If YES, explain:

______

JSS243 02/2017 39 CRIMINAL HISTORY

YES NO Have you ever paid for or solicited a sex act in relation to prostitution?

If YES, explain:

______

YES NO Have you ever committed or been accused of theft from your employer?

If YES, explain:

______

YES NO Have you ever taken a polygraph exam for any reason?

Did they tell you the outcome? ______

If YES, explain:

______

YES NO Have you ever stolen or shoplifted anything?

If YES, explain:

______

JSS243 02/2017 40 CRIMINAL HISTORY

YES NO Have you ever entered a vehicle and stolen anything out of it?

If YES, explain:

______

YES NO Have you ever taken a vehicle without the permission of the owner?

If YES, explain:

______

YES NO Have you ever engaged in sexual activity with a minor, regardless of your age?

If YES, explain:

______

YES NO Have you ever committed a serious undetected crime?

If YES, explain:

______

JSS243 02/2017 41 CRIMINAL HISTORY

YES NO Have you ever caused the death of another person?

If YES, explain:

______

YES NO Have you ever committed any criminal mischief offenses? (Criminal mischief is intentional damage done to property belonging to someone other than yourself)

If YES, explain:

______

YES NO Have you ever intentionally set someone’s property on fire, either for personal reasons, for profit, revenge, or to receive any type of gratification?

If YES, explain:

______

YES NO Have you ever assaulted (struck, pushed, etc.) anyone, including family members?

If YES, explain:

______

JSS243 02/2017 42 CRIMINAL HISTORY

YES NO Have you ever forged any checks, prescriptions, or other documents?

If YES, explain:

______

YES NO Have you ever written a check on another person’s account without their permission?

If YES, explain:

______

YES NO Have you ever taken money from anyone by force or intimidation?

If YES, explain:

______

YES NO Have you ever had a sexual harassment complaint made against you?

If YES, explain: ______

______

JSS243 02/2017 43 CRIMINAL HISTORY

YES NO Have you ever bought anything that you suspected, or knew, was stolen?

If YES, explain:

YES NO Have you ever sold or pawned anything that you believed or suspected to be stolen?

If YES, explain:

YES NO Have you ever been, or are you currently on, probation / deferred adjudication for any offense?

If YES, explain:

Have you ever used an altered identification or the identification of someone YES NO else for any purpose?

If YES, explain:

JSS243 02/2017 44 CRIMINAL HISTORY

Have you ever caused anyone to believe that you were acting in the official capacity as a police officer, YES NO when you were not a police officer?

If YES, explain:

YES NO Have you ever been a member of any street gang or paramilitary organization?

If YES, explain:

YES NO Have you ever engaged in a sexual act for money?

If YES, explain:

YES NO Have you ever done any window peeping?

If YES, explain:

JSS243 02/2017 45 CRIMINAL HISTORY

YES NO Have you ever been employed in the law enforcement field?

YES NO Have you ever accepted money or a material object in return for not enforcing a law?

YES NO Have you ever made a false statement in any type of police report or document?

YES NO Have you ever committed any crime as a law enforcement employee?

YES NO Have you ever been accused of hurting a person?

BY WHOM RESULT OF ACCUSATION

YES NO Have you ever been disciplined while an officer or law enforcement employee?

FOR WHAT LEVEL OF DISCIPLINE

JSS243 02/2017 46 CRIMINAL HISTORY

YES NO Have you ever had an excessive force complaint filed against you?

If yes, list the number of complaints and disposition:

YES NO Have you ever physically abused a prisoner?

YES NO Have you ever slept on duty?

Approx. number of times:______Reason: ______

______

YES NO Have you ever been classified as ineligible for rehire by a former law enforcement agency?

If yes, list the agency and reason:

JSS243 02/2017 47 CRIMINAL HISTORY

YES NO Have you ever resigned while under investigation?

If yes, explain:

YES NO Have you ever resigned while under investigation in exchange for a favorable recommendation to a future employer?

If yes, explain:

Have you had any type of unauthorized physical or sexual contact while you were on duty as a police YES NO officer or law enforcement employee?

If yes, explain:

Have you ever consumed any type of alcoholic beverage while you were on duty and/or in violation of YES NO your departmental policies?

Have you ever used marijuana, illegal drugs or narcotics while on duty and/or in violation of your YES NO departmental policies?

YES NO Have you ever confiscated a prisoner’s personal property and made personal use of it?

YES NO Have you ever committed any undetected act as a law enforcement employee, which, were it to be discovered would result in disciplinary action?

JSS243 02/2017 48 APPLICATION WITH OTHER LAW ENFORCEMENT ENTITIES

Have you ever made application for employment with this or any other law enforcement or related YES NO agency?

If yes, list ALL agencies, dates and status of application (attach another page if necessary). AGENCY DATE STATUS

Are there any incidents in your life or details not mentioned herein which may influence this YES NO department's evaluation of your application for employment as a police officer?

If YES, explain:

JSS243 02/2017 49 REFERENCES

List eight persons who know you well enough to provide current information about you. DO NOT list relatives, former employers, supervisors or anyone listed previously in this statement. Include people that see you regularly in social settings, not friends of your parents. Provide their complete address (city, state, zip code) and phone number.

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

JSS243 02/2017 50

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

NAME______HOME/CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

EMAIL ADDRESS______

JSS243 02/2017 51

CLUB/GROUP OR ASSOCIATION MEMBERSHIPS

OFFICIAL NAME OF TYPE: SOCIAL, DATES OF ORGANIZATION FRATERNAL, OFFICE(S) HELD MEMBERSHIP PROFESSIONAL, ECT. FROM TO

HOBBIES AND SPORTS

NAME OF SPORT/HOBBY DURATION LEVEL OF PROFIEICNCY

JSS243 02/2017 52

NEIGHBORS List neighbors that live on both sides of your current residence and previous or permanent residence. If you don't know your neighbors, meet them. If a house or apartment is empty, make a notation. This section must be complete.

NAME______HOME/ CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

NAME______HOME/ CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

NAME______HOME/ CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

NAME______HOME/ CELL PHONE (______)______

ADDRESS______

BUSINESS NAME______WORK PHONE (______)______

BUSINESS ADDRESS______

HOURS OF WORK______YEARS KNOWN______

JSS243 02/2017 53 NARRATIVE & AGREEMENT

In your own words explain why you want to work for the Grand Prairie Police Department. (Minimum 100 words)

JSS243 02/20 21

54 AGREEMENT

I hereby certify that there are no misrepresentations, omissions, or falsification the foregoing statements and answers. I am fully aware that any such misrepresentations, omissions, or falsifications can be grounds for immediate rejection or termination of employment.

______Printed name of applicant

______Signature of applicant

______Date

Before me personally appeared ______who stated this document and its intent was explained to him/her that he/she has full knowledge of its purpose and that he/she executed this instrument of his/her free will and accord.

Sworn to and subscribed before me on this ______day of ______, ______

SEAL or STAMP ______Signature of Notary

My commission expires :______

55 \

Attach a photograph of yourself taken during the past 90 days. Attach the photo above, drag and drop from your device or computer.

NAME______LAST FIRST MIDDLE

JSS243 02/2017 56 AUTHORITY TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

I hereby authorize the Grand Prairie Police Department and its authorized representatives bearing this release, or a copy thereof, within one year of its date, to obtain any information in your files pertaining to my employment history, military service, credit reports, educational records, medical records, attendance, athletic endeavors, personal history, disciplinary records, and polygraph examination(s). This includes but is not limited to personal accounts/recollection. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for official use. Consent is granted to all parties to furnish such information, as described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as custodian of such records, and any school, college, university, or other educations institution, hospital, or other repository of medical records, credit bureau, lending institution, consumer reporting agency, or retail business establishment including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or attempt to comply with it. I am furnishing my Social Security Account Number on a voluntary basis with the understanding such is not required by any law or regulation. I have been advised that all parties will utilize this number only to facilitate the location of employment, military, credit, and educational records concerning me in connection with this application. Should there be any question as to the validity of this release, you may contact me as indicated below:

Applicant’s Printed Full Name: ______

D.O.B.: ______SSN#______Address: ______Telephone Number: ______

Applicant’s Notarized Signature: ______Sworn to and signed before me, on this the _____ day of ______, ______, in and for ______county, in the state of ______.

Signature of Notary Public: ______

NOTARY SEAL Printed Name of Notary Public: ______My Commission Expires:

JSS243 02/2017 57 JSS243 02/2017 58