Background Investigation Checklist Form
Uploaded by
Cassey Koi FarmBackground Investigation Checklist Form
Uploaded by
Cassey Koi FarmDAVAO SECURITY & INVESTIGATION AGENCY, INC.
COR. JUAN LUNA & DAMASO SUAZO STS.,DAVAO CITY
Commission on
State of California Department of Justice
TEL. NOS. 221-7860; 221-4595; 227-7979 FAX (82) 226-2291
Peace
Officer
Standards
and
Training
(POST)
PERSONAL HISTORY STATEMENT
Peace Officer
__________________________________________________________________
860 Stillwater Road, Suite 100
POST 2-251 (Rev 02/2013)
As Best Security Agency, for 1981, 1985, 1994 and 2006 and
West Sacramento, CA 95605-1630
Most Outstanding Private Security Agency of the Phils. 2012,2013 2014
with Nationwide Branches
Instructions to the Applicant
The information you provide in this Personal History Statement will be used in the background investigation to assist
in determining your suitability for the position of California Peace Officer, in accordance with POST Commission
Regulation 1953.
It is your responsibility to complete this form and provide all required information.
If you are filling out a printed copy of this form, neatly print in blue or black ink.
You must respond 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 need more space for any response, use the last page of this form (page 27) and identify the additional
information by the question number.
Send the completed form to your background investigator or the agency to which you are applying. Do NOT send
the form to POST.
Disqualification
There are very few automatic bases for rejection. Even issues of prior misconduct, such as prior illegal drug use,
driving under the influence, theft, or even arrest or conviction are usually not, in and of themselves, automatically
disqualifying. However, 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 fact, the number one reason
individuals fail background investigations is because they deliberately withhold or misrepresent job-relevant
information from their prospective employer.
BOTTOM LINE: You are responsible for providing complete, accurate, and truthful responses.
Disclosure of Medically-Related Information
In accordance with the U.S. Americans with Disabilities Act, the Genetic Information Nondiscrimination Act
(GINA), and the California Fair Employment and Housing Act, applicants are not expected or required to reveal
any medical or other disability-related information about themselves or their family members in response to
questions on this form.
I have read and I understand the above instructions.
Signature: _________________________________________________
Page 1 of 27
Date: ________________________
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 1: PERSONAL
1. YOUR FULL NAME
LAST
FIRST
MIDDLE
2. OTHER NAMES YOU HAVE USED OR BEEN KNOWN BY (INCLUDE MAIDEN NAME AND NICKNAMES)
N/A
3. ADDRESS WHERE YOU LIVE
NUMBER / STREET
APT / UNIT
PROVINCE
CITY
STATE
ZIP
4. MAILING ADDRESS, IF DIFFERENT FROM ABOVE (FOR EXAMPLE, PO BOX)
5. CONTACT NUMBERS
HOME
WORK
EXT
6. CONTACT EMAIL
OTHER
CELL
FAX
7. LIST ALL OTHER EMAIL ADDRESSES (SEPARATED BY COMMAS)
8. CITIZENSHIP
Filipino
Citizen?
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
9. BIRTH PLACE (CITY / COUNTY / STATE / COUNTRY)
10. BIRTHDATE (MM/DD/YYYY)
11. SOCIAL SECURITY NUMBER
12. DRIVERS LICENSE
PROVINCE
STATE:
NUMBER:
EXPIRES:
13. PHYSICAL DESCRIPTION
HEIGHT:
WEIGHT:
HAIR COLOR:
EYE COLOR:
SECTION 2: RELATIVES AND REFERENCES
14. IMMEDIATE FAMILY
14.A
Provide all applicable information in the spaces below.
Mark N/A if a category is not applicable.
Mark Deceased, if appropriate.
If more space is needed, continue on page 27 reference corresponding numbers.
Spouse / Registered Domestic Partner
NAME
HOME PHONE
Deceased
N/A
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
DATE OF MARRIAGE/REGISTRATION
/
14.B
Is there, or has there ever been, a restraining or stay-away
order in effect involving you and this individual? .......................
(MM/YYYY)
Former Spouse / Former Registered Domestic Partner
NAME
HOME PHONE
Deceased
No
N/A
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
DATE OF MARRIAGE/REGISTRATION
Page 2 of 27
Yes
(MM/YYYY)
DATE OF DISSOLUTON
(MM/YYYY)
Is there, or has there ever been, a restraining or stay-away
order in effect involving you and this individual? .......................
Yes
No
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 2: RELATIVES AND REFERENCES continued
Parents / Guardians
14.C
List ALL parents/guardians, living or deceased, including biological, adoptive, foster, step-parents, in-laws, etc.
14.C.1
Parent / Guardian:
Mother
Father
NAME
HOME PHONE
14.C.2
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
Parent / Guardian:
Mother
Father
Step-mother
Step-father
In-law
Other:
Deceased
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
Parent / Guardian:
Mother
HOME PHONE
Father
NAME
Step-mother
Step-father
In-law
Other:
Deceased
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
Parent / Guardian:
Mother
HOME PHONE
Father
NAME
Deceased
HOME PHONE
14.C.4
Other:
ZIP
CELL PHONE
In-law
STATE
Step-father
CITY
WORK PHONE
NAME
14.C.3
Step-mother
HOME ADDRESS (NUMBER / STREET / APT)
Step-mother
Step-father
In-law
Other:
Deceased
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
WORK PHONE
CELL PHONE
Brothers / Sisters
14.D
N/A
List ALL LIVING siblings, including half-siblings, step-siblings, foster-siblings, etc.
14.D.1
Sibling:
Brother
NAME
Sister
AGE
HOME PHONE
14.D.2
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
)
CELL PHONE
)
Brother
Sister
AGE
HOME PHONE
Other:
STATE
(
Sibling:
Half-sister
CITY
WORK PHONE
NAME
Page 3 of 27
Half-brother
HOME ADDRESS (NUMBER / STREET / APT)
Half-brother
Half-sister
Other:
WORK PHONE
CELL PHONE
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 2: RELATIVES AND REFERENCES continued
14.D.3
Sibling:
Brother
Sister
NAME
AGE
HOME PHONE
14.D.4
Half-brother
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
)
CELL PHONE
)
Brother
Sister
NAME
AGE
HOME PHONE
Other:
CITY
WORK PHONE
Sibling:
Half-sister
HOME ADDRESS (NUMBER / STREET / APT)
Half-brother
Half-sister
Other:
WORK PHONE
CELL PHONE
Children
14.E
N/A
List ALL 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/guardian, if other than you.
14.E.1
Child:
Son
Daughter
NAME
Other:
AGE
CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
CONTACT NUMBER
(
14.E.2
Child:
Son
Daughter
NAME
(
Son
Daughter
CONTACT NUMBER
(
Child:
Son
Daughter
CITY
STATE ZIP
Other:
AGE
CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
CONTACT NUMBER
Page 4 of 27
STATE ZIP
CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
ADDRESS (NUMBER / STREET / APT)
14.E.4
CITY
Other:
AGE
NAME
STATE ZIP
CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)
CONTACT NUMBER
Child:
CITY
Other:
AGE
NAME
STATE ZIP
ADDRESS (NUMBER / STREET / APT)
14.E.3
CITY
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 2: RELATIVES AND REFERENCES continued
15. LIST OF REFERENCES
List 7 10 people who know you well, such as close personal relationships, social and family friends, teachers, military colleagues, and/or
co-workers. Do NOT include relatives, employers, housemates, or any individuals listed elsewhere.
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.1
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.2
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.3
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.4
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.5
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.6
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
Page 5 of 27
)
How long have you known this person?
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 2: RELATIVES AND REFERENCES continued
NAME OF REFERENCE
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.7
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.8
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.9
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
NAME OF REFERENCE
How long have you known this person?
HOME ADDRESS (NUMBER / STREET / APT)
CITY
STATE ZIP
WORK ADDRESS (NUMBER / STREET / SUITE)
CITY
STATE ZIP
15.10
HOME PHONE
WORK PHONE
CELL PHONE
How do you know this person?
How long have you known this person?
SECTION 3: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims in Section 3.
If more space is needed, continue your response on page 27.
16. CHECK APPLICABLE
High School Diploma:
MM/YYYY
MM/YYYY
GED:
MM/YYYY
California High School Proficiency Certificate:
17. LIST HIGH SCHOOL(S) ATTENDED
NAME OF HIGH SCHOOL
FROM (MM/YYYY)
17.1
TO (MM/YYYY)
/
CITY
NAME OF HIGH SCHOOL
FROM (MM/YYYY)
17.2
TO (MM/YYYY)
/
CITY
Page 6 of 27
/
STATE
/
STATE
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 3: EDUCATION continued
18. LIST ALL COLLEGES AND UNIVERSITIES ATTENDED
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
18.1
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM
ADDRESS (NUMBER / STREET)
SEM SYSTEM
TYPE OF DEGREE EARNED
CITY
STATE
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
18.2
ZIP
MAJOR / AREA OF STUDY
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM
ADDRESS (NUMBER / STREET)
SEM SYSTEM
TYPE OF DEGREE EARNED
CITY
STATE
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
18.3
ZIP
MAJOR / AREA OF STUDY
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM
ADDRESS (NUMBER / STREET)
SEM SYSTEM
TYPE OF DEGREE EARNED
CITY
STATE
NAME OF COLLEGE/UNIVERSITY
FROM (MM/YYYY)
18.4
ZIP
MAJOR / AREA OF STUDY
TO (MM/YYYY)
TOTAL UNITS COMPLETED
QTR SYSTEM
ADDRESS (NUMBER / STREET)
SEM SYSTEM
TYPE OF DEGREE EARNED
CITY
STATE
ZIP
MAJOR / AREA OF STUDY
19. LIST ALL TRADE, VOCATIONAL, AND BUSINESS SCHOOLS / INSTITUTES ATTENDED
NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE
19.1
TO (MM/YYYY)
/
CITY
STATE
NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE
19.2
Yes
TO (MM/YYYY)
DID YOU COMPLETE THE COURSE?
Yes
Yes
No
LOCATION (CITY / STATE)
B. COURSE COMPLETION
COMPLETION DATE (MM/YYYY)
Did you successfully complete the course? ..................................................................
Page 7 of 27
No
TYPE OF SCHOOL OR TRAINING
Have you ever taken a PC832 (Arrest and/or Firearms) Course? ....................................................................................................
IF YES, provide the following information:
A. COURSE PRESENTER NAME
No
TYPE OF SCHOOL OR TRAINING
FROM (MM/YYYY)
STATE
DID YOU COMPLETE THE COURSE?
/
CITY
20.
FROM (MM/YYYY)
Yes
No
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 3: EDUCATION continued
Have you ever attended a POST Basic Course/Academy: Regular, Specialized Investigators, Reserve, or Dispatcher? ..............
IF YES, provide the following information:
21.
NAME OF ACADEMY
FROM (MM/YYYY)
21.1
TO (MM/YYYY)
/
LOCATION (CITY, STATE)
Yes
21.2
TO (MM/YYYY)
/
LOCATION (CITY, STATE)
DID YOU PASS/GRADUATE?
Yes
NAME OF TRAINING OFFICER / ACADEMY COORDINATOR
No
CONTACT NUMBER
Have you ever been subject to any disciplinary action, including academic probation, civil fine, suspension, or expulsion
from any high school(s), college/university, business, trade school, or POST basic course/academy? ............................................
22.
No
CONTACT NUMBER
(
FROM (MM/YYYY)
No
DID YOU PASS/GRADUATE?
NAME OF TRAINING OFFICER / ACADEMY COORDINATOR
NAME OF ACADEMY
Yes
Yes
No
IF YES, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school, educational institution, or
POST basic course. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 4: RESIDENCE HISTORY
23. LIST OF RESIDENCES
List all residences during the last 10 years or since age 15.
Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit/apt number). Do NOT use PO 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 your response on page 27.
ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT)
FROM (MM/YYYY)
23.1
TO (MM/YYYY)
Present
/
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)
CONTACT NUMBER
(
CITY
STATE
ZIP
Name(s) of those with whom you live:
FORMER ADDRESS (NUMBER / STREET / APT)
FROM (MM/YYYY)
23.2
TO (MM/YYYY)
/
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)
CONTACT NUMBER
(
CITY
STATE
ZIP
Name(s) of those with whom you lived:
Reason for moving:
Page 8 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 4: RESIDENCE HISTORY continued
FORMER ADDRESS (NUMBER / STREET / APT)
FROM (MM/YYYY)
23.3
TO (MM/YYYY)
/
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)
CONTACT NUMBER
(
CITY
STATE
ZIP
Name(s) of those with whom you lived:
Reason for moving:
FORMER ADDRESS (NUMBER / STREET / APT)
FROM (MM/YYYY)
23.4
TO (MM/YYYY)
/
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)
CONTACT NUMBER
(
CITY
STATE
ZIP
Name(s) of those with whom you lived:
Reason for moving:
FORMER ADDRESS (NUMBER / STREET / APT)
FROM (MM/YYYY)
23.5
TO (MM/YYYY)
/
CITY
STATE
ZIP
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)
CONTACT NUMBER
(
CITY
STATE
ZIP
Name(s) of those with whom you lived:
Reason for moving:
24. LIST OF HOUSEMATES
Provide contact information for all housemates listed in Question 23 with whom you have resided during the past 10 years or since age 15.
Do NOT list anyone for whom you have already provided contact information.
If more space is needed, continue your response on page 27.
NAME OF HOUSEMATE
CONTACT NUMBER
24.1
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
Page 9 of 27
CITY
)
STATE
ZIP
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 4: RESIDENCES continued
NAME OF HOUSEMATE
CONTACT NUMBER
24.2
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
CITY
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
STATE
ZIP
NAME OF HOUSEMATE
CONTACT NUMBER
24.3
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
CITY
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
STATE
ZIP
NAME OF HOUSEMATE
CONTACT NUMBER
24.4
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
CITY
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
STATE
ZIP
NAME OF HOUSEMATE
CONTACT NUMBER
24.5
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
CITY
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
STATE
ZIP
NAME OF HOUSEMATE
CONTACT NUMBER
24.6
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
CITY
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
STATE
ZIP
NAME OF HOUSEMATE
CONTACT NUMBER
24.7
(
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)
CITY
)
STATE
ZIP
25.
Have you ever been evicted or asked to leave a residence? ..........................................................................................................
Yes
No
26.
Have you ever left a residence owing rent, utilities, or other household expenses? ........................................................................
Yes
No
If you answered YES to Questions 25 and/or 26, explain (include when, where, and circumstances):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Page 10 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT
27. JOB EXPERIENCE
List ALL jobs you have had, including part-time, temporary, self-employment, and volunteer. (Begin with your most current.)
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.
If more space is needed, continue your response on page 27.
NAME OF CURRENT EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.1
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR WANTING TO LEAVE
FT
1)
PT
Temp
Self-employed
Volunteer
2)
Would there be a problem if we contact your current employer? ...................................................................................................
Yes
No
IF YES, explain:
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.2
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
Other:
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.3
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.4
TO (MM/YYYY)
Student
Page 11 of 27
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
Other:
TO (MM/YYYY)
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.5
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
TO (MM/YYYY)
Other:
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.7
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.8
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.6
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
TO (MM/YYYY)
Other:
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.9
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.10
TO (MM/YYYY)
Student
Page 12 of 27
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
Other:
TO (MM/YYYY)
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.11
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
TO (MM/YYYY)
Other:
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.13
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.14
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.12
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
TO (MM/YYYY)
Other:
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.15
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.16
TO (MM/YYYY)
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
Other:
TO (MM/YYYY)
2) Employment
Page 13 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.17
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.18
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
TO (MM/YYYY)
Other:
NAME OF EMPLOYER OR MILITARY UNIT
FROM (MM/YYYY)
27.19
TO (MM/YYYY)
/
ADDRESS (NUMBER / STREET / SUITE / OR BASE)
SUPERVISOR
CITY
STATE
ZIP
CONTACT NUMBER
(
JOB TITLE / RANK
EXT
DUTIES / ASSIGNMENTS
TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
NAMES OF CO-WORKERS
REASON FOR LEAVING
FT
1)
PT
Temp
Self-employed
Volunteer
2)
PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)
27.20
TO (MM/YYYY)
Student
Between jobs
FROM (MM/YYYY)
Leave of absence
Travel
Other:
TO (MM/YYYY)
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
29.
Have you ever been fired, released from probation, or asked to resign from any place of employment? .........................................
Yes
No
30.
Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer? ...............................................
Yes
No
31.
Have you ever quit without giving notice? .......................................................................................................................................
Yes
No
32.
Have you ever resigned in lieu of termination? ...............................................................................................................................
Yes
No
33.
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
34.
Were you ever the subject of a written complaint at work? ..............................................................................................................
Yes
No
35.
Have you ever been counseled at work due to lateness or absences? ...........................................................................................
Yes
No
28.
Page 14 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
36.
Did you ever receive an unsatisfactory performance review?..........................................................................................................
Yes
No
37.
Have you ever sold, released, or given away legally confidential information? ................................................................................
Yes
No
38.
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?
_ Days
If you answered YES to any of Questions 2838, explain (include when, where, and circumstances reference corresponding numbers).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
39.
In the past three years, have you missed days or been late to work due to drug or alcohol consumption? ....................................
Yes
No
Yes
No
Yes
No
Yes
No
IF YES, how often?
40.
Has your work performance ever been affected by your use of alcohol or drugs? ...........................................................................
IF YES, when?
41.
Name of employer:
In the past three years, have you been warned by an employer about your drinking or drug habits and their impact
on your performance? ....................................................................................................................................................................
IF YES, when?
42.
Name of employer:
Have you ever applied for any position at another law enforcement agency (city, county, state, or federal)? .................................
If you answered YES to Question 42, 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 page 27.
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.1
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Page 15 of 27
Written
On Eligibility List
Physical Ability
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Background
Chiefs Oral
Conditional Offer
List Expired
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.2
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Written
On Eligibility List
Physical Ability
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Chiefs Oral
Background
Conditional Offer
List Expired
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.3
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Written
On Eligibility List
Physical Ability
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Chiefs Oral
Background
Conditional Offer
List Expired
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.4
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Written
On Eligibility List
Physical Ability
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Chiefs Oral
Background
Conditional Offer
List Expired
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.5
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Page 16 of 27
Written
On Eligibility List
Physical Ability
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Background
Chiefs Oral
Conditional Offer
List Expired
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 5: EXPERIENCE AND EMPLOYMENT continued
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.6
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Written
Physical Ability
On Eligibility List
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Chiefs Oral
Background
Conditional Offer
List Expired
NAME OF LAW ENFORCEMENT AGENCY
DATE APPLIED (MM/YYYY)
42.7
/
BACKGROUND INVESTIGATORS NAME (IF KNOWN)
ADDRESS (NUMBER / STREET)
CITY
STATE
ZIP
CONTACT NUMBER
(
POSITION APPLIED FOR
EXT
CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:
STEP:
Application
STATUS:
Hired
Written
Physical Ability
On Eligibility List
Withdrawn
Oral
Polygraph/CVSA
Disqualified
Background
Chiefs Oral
Conditional Offer
List Expired
SECTION 6: MILITARY EXPERIENCE
43.
Are you required to register for the Selective Service? ...................................................................................................................
Yes
No
IF YES, have you registered? .........................................................................................................................................................
Yes
No
Yes
No
IF NO, explain:
44.
Have you ever served in the military?
..........................................................................................................................................
45.
If you answered YES to Question 44, include the following service information:
BRANCH OF SERVICE
FROM (MM/YYYY)
TO (MM/YYYY)
TYPE OF DISCHARGE
Entry Level
Honorable
General
OTH (Other than Honorable)
Bad Conduct
Dishonorable
Re-entry Code (14) if applicable refer to your DD-214:
46.
Are you currently participating in one of the following?
Military Reserve
National Guard
IF CHECKED, date obligation ends (MM/DD/YY):
Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captains mast,
office hours, company punishment)? ...........................................................................................................................................
Yes
No
48.
Were you ever denied a security clearance, or had a clearance revoked, suspended, or downgraded?
......................................
Yes
No
49.
Have you ever taken military property without permission for personal use, to sell, or to give away? ...........................................
Yes
No
47.
Page 17 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 6: MILITARY EXPERIENCE continued
If you answered YES to any of Questions 4749, explain (include dates and circumstances).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 7: FINANCIAL
50. INCOME AND EXPENSES
For each of the following questions (50A, B, C), fill in the amounts to the nearest dollar.
For Question 50C: 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 obligations you may have.
A) From your employer(s), what is your take-home monthly income?..............................................................
per month
B) Do you have other sources of income? (IF YES, fill in amount and explain.) .....................
No
per month
C) How much do you spend each month? .......................................................................................................
per month
Yes
Explain:
51.
Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)? .........................................................................................
Yes
No
52.
Have any of your bills ever been turned over to a collection agency?
..........................................................................................
Yes
No
53.
Have you ever had purchased goods repossessed? ....................................................................................................................
Yes
No
54.
Have your wages ever been garnished? ......................................................................................................................................
Yes
No
55.
Have you ever been delinquent on income or other tax payments?
.............................................................................................
Yes
No
56.
Have you ever failed to file income tax or cheated/lied on an income tax form? ...........................................................................
Yes
No
57.
Have you ever had an employment bond refused? ......................................................................................................................
Yes
No
58.
Have you ever avoided paying any lawful debt by moving away?
................................................................................................
Yes
No
59.
Have you ever defaulted on (failed to pay) a loan?
......................................................................................................................
Yes
No
60.
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
61.
Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)?
........
Yes
No
62.
Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)? ...............
Yes
No
63.
Have you written three or more bad checks in a one-year period? ...............................................................................................
Yes
No
If you answered YES to any of Questions 5163, explain (include when, where, and why reference corresponding numbers).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Page 18 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 8: LEGAL
Disclosure of Arrests and Convictions
This section requires you to report detentions, arrests, and convictions, including diversion programs that were not successfully completed,
and in some cases, offenses that may have been pardoned. As a peace officer applicant, you are required to disclose this information,
unless specifically exempted by state or federal law. It is strongly recommended that you consult with an attorney before omitting
any information.
If more space is needed, continue your response on page 27.
64.
Have you EVER been detained by law enforcement for investigation, arrested, indicted, charged, or convicted of any
misdemeanor or felony offense in this state or any other legal jurisdiction (including offenses in the Uniform Code
of Military Justice)? ......................................................................................................................................................................
Yes
No
IF YES, explain each incident:
CHARGE
APPROX DATE (MM/YYYY)
64.1
ARRESTING OR DETAINING AGENCY
/
DISPOSITION OR PENALTY
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
CHARGE
APPROX DATE (MM/YYYY)
64.2
ARRESTING OR DETAINING AGENCY
/
DISPOSITION OR PENALTY
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
CHARGE
APPROX DATE (MM/YYYY)
64.3
ARRESTING OR DETAINING AGENCY
/
DISPOSITION OR PENALTY
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
65.
Have you ever been placed on court probation? ..........................................................................................................................
Yes
No
66.
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
Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity,
support, etc.)? .............................................................................................................................................................................
Yes
No
68.
Have the police ever been called to your home for any reason?
Yes
No
69.
Have you or your spouse/partner ever been referred to Child Protective Services?
.....................................................................
Yes
No
70.
Have you ever been the subject of an emergency protective order/restraining order/stay-away order? ........................................
Yes
No
67.
Page 19 of 27
..................................................................................................
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 8: LEGAL continued
71.
72.
73.
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
Have you ever fraudulently received welfare, unemployment compensation, workers compensation, or other state
or federal assistance? .................................................................................................................................................................
Yes
No
Have you ever been required to repay any welfare payments, unemployment compensation, or other state or
federal assistance? ......................................................................................................................................................................
Yes
No
Have you ever filed a false insurance or workers compensation claim?
Yes
No
......................................................................................
If you answered YES to any of Questions 6574, explain (include court case or document, dates, and circumstances reference corresponding
numbers).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Involvement in Criminal Acts Part 1
Have you committed any of the following acts within the past 10 years? (You do NOT have to report any acts committed prior to age 15.)
75.
You MUST include any acts committed at any time after you were first employed in law enforcement, including as a Police Explorer/
Police Cadet.
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.
75.1
Animal abuse and/or neglect .................................................................................................................................................
Yes
No
75.2
Annoying, obscene, or harassing contacts by telephone or other electronic communication device .......................................
Yes
No
75.3
Battery (use of force or violence upon another) ........................................................................................................................
Yes
No
75.4
Brandishing a weapon (any type of weapon) ............................................................................................................................
Yes
No
75.5
Carrying a concealed weapon without a permit ........................................................................................................................
Yes
No
75.6
Contributing to the delinquency of a minor .............................................................................................................................
Yes
No
75.7
Defrauding an innkeeper (not paying for food or room at a hotel/motel, campground, etc.) ....................................................
Yes
No
75.8
Driving under the influence of alcohol and/or drugs
...............................................................................................................
Yes
No
75.9
Drunk in public (being so intoxicated in a public place that youre not able to care for yourself) .............................................
Yes
No
75.10
Filing a false police report ......................................................................................................................................................
Yes
No
75.11
Hit & run collision (no injuries) ..................................................................................................................................................
Yes
No
75.12
Illegal gambling ........................................................................................................................................................................
Yes
No
75.13
Illegal hunting and/or fishing (for example, without a license, out of season) ............................................................................
Yes
No
Page 20 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 8: LEGAL continued
75.14
Impersonating a peace officer (pretending to be a police officer) ...........................................................................................
Yes
No
75.15
Indecent exposure and/or lewd or obscene conduct ..............................................................................................................
Yes
No
75.16
Intentionally writing a bad check ............................................................................................................................................
Yes
No
75.17
Joyriding (using a car or other vehicle without owners permission) ..........................................................................................
Yes
No
75.18
Peeping (including, but not limited to, looking through a window or opening with the intent to invade someones privacy) ........
Yes
No
75.19
Petty theft (value up to $950, including shoplifting/switching price tags) ..................................................................................
Yes
No
75.20
Possession of alcohol as a minor .............................................................................................................................................
Yes
No
75.21
Possession of falsified or altered identification, including use of another persons ID (for any reason) ......................................
Yes
No
75.22
Possession of stolen property (including, but not limited to, vehicles, credit/debit cards, etc.) ...................................................
Yes
No
75.23
Prostitution or solicitation of prostitution (including, but not limited to, patronizing illegal massage parlors)...............................
Yes
No
75.24
Reckless driving .......................................................................................................................................................................
Yes
No
75.25
Resisting arrest and/or delaying or obstructing an officer (including, but not limited to, running from the police) .......................
Yes
No
75.26
Trespassing .............................................................................................................................................................................
Yes
No
75.27
Vandalism (including, but not limited to, tagging, malicious mischief, and/or property damage) ..............................................
Yes
No
75.28
Any other act amounting to a misdemeanor .............................................................................................................................
Yes
No
If you answered YES to ANY of the item(s) in Question 75, fully explain circumstances, including dates, names of individuals involved,
and resolution. Reference the corresponding number (e.g., 75.5) for each explanation.
If more space is needed, continue your response on page 27.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Involvement in Criminal Acts Part 2
76.
At any time in your life, have you EVER committed any of the following acts?
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.
76.1
Arson (intentionally destroying property by setting a fire) .......................................................................................................
Yes
No
76.2
Assault with a deadly weapon (struck or threatened to strike someone with an instrument likely to cause great bodily
injury or death) ......................................................................................................................................................................
Yes
No
76.3
Blackmail or extortion ............................................................................................................................................................
Yes
No
Page 21 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 8: LEGAL continued
76.4
Burglary (entering a structure or vehicle to commit theft or other crime)
76.5
Child molestation (performing unlawful acts with a child, inappropriate touching of a child)
Yes
No
...................................................
Yes
No
76.6
Elder abuse and/or neglect (physical and/or financial) ...........................................................................................................
Yes
No
76.7
Embezzlement (theft of money or other valuables entrusted to you) ......................................................................................
Yes
No
76.8
Felony drunk driving (involving injuries) .................................................................................................................................
Yes
No
76.9
Forcible rape .........................................................................................................................................................................
Yes
No
76.10
Forgery (falsifying any type of document, check certificate, license, currency, etc.) ...............................................................
Yes
No
76.11
Fraudulent use of a credit, ATM, debit, and/or check card .....................................................................................................
Yes
No
76.12
Grand theft (value of over $950, or any firearm)
....................................................................................................................
Yes
No
76.13
Hit & run (with injuries)
..........................................................................................................................................................
Yes
No
76.14
Hate crime .............................................................................................................................................................................
Yes
No
76.15
Illegal sex acts ........................................................................................................................................................................
Yes
No
76.16
Insurance fraud
.....................................................................................................................................................................
Yes
No
76.17
Murder, homicide, or attempted murder .................................................................................................................................
Yes
No
76.18
Perjury (lying under oath) ......................................................................................................................................................
Yes
No
76.19
Possession of an explosive/destructive device
Yes
No
76.20
Robbery (theft from another person using a weapon, force, or fear)
......................................................................................
Yes
No
76.21
Stalking .................................................................................................................................................................................
Yes
No
76.22
Theft of a vehicle and/or vehicle parts
...................................................................................................................................
Yes
No
76.23
Viewing and/or possessing child pornography .......................................................................................................................
Yes
No
76.24
Any other act amounting to a felony
Yes
No
................................................................................
......................................................................................................................
......................................................................................................................................
If you answered YES to ANY of the item(s) in Question 76, fully explain circumstances, including dates, names of individuals involved,
and resolution. Reference the corresponding number (e.g., 76.3) for each explanation.
If more space is needed, continue your response on page 27.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Page 22 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 8: LEGAL continued
Illegal Use of Drugs
For the purpose of responding to the following questions, illegal drugs include the unauthorized or illegal use of prescription medications
or over-the-counter drugs; it also includes the illegal use of any other substance for the purpose of getting high.
Your responses should include but not be limited to your use of any of the following:
77.
Amphetamines / Methamphetamines (Uppers, Speed, Crank, etc)
Marijuana (with or without a prescription)
Barbiturates (Downers)
Mescaline
Cocaine / Crack Cocaine
Morphine
Designer Drugs (Ecstasy, Synthetic Heroin, etc.)
PCP / Angel Dust
GHB (Date Rape Drug)
Quaaludes
Hallucinogens (Peyote, LSD, Mushrooms)
Steroids
Hashish / Hashish Oil
Tetrahydrocannabinal (THC)
Heroin / Opium
Glue, paint, or any substance containing toluene
Within the past six months, have you used any drug(s) as indicated above? ............................................................................
Yes
No
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
IF YES, give details including drug(s) used, most recent date used, and circumstances:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
78.
Prior to the past six months:
I have never used 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 YOU CHECKED BOX 2, give details including drug(s) used, most recent date used, and circumstances:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
79.
Have you EVER engaged in any of the activities listed below involving drugs, narcotics or illegal substances, including marijuana and/or prescription
drugs without a prescription:
Sold
Manufactured
Purchased
Furnished
Cultivated
Carried or Held for Another
IF ANY ITEM IS CHECKED, give details including drug(s) involved, over what time period(s), and circumstances.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
80.
During the past five years, have you associated with friends, acquaintances, housemates, or family members who
have illegally used drugs or narcotics, and/or illegally used prescription medications? ..................................................................
Yes
No
IF YES, explain:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Page 23 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 9: MOTOR VEHICLE INFORMATION
81.
Current Drivers License:
STATE
PLACE OF
OF ISSUE
ISSUE
LICENSE NUMBER
EXPIRATION DATE (MM/DD/YYYY)
/
82.
List other states where you have been licensed to operate a motor vehicle:
STATE OF
OF ISSUE
ISSUE
PLACE
83.
NAME UNDER WHICH LICENSE WAS GRANTED
LICENSE NUMBER (IF KNOWN)
TYPE OF LICENSE
NAME UNDER WHICH LICENSE WAS GRANTED
PROVINCE?.......
Have you ever been refused a drivers license by any state?
........................................................................................................
Yes
No
Yes
No
IF YES, explain (include when, where, and circumstances):
84.
Has your drivers license ever been suspended or revoked?
........................................................................................................
IF YES, explain (include when, where, and circumstances):
85.
List your current liability insurance on your vehicle(s).
TYPE OF COVERAGE
85.1
Insured
VEHICLE MAKE
Bonded
YEAR (YYYY)
VEHICLE LICENSE
Cash Deposit
INSURANCE COMPANY
POLICY NUMBER
EXPIRATION DATE (MM/DD/YYYY)
/
ADDRESS (NUMBER/STREET)
CITY
STATE
ZIP
TYPE OF COVERAGE
VEHICLE MAKE
YEAR (YYYY)
(
85.2
Insured
Bonded
VEHICLE LICENSE
Cash Deposit
INSURANCE COMPANY
POLICY NUMBER
EXPIRATION DATE (MM/DD/YYYY)
/
ADDRESS (NUMBER/STREET)
CITY
STATE
ZIP
TYPE OF COVERAGE
VEHICLE MAKE
YEAR (YYYY)
Insured
Bonded
VEHICLE LICENSE
Cash Deposit
INSURANCE COMPANY
POLICY NUMBER
EXPIRATION DATE (MM/DD/YYYY)
/
ADDRESS (NUMBER/STREET)
CITY
STATE
ZIP
CONTACT NUMBER
Page 24 of 27
CONTACT NUMBER
(
85.3
CONTACT NUMBER
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 9: MOTOR VEHICLE OPERATION continued
86.
List all traffic citations, excluding parking citations, you have received within the past seven years.
NATURE OF VIOLATION
LOCATION (STREET)
CITY
STATE
86.1
DATE VIOLATION OCCURRED
Month:
ACTION TAKEN
Year:
Not Guilty
NATURE OF VIOLATION
Fined
Traffic School
LOCATION (STREET)
Dismissed
CITY
STATE
86.2
DATE VIOLATION OCCURRED
Month:
ACTION TAKEN
Year:
Not Guilty
NATURE OF VIOLATION
Fined
Traffic School
LOCATION (STREET)
Dismissed
CITY
STATE
86.3
DATE VIOLATION OCCURRED
Month:
87.
ACTION TAKEN
Year:
Not Guilty
Fined
Traffic School
Dismissed
Has a traffic citation ever resulted in a warrant or caused your drivers 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:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
88.
Have you been involved as the driver in a motor vehicle accident within the past seven years? ..................................................
Yes
No
IF YES, give details below.
DATE OF ACCIDENT (MM/YYYY)
88.1
POLICE REPORT
Yes
CITY
LAW ENFORCEMENT AGENCY
AT FAULT?
LOCATION (STREET)
CITY
LAW ENFORCEMENT AGENCY
AT FAULT?
LOCATION (STREET)
CITY
LAW ENFORCEMENT AGENCY
AT FAULT?
No
DATE OF ACCIDENT (MM/YYYY)
88.2
STATE
Yes
WAS THE ACCIDENT?
No
Injury
Non-injury
STATE
/
POLICE REPORT
Yes
No
DATE OF ACCIDENT (MM/YYYY)
88.3
Yes
WAS THE ACCIDENT?
No
Injury
Non-injury
STATE
/
POLICE REPORT
Yes
89.
LOCATION (STREET)
No
Yes
Have you ever driven a vehicle without auto insurance, as required by law?
IF YES, GIVE REASON
WAS THE ACCIDENT?
No
Injury
................................................................................
FROM (MM/YYYY)
Non-injury
Yes
TO (MM/YYYY)
/
90.
Have you ever been refused automobile liability insurance or a bond, or had them cancelled? .....................................................
No
/
Yes
No
DATE (MM/YYYY)
IF YES, GIVE REASON
/
INSURANCE COMPANY
Page 25 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
SECTION 10: OTHER TOPICS
91.
Have you ever been refused a permit to carry a concealed weapon? .............................................................................................
Yes
No
92.
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
93.
Have you ever hit or physically overpowered a spouse or romantic partner? ..................................................................................
Yes
No
94.
Since the age of 15, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act? ...........
Yes
No
95.
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
If you answered YES to any of Questions 9195, give details including dates and circumstances reference corresponding numbers).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SECTION 11: CERTIFICATION
96.
I hereby certify that I have personally completed and initialed each page of this form and any attached supplemental page(s), 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.
Signature in Full:
Date:
Use the following page to continue any of your responses.
Be sure to reference corresponding numbers.
Page 26 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
PERSONAL HISTORY STATEMENT Peace Officer
POST 2-251 (Rev 02/2013)
ADDITIONAL COMMENTS
Use this space to provide information that does not fit elsewhere on this form (e.g., additional family members, schools, residences, employers,
explanations to questions, etc.). Reference the corresponding questions and/or specific items.
You may print copies of this page as needed. If you are filling in this page online, text will flow to additional pages automatically.
Page 27 of 27
Initial this page to indicate that you have provided complete and accurate information: _____
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