PERSONAL HISTORY STATEMENT. Personal. Relatives and References: ) Home ( ) Work ( ) Other

Transcription

1 .. PERSONAL HSTORY STATEMENT Personal Thefoiowing information is requested ofyoufor verification and coiztact purposes 1. YourName Please print ortype) Last First Middle Other names including nicknames) you have used or been known by: 2 Please list address at which you can be contacted Number Street City State Zip Code 3. Please you list the local can be contacted. Birthdate telephone numbers) at which You must be a citizen of United Month) Day) Year) citizenship. you provide 6. Can L UYes JNo Social Security Number 7. For Height n identification the purposes of identification, please the accordance with purposes Hrs. you States or can be contacted: a permanent resident such documentation? the Federal to Privacy Act of 1 974, disclosure ensure that proper records are obtained.) Hrs. you alien who is eligible for is voluntary. The SSN can be contacted: and hasapplied will be provide followirg: Weight Hair Color Eye Color the used for for Scars, tatoos, or other distinguishing marks Relatives and References: During the course ofthe background investigation, persons who know you will be asked to comment upon your suitabilityfor the position ofpeace officer. nquiries will be confined tojobrelevant matters. 8. Please supply the appropriate Father f living, name information in of your: the spaces Address where person can be contacted Telephone provided below. f nclude City, State and a category is not write in N/A. Zip Code)person at which can be contacted applicable, Mother FatherinLaw ) Home ) Work ) Other MotherinLaw Spouse Former Spouses) ) Home ) Work ) Other Page 1

2 Page 2 ) Home ) Work ) Other ) Home ) Work ) Other ) Home ) Work ) Other ) Home ) Work ) Other Exclude_family_members. 9. Below, please list those individuals with whom you have resided during the last 1 0 years list no information prior to your 1 5th birthday) Relationship Other relatives with whom you have a close personal relationship including children) ) Home ) Work ) Other Stepbrothers) and StepSisters) StepFather StepMother Brothers) and Sisters) f living, name of your: ncude City, State and Zip Code) person can be contacted Address where person can be contacted Telephoneat which Continued Relatives and References t tmunal M WHY STATEMENT

3 f )Home rcflo%jnml flo ijflt tvtn Relatives and References Continued 1O.Below, please list those individuals with whor you have resided during the last 10 years list noinfori ation priorto your 15th birthday). Exclude family members. Address where person can be contacted Telephone at which Mng. name of your: nclude City. State and Zip Code) person can be contacted [ )Work )Other )Home )Work )Other )Home )Work )Other )ome )Work )Other )Home )Work )Other )Home )Work )Other )Home )Work )Other )Home )Work )Other j )Home )Work )Other )Home )Work )Other Education 1. The Commission on Peace Officer Standards and Training requires a peace officer to possess a U.S. high school diploma or its equivalent Please indicate your current situation with regard to this requirement by checking one of the appropriate boxes. U possess a high school diploma from a U.S. institution. 13 possess the G.E.D. General Educational Development) test. i possess the High School Proficiency Examination. U possess a twoyear college degree. Li i possess a fouryear college or university degree. Li i When: do not currently have a high school diploma or its equivalent, but plan to satisfy the requirement in the future as follows: How: 1 2. Please indicate below all the school you have attended beginning with high school. During the background investigation, persons who have known you in a learning environment will be contacted. A review of your school records maybe made in coniunction with those contacts. Location of School Dates Attended Schl References Name of School City & State) From To teachers, counselors, etc.) Month/Year Month/Year Page 3

4 Reason for leaving Page 4 Yr., Mo., Yr. To Mo. J Military Service U Not employed {From Reason for leaving U Voluntary La PartTime U Full Time Title or duties for identification purposes) Telephone No. Names) of coworkers) Mo. Yr. Mo. Yr. From To Dates of employment Name and address of employer Name of supervisor, Yr. Mo., Yr. To Mo. J Military Service U Not employed From Reason for leaving EJ Voluntary L PartTime L Full Time Title or duties for identification purposes) Telephone No. Names) of coworkers) fl Mo. Yr. Mo. Yr. From To Dates of employment Name and address of employer Name of supervisor, Yr. Mo. J Military Service U Not employed From Mo., Yr. j To Reason for leaving EJ Voluntary i Part Time U Full Time The or duties for identification purposes) Telephone No. Names) of coworkers) Mo. Yr. Mo. Yr. From To Dates of employment Name and address of employer Name of supervisor, Yr. Li Military Service Li Not employed j From Mo., Yr. T]0. EJ Voluntary L Part Time U Full Time Title or duties for identification purposes) Telephone No. Names) of coworkers) Mo. Yr. Mo. Yr. From To Dates of employment Name and addressof employer Name of supervisor 3. Continued) Continued Experience and Employment rtnatjnml flthuky timtmtn

5 rcnoijflml flul1y SAtMtN z Experience and Employment Continued : 6. Would any problem result if your present employer was contacted during the course of the background investigation? U Yes 1 No f no, when should such contact be made? 1 7. f you have had no prior employment, please explain in the space below Have you had any extended work absences for reasons other than earned vacations? U Yes U No f yes, please explain include when, name of employer, why) Have you ever been fired or asked to resign from any place of employment? L Yes U No f yes, please give details include when, where, circumstances). 20. Have you ever been a successful or unsuccessful candidate for another position requiring peace officer powers? L Yes Li No f yes, please give details include when, name of agency, circumstances). Military Service 21. f you are a male under age 26,please provide the following: Selective Service Number Approximate Date of Registration Address attime of Registration 22. Have you ever served in the armed forces, National Guard or military reserves? U Yes J No Jf yes, please supply the following information: Branch of Service Service Number Dates of Service Type of Discharge Are you currently participating in any military reserve or National Guard program? U Yes U No 24. Have you ever been the subject of anyjudicial or nonjudicial disciplinary action while in the military, National Guard or military reserves? DYes LNo f yes, please give details include branch of service, when, where, circumstances). Page 5

6 Mi1itary Service Continued FhV 1HL fl UlT M tmtn i: Past commanding officers or military acquaintances are potential sources of relevant information pertaining to your background. Please list those individuals who know you well enough to provide accurate information about you. Name Contact Address Contact Telephone Years Known From _Zio Financial 25. The management ofpersonal finances is relevant to an individual s qualifications for the position of peace officer. Therefore, please fill in the financial statement below. Be complete and accurate. The amount of indebtedness in itself will not be used in evaluating your qualifications, but rather the behavior exhibited in meeting your financial obligations. Monthly salary Spouse s salary Other monthly income describe Current Monthly ncome $ Real Estate mortgage) payments) Rent Other monthly payments describe Current Monthly Expenditures $ Estimated monthly cost of living include utilities, food, gasoline, home and car maintenance, entertainment, etc.) and any other obligations... TOTAL MONTHLY NCOME Current Assets $ TOTAL MONTHLY EXPENDTURES Current Liabilities $ Savings $ Real Estate ndebtedness $ Checking Longterm Loans Real Estate Charge Accounts Stocks and Bonds Other Liabilities describe: Life nsurance cash value of whole life policy) Autos Other Assets describe: TOTALASSETS $ TOTALLABLTES $ Page 6

7 rcnotjml flouft MltMtP1 Financial Continued 27. Please supply more detailed information about your charge accounts, contracts, or other financial liabilities. Name of Firm Address Account Number 28. Have you ever filed for or declared bankwptcy? L Yes L No f yes, please give details include when, where, why). 29. Have any of your bills ever been turned over to a collection agency? J Yes U No f yes, please give details include when, firms involved, circumstances). 30. Have you ever had purchased good repossessed? L Yes U No f yes please give details include when, firms involved, circumstances). Page 7

8 Page 8 f yes, please give details include when, where, why). f yes, please give details include when, where, why). f yes, please give details include when, where, why). f yes, please qive details include when, where, why). 35. Were you ever required to appear before a juvenile court for an act which would have been a crime if committed by an adult? Li Yes Li No 34.lf have you ever been placed on court probation as an adult? L Yes U No Approx. Date Police Agency Circumstances Please see the NSTRUCTON page bra detailed guida) have been affected by a a sealing, an expungement, a release, or a pardon has specific legal implications as to how you should answer this question. 33. f you have ever been arrested or convicted for any crime excluding traffic citations), please give the following information: The fact that your record may 32. Have you ever been dehnquent on income or other tax payments? 1 Yes No UNo 31. Have your wages ever been garnished? U Yes Financial Continued rtrwuplml 1 UY 5 M 1MtN

9 . Motor VtKUNL Miti UKY 5TATLMENT 1 Continued 36.Have you ever been reported to a law enforcement agency as a missing person or a runaway? U Yes No f yes, please give details include date, law enforcement agency, circumstances). 37. Are you now or have you ever been involved as a plaintiff or defendant in any civil court action? L Yes L No f Lyes, please give detailslinclude when, where, name and location of court, circumstances). Vehicle Operation Operation ofa motor vehicle is an integralpart ofthe position ofpatrol officer. An investigation ofyour driving history will be made through a records check. To expedite this procedure, please supply thefollowing information: 38. Driver s license number Expiration date Name under which license was granted 39. Please listother states where you have been licensed to operate a motor vehicle. State State State State Name under which license was Name under which license was Name under which license was Name under which license was granted granted granted granted 40. Have you ever been refused a driver s license by any state? Li Yes J No f ye&, please explain include when. where. why). 41. Ohio law requires that operators and owners of motor vehicles be covered by automobile liability insurance or bond or deposit of $35,000 with the Departmen of Motor Vehicles. Therefore, please list the current liability insurance you have with your motor vehicles. Company Address Policy Number Date of Expiration f you are bonded or have deposited $35,000 to meet your motor vehicle financial responsibility, please indicate. Bond L $35,000 Page 9

10 Page 10.. ndicate whether fined or action f yes, please give details foreach accident. f yes, please give details include what, when, where, why). 45. Has your license ever been suspended, revoked, or placed on negligent operator s probation? Li Yes Li No Police investjqation? Police Agency 44. f there is anything you wish to discuss about your driving record, please use the space below. JYes LJNo Date Location njury J Noninjury DYes LJNo Police investjation? Police Agency Date Location njury L Noninjury JYes LJNo Police investjauon? Police Agency Date Location njury E Noninjury UYes LJNo Police investjation? Police Agency Date Location L njury Li Noninjury UYes UNo Police investigation? Police Agency Date Location j J njury U Noninjury 43. Have you ever been invcved as a driver in a motor vehicle accident within the last5years? L Yes L No taken on driver s license Nature of violation Location city) Approximate Date 42. Please list all traffic citations exclude parking citations)youhave received within the last 5 years. Motor Vehicle Operation J*UNAL HSTORY STATEMENT

11 VttiUNAL tstuhy STATEMENT 4 General nformation Have you ever been refused nsurance for any reason other thanfailure to pay a premium? U Yes U No f yes, please explain nclude company name and address, date, and reason). 47. Have you ever applied for a permit to carry a concealed weapon? Li Yes Li No f yes, please provide the following information: Date Permit granted? 13 Yes No L Name of law enforcement agency Date Location Purpose hereby certify that all statements made in this personal history statement are true and complete, and of material facts will subject me to disqualification or dismissal. understand that any misstatements Signature in full Date completed Page 11

12