Anne Arundel County. Police Department. Personal History Statement. Revised 3/26/18

Transcription

1 Anne Arundel County Police Department Personal History Statement Revised 3/26/18

2 Anne Arundel County Police Department Personal History Statement Table of Contents Page Number INSTRUCTIONS TO THE APPLICANT 1-4 PART 1 (PAPERS-DOCUMENTS THAT ARE REQUIRED) 5 PART II (PERSONAL DATA) 6-8 PART III (MILITARY DATA) 9 PART IV (SELECTIVE SERVICE) 9 PART V (FINANCIAL DATA) 10 PART VI (REFERENCES) PART VII (ASSOCIATES/FRIENDS) PART VIII (RESIDENCE DATA) PART IX (EDUCATION) PART X (EMPLOYMENT DATA) PART XI (DRIVING RECORD) PART XII (CONVICTION DATA/ILLEGAL DRUG SALES/USE) 26 PART XIII (MISCELLANEOUS) PART XIV (REMARKS SECTION/CONTINUATION SHEETS) APPLICANT SIGNATURE PAGE 37 1

3 Instructions to the Applicant The information that you provide will be the sole property of the Anne Arundel County Police Department. You are responsible for providing complete, accurate, and truthful responses. This form must be PRINTED IN BLACK INK by the applicant and each question answered accurately. If a question does not apply to you, write N/A (Not Applicable) as your response to that question. Incomplete and /or inaccurate answers will substantially extend the time required to process your application. The personal history statement booklet must be completed per instructions in the booklet. If the personal history statement booklet is incomplete when you return it, you may be eliminated from the process for failing to follow instructions. The information you provide in this personal history statement will be used in the investigation into your background to assist in determining your suitability for the positi on for which you have applied. Please fill out the questionnaire completely and accurately. Keep in mind that: (1) The completion of this form is mandatory to receive consideration for appointment. (2) All statements are subject to verification (3) Deliberate inaccuracies or incomplete statements may bar or remove you from employment (4) All time periods in your background must be accounted for. It is to your advantage to respond openly. Any negative factor contained in the information provided by you will be evaluated in terms of the circumstances and facts surrounding it and its degree of relevance to the job. However, you will be disqualified if you intentionally make a false statement of material fact or intentionally omit a material fact or if you practice or attempt to practice any form of deception or fraud in the statement. If additional space is required for an answer to any question, continuation sheets are provided in the Remarks Section (PART XIV) at the end of this form. Be sure to identify each entry on the continuation sheets with the appropriate section and question n umber. 2

4 Additional Instructions For The Personal History Statement A frequent problem encountered by applicants in the completion of this booklet is the failure to follow instructions. You are required to complete this booklet by answering every question. Every question is to be answered with either a yes, yes with an explanation, no, or N/A because it does not apply to you. Additional space for answers is provided in the back of the booklet beginning on page 30. To ensure that your booklet is processed, you must answer all questions. The booklet has several areas where it may ask for names, addresses, and phone numbers. The proper way to include names is to use complete names (first and last). We will accept a title, such as, Mr., Mrs., Ms., Reverend, Captain, Sergeant, etc., and a last name. Unacceptable are first names only, and nick names, as well as a blank space. Addresses are to include, building number, apartment/suite number if applicable, street name, city, state, and complete zip code as well as a phone number if applicable. Please limit the use of post office boxes and rural route numbers for addresses only. If you must use a post office or rural route number, be sure you use the back of the booklet and the extra sheets of paper to provide directions of how to get there. Phone numbers, in state and out of state, are to include area codes. You should make every attempt to provide complete information regarding addresses of employers and residences. Provide the information on every employer since you started working, regardless of the duration of employment. Even if the company is out of business or moved, list it chronologically and provide the required information. This is an integral part of the investigation and if the information is not complete the process may be terminated and your file closed. Family members are a good source of information; what you may have forgotten they can remember. If you have been in the military do your best to remember addresses, and any part-time employment you may have had. A base or military installation for overseas deployment will suffice in most cases. Employment information should include addresses, names of supervisors, telephone numbers, dates worked from and to, and an explanation as to why you left. Limit the use of vague phrases to explain why you left, such as marital problems, family problems, or personal reasons ; explain in detail why you left. Finally, you are responsible for providing copies of the documents that must accompany this booklet. You are to maintain the original documents and you must bring them with you when you are scheduled for your interview with an investigator. You will be required to provide transcripts for high school and college, if applicable. 1) If you have an out-of-state driver s license, or if you have ever had a license from any other state: You must contact that State s Department of Motor Vehicles and obtain a certified copy of your driving record. 2) To those applicants who have attended high school and/or college, contact the school(s) and arrange to obtain your official transcript(s). You may have them sent directly to us by the school, or you may pick them up and bring them to us. Either way, they must be received in a sealed envelope with the school s official seal. 3

5 3) Do not forget the due date for your Personal History Statement. If you want to be considered for further processing, your Personal History Statement MUST be returned on or before the due date, and the booklet must be completed as per instructions. If you fail to complete the booklet per instructions it may not be processed and your file may be closed. If you have any questions regarding the completion of this booklet, or about the documents you must provide with the booklet, contact the Police Personnel Section between the hours of 08:00am and 04:00pm Monday through Friday at or There is a voice mail for these numbers if no one is able to take your call. Always leave your name and a telephone number where you can be reached during the above hours, as well as a brief message. Include in your message the position for which you have applied and the name of your investigator if you have been assigned one. ANNE ARUNDEL COUNTY POLICE DEPARTMENT POLICE PERSONNEL SECTION 8495 Veterans Highway Millersville, Maryland Fax

6 ANNE ARUNDEL COUNTY POLICE DEPARTMENT PART I DOCUMENTS THAT ARE REQUIRED A thorough background investigation is included in the selection process for the position for which you are applying. The following are documents which are required to complete your background investigation. All documents, which are applicable to you, should be submitted with your Personal History Statement. Clearly legible photocopies are acceptable; however, original copies should be available for verification by the Police Personnel Office. 1. Birth Certificate 2. High School Diploma or G.E.D. and Transcripts 3. College Diploma and Transcripts 4. Marriage Certificate 5. Divorce Decrees, Separation Papers 6. Military Discharge (DD214) 7. Selective Service Acknowledgement 8. Court Ordered Name Changes 9. Certificates or Continued Education or Special Training 10. Awards or Letters of Commendation 11. Naturalization Papers 12. Social Security Card 13. MPTC-Card and Certificate (Current Police/Correctional Officers) 14. Driver s License - Maryland and Out of State (Certified Copy Required) 15. Financial Aid Transcript (Student Loan) 16. Vehicle Registration and Insurance Cards 17. Child Support Paperwork, Case Number, Contact Person 5

7 1. Name (LAST, FIRST, MIDDLE) ANNE ARUNDEL COUNTY POLICE DEPARTMENT PART II - PERSONAL DATA Last First Middle 2. Aliases, Maiden Names/Nicknames (specify which) 3. Date of birth: 4. Place of birth: City, County, State, Country 5. Height Weigh Hair Color Eye Color Scars/Tattoos or Identifying Marks 6. Social Security Number 7. Citizenship U.S. Citizen By Birth Alien Registration Number Alien Naturalization Date, Place and Court Certificate No. Petition No. Derived Parent s (s) Cert. No.(s), specify which or both Native Country Date, Place, & Port of Entry into U.S. Sponsor 8. Address Currently Residing House Number and Street Apt # City: County: State: ZIP Code: 9. Legal Residence House Number and Street Apt # 10. Home Telephone (Include area code and hours during which you can be reached) Area Code ( ) Hours 10a. Mobile Number Area Code ( ) 10b Work Telephone (Include area code and hours during which you can be reached) Area Code ( ) Hours 12. Present Marital Status Married Divorced Widowed Separated Single 13. Full Name of Current Spouse Last First Middle Maiden 14. Marriage Date (Include present and ALL former marriages) Date (s) of Marriage Place (s) of Marriage (City and State) A. B. C. D. 6

8 ANNE ARUNDEL COUNTY POLICE DEPARTMENT 15. Spouse s Employment Company Name Address City State Office Telephone # 16. Have you ever been: Widowed Choose an item. Separated Choose an item. Divorced Choose an item. 17. We are going to contact your spouse or former spouse (s). Please state if you have any objections and explain why. 18. List below the name(s) of each of your children, the name and address of each child s other parent, the name and address of each child s guardian (if other than either parent) and each child s birth date, place of birth, and current residence (go to Part XIV if additional space is needed). Name of Child Date of Birth Place of Birth Current Residence of Child A. B. C. D. E. Name and Address of Other Parent of Each Child Listed Above A. B. C. D. E. Name and Address of Guardian of Each Child Listed Above (If other than either parent) A. B. C. D. E. 19. Do you have any dependents other than those listed above: Choose an item. If yes, list the following information: Name Address Relationship A. B. C. D. E. 7

9 ANNE ARUNDEL COUNTY POLICE DEPARTMENT 20. Are you receiving and/or responsible for paying court ordered child support? Choose an item. If yes, list the following information: To Whom Paid or From Who Received Amount Paid Amount Received Frequency Pd/Received 21. Have you EVER been involved as a complainant or defendant in a paternity proceeding? Choose an item. If, yes, enter full details on continuation sheets (Part XIV) 22. Parents Applicants must provide ALL information requested below concerning their Mother and Father. If your parents are deceased, the information requested in Sections A, B, G, H and I MUST still be provided. A. Name of Father Last C. Father s Address Street, City, State Zip Code First Middle B. Name of Mother Last D. Mother s Address Street, City, State Zip Code First Middle E. Father s Telephone Number ( ) G. Place of Birth City, State Mother: H. Date of Birth Father: Month Day Year F. Mother s Telephone Number ( ) Father: Mother: Month Day Year I. If Deceased, List Date of Death Month Day Year 23. If you were raised by anyone other than your parents, provide the following information concerning those who raised you (other than institutions or foster homes) A. Name of Person Who Raised You Last B. Address Street, City, State Zip Code First Middle C. Home Telephone Number ( ) D. Relationship Mo Day Yr Mo Day Yr From To 8

10 ANNE ARUNDEL COUNTY POLICE DEPARTMENT USE CONTINUATION SHEET IN PART XIV TO PROVIDE ADDITIONAL DATA IF NECESSARY PART III MILITARY DATA 24. Branch of Service Last Organization, if known Primary M.O.S./A.F.S.C. Dates of Active Duty Choose an item. Service Number During This Period Reserve Service Choose an item. Branch of Reserve Service Date Membership Choose an item. Service Number During this Period Army Air List YOUR Organization and Address on this Line State Began Ended 25. Type of discharge (i.e., Character of Service) 26. Rank at discharge (following most recent period of military service) 27. Highest rank attained 28. Were you recommended for re-enlistment after each period of military duty? Choose an item. 29. Have you ever received a discharge from the Armed Forces which was other than honorable? Choose an item. 30. If you answered Yes to Question 33, What type of discharge did you receive? Explain the circumstances in PART - XIV 31. Were you ever subjected to any disciplinary actions (judicial or non-judicial) while in the Armed Forces? Choose an item. If yes, explain the circumstance in PART - XIV 32. Were you ever subjected to any criminal investigation which was being conducted by the military authorities concerning any alleged misconduct on your part? Choose an item. If yes, explain the circumstance in PART - XIV 33. If you still have a National Guard or a Reserve obligation, designate the type of service obligation you currently have and list the date such obligation is scheduled to terminate. 34. Selective Service Number: PART IV - SELECTIVE SERVICE 9

11 ANNE ARUNDEL COUNTY POLICE DEPARTMENT PART V FINANCIAL DATA 35. Do you presently hold a controlling interest in any company? Choose an item. If yes, explain Your interest. 36. Have you ever been found delinquent on income or other tax payments? Choose an item. If yes, explain in PART - XIV 37. Have you ever had a court ordered financial judgment pending in court? Choose an item. If yes, explain in PART - XIV 38. Do you presently have a financial judgment pending in court? Choose an item. If yes, explain in PART - XIV 39. What is your monthly income? 40. Spouse s monthly income? 41. Do you or your Spouse have any other source(s) of income? Choose an item. If yes, list the source(s) of such income and the monthly amount(s). Convert to monthly amounts ANY income received on other than a monthly basis. Source of Income Self or Spouse Monthly Income 42. List Other Assets List below ALL pertinent information concerning your present assets: Type of Asset Total Amount $ $ $ $ $ $ $ Total Assets $ For Additional Space Use Remarks Section (PART XIV) PART VI REFERENCES $ $ $ $ $ 43. Provide the data requested below on three (3) references, not related by blood or marriage, not former employers and not mentioned elsewhere in this form, who are responsible adults with reputable standing in their community, and who have known you for at least five (5) years. These references may include, but are not limited to: teachers, counselors, tenants/subtenants, landlords, members of the clergy, or business people. A. Name Mr. Mrs. Ms. Miss Residence Address Last Street First Middle Initial City State/Zip Code Home Telephone Number Years Known 10

12 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Occupation Place of Employment Address of Employment: Street City State/Zip Code Business Telephone Number ( ) B. Name Mr. Mrs. Ms. Miss Residence Address Last Street First Middle Initial City State/Zip Code Home Telephone Number Occupation Years Known Place of Employment Address of Employment: Street Business Telephone Number ( ) City State/Zip Code C. Name Mr. Mrs. Ms. Miss Residence Address Last Street First Middle Initial City State/Zip Code Home Telephone Number Occupation Years Known Place of Employment Address of Employment: Street Business Telephone Number ( ) City State/Zip Code 11

13 ANNE ARUNDEL COUNTY POLICE DEPARTMENT PART VII ASSOCIATES/FRIENDS 44. Provide the data requested below on three (3) persons with whom you have associated (i.e., persons whom you have seen frequently) during the past three (3) years. Exclude relatives, former employees and persons mentioned elsewhere in this form. A. Name Mr. Mrs. Ms. Miss Residence Address Last Street First Middle Initial City State/Zip Code Home Telephone Number Occupation Years Known Place of Employment Address of Employment: Street Business Telephone Number ( ) City State/Zip Code B. Name Mr. Mrs. Ms. Miss Residence Address Street Last First Middle Initial City State/Zip Code Home Telephone Number Occupation Years Known Place of Employment Address of Employment: Street Business Telephone Number ( ) City State/Zip Code C. Name Mr. Mrs. Ms. Miss Residence Address Street Last First Middle Initial City State/Zip Code Home Telephone Number Years Known 12

14 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Occupation Place of Employment Address of Employment: Street Business Telephone Number ( ) City State/Zip Code PART VIII RESIDENCE DATA 45. Provide the information requested below on ALL of your residences since birth, beginning with your present residence. In each case, list the name and present correct street address of one neighbor (not necessarily a personal acquaintance), and the name and address of the realty company or property owner to whom YOU pay/paid rent if applicable, or the name and address of the mortgage holder. Include your mailing and/or street address during ALL periods of military service. A. Start with Your Present Residence Dates of Residence Location of Residence From To Month Day Year Present Neighbor s Name Mr. Mrs. Ms. Miss Neighbor s CURRENT Address Last First Initial Neighbor s Telephone Realty/Owner s Telephone Realty Company or Property Owner s Name Realty Company or Property s Owner s Address B. For PRESENT Residence Only: Do you: Rent or Own this Property? Do you reside with: Self Spouse & Children, if any or Other (If Other, list with whom you Reside) C. Next, list your residence prior to the one above and so on Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Neighbor s CURRENT Address Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address D. Location of Residence 13

15 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address E. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address F. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address G. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address H. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address I. Location of Residence 14

16 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address J. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address K. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address L. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address M. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address N. 15

17 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address O. Location of Residence Month Day Year Neighbor s Name Neighbor s CURRENT Telephone Realty Company or Property s Owner s Name Realty/Owner s Telephone No. Realty Company or Property s Owner s Address PART IX EDUCATION 46. Provide the information requested below on ALL schools you have attended since the ninth (9 th ) grade, beginning with the most recent. Be sure to include colleges, universities, business, trade schools, and if relevant to the position for which you are applying, military schools. A. Name of School B. Address of School C. Dates Attended D. Highest Grade Completed E. Did you Graduate? From To Month Year Month Year Choose an item. A. Name of School B. Address of School C. Dates Attended D. Highest Grade Completed E. Did you Graduate? From To Month Year Month Year Choose an item. A. Name of School B. Address of School C. Dates Attended D. Highest Grade Completed E. Did you Graduate? From To Month Year Month Year Choose an item. A. Name of School B. Address of School 16

18 ANNE ARUNDEL COUNTY POLICE DEPARTMENT C. Dates Attended D. Highest Grade Completed E. Did you Graduate? From To Month Year Month Year Choose an item. A. Name of School B. Address of School C. Dates Attended D. Highest Grade Completed E. Did you Graduate? From Month Year Month Year To 47. Did you graduate from High School? Yes No Choose an item. 48. Did you pass a G.E.D. (General Education Development) Test? Yes No I have NOT taken the test GED# Date Received 49. Did you obtain your G.E.D. Certificate from the Armed Forces? Yes No Not Applicable 50. If you have a G.E.D. Certificate, has it been presented to a Board of Education? Yes No Not Applicable 51. If YOU have answered Yes to Question 50, did that Board present you with a High School Diploma? Yes No If Yes, complete the following: Name of Board of Education Board s Complete Mailing Address Date Diploma Issued 52. If you have taken the G.E.D., but you answered No to Question 50 and 51, explain: 53. If you attended college, list your area(s) of concentration: 54. What, if any, degree(s) have been conferred upon you beyond the high school level? 55. If you attended college, but did NOT graduate, please provide a brief explanation. Also, give the number of semester (or quarter) hours satisfactorily completed. 56. Have you ever been dismissed or expelled from ANY school or college for any academic or disciplinary reason? Yes No If Yes, give full details below: 17

19 ANNE ARUNDEL COUNTY POLICE DEPARTMENT PART X EMPLOYMENT DATA 57. List below your completed Work History, starting with your present position. Be sure to list ALL periods of active military duty (including active duty for training for more than fifteen days) and ALL periods of unemployment (identifying it as such). Also include ALL part -time, temporary, and/or voluntary employment and identify it as such. A. Start with PRESENT Employment Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) Place An X in One Box Full-Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving B. Would any problem result if your present employer was contacted during the course of this background investigation? Yes No If yes, please explain C. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving D. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency 18

20 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving E. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving F. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving G. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Address of Employer/Firm/Agency 19

21 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Full Time Temporary Intermittent Part-Time Voluntary Unemployed Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving H. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving I. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving J. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency 20

22 ANNE ARUNDEL COUNTY POLICE DEPARTMENT From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving K. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving L. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving 21

23 ANNE ARUNDEL COUNTY POLICE DEPARTMENT M. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving N. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ Your Title/Position Describe your duties (briefly) and reason(s) for leaving O. Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency From To Choose an item. Month Day Year Present Work Telephone Number ( ) - Place An X in One Box Full Time Part-Time Temporary Voluntary Intermittent Unemployed Address of Employer/Firm/Agency Name of Supervisor Title of Supervisor Supervisor s Phone No. Your Salary Supervisor s $ 22

24 ANNE ARUNDEL COUNTY POLICE DEPARTMENT Your Title/Position Describe your duties (briefly) and reason(s) for leaving 58. Have you ever received any disciplinary actions for any reason documented or otherwise? Yes No If yes, explain including when, name of employer, and why. 59. Have you: A. Even been discharged from employment (fired) for ANY reason? Yes No B. Ever resigned (quit) after being informed that your employer intended to discharge (fire) you for ANY reason? Yes No C. Ever resigned (quit) after being informed that your employer intended to take ANY form of disciplinary action against you? Yes No If you answered Yes to ANY of the above three questions, give full details in the space provided below, including the name and address of the employer, approximate date(s), and the circumstances in each case. If additional space is needed, use Remarks Section (PART XIV). PART XI DRIVING RECORD 60. Indicate below ALL traffic violations or citations (excluding parking tickets) that you have received. Include in your response, but do NOT limit it to, such violations as speeding, reckless driving, changing lanes without caution, defective equipment, stop sign violations, and red light violations. For each incident, give the following data: Date Violation/Charge Location/City/State Police Agency Final Disposition Amount of Fine Points 61. Provide the information requested below on ALL driver s licenses which are now or have been issued to you from ANY state (even though these licenses may now be expired or have been replaced by another issuing agency or state). Issuing State License Number Expiration Date Type of License 23

25 ANNE ARUNDEL COUNTY POLICE DEPARTMENT 62. Is your driver s license now or has it ever been: A. Denied or refused? Yes No B. Suspended? Yes No C. Revoked? Yes No D. Subjected to ANY other similar penalty or action? Yes No If you answered Yes to ANY of the above, explain in detail below: 63. Are your vehicle license plates now or have they ever been: A. Denied or refused? Yes No B. Suspended? Yes No C. Revoked? Yes No D. Subjected to ANY other similar penalty or action? Yes No If you answered Yes to any of the above, explain in detail below: 64. Do you currently have a valid driver s permit? Yes No 65. Were you ever involved in an accident? Yes No If yes, give complete details in item number 68 below, or in the Remarks Section (PART XIV) for each accident. Include (as a minimum) date, place, fault, charges, injuries, and name of the police department that made the report. 66. Enter the following information concerning ANY motor vehicle(s) owned or operated by you: Make Model Year License Plate Number State Registered Name and Address of Owner(s) Vehicle No. 1 Vehicle No. 2 Make Model Year License Plate Number State Registered Name and Address of Owner(s) 67. Please check the types of insurance coverage which you carry on your primary automobile. Please include the name of your insurance company, and the policy number. Insurance Company: Police Number: Liability Collision Property Damage Medical Comprehensive (Fire, Theft, Etc.) 24

26 68. If there is anything you wish to state about your driving record, please use this space below. Include any insurance cancellations since you began driving, and the reason for the cancellations. 69. Have you ever been: PART XII CONVICTION DATA/ILLEGAL DRUG SALES AND USES A. Charged with a criminal offense? Yes No B. Convicted of ANY offense against the law? Yes No C. Subjected to forfeiture of collateral in connection with an arrest? Yes No D. Placed on probation? Yes No E. Have you ever had to appear before a juvenile court? Yes No F. Have you ever been served with a summons to appear in court as a witness in a criminal proceeding? Yes No G. Have you ever received probation before judgment or any disposition other than not guilty in a criminal proceeding? Yes No 70. Are you now: A. Charged with an offense by ANY law enforcement authority? Yes No B. Presently on bail or out on personal recognizance or other conditional release? Yes No C. On probation of any type? Yes No 71. Are you now or have you ever been involved as a plaintiff or defendant in ANY civil court action? Yes No 72. If you answered Yes to ANY part of questions 69, 70, or 71, give complete details in the section below. Include (as a minimum): (1) the date of the offense, (2) charge(s), (3) city and state, (4) name of law enforcement agency involved, and (5) final disposition. For additional space, use the Remarks Section (PART XIV). 25

27 PART XII ILLEGAL DRUG SALES AND USES In the space below complete with respect to ANY use you have had of the following illegal drugs, illegal use of legal drugs (not prescribed by a physician for you) Drug Date First Used Date Last Used Number of Times Marijuana Hashish PCP Angel Dust THC LSD Peyote Mescaline Mushrooms Psilocybin Heroin Cocaine Quaaludes Uppers Downers Tranquilizers Amphetamines Biphetamines Ecstasy (XTC) Preludin Talwin & PBZ Speed Inhalants Methamphetamine Opium Steroids Others Have you ever sold ANY illegal drugs or legally prescribed drugs (other than in the course of legal employment), regardless of whether or not you received any profit? Yes No If you have sold ANY drugs as described above, what was the total estimated value? Have you ever used illegal drugs (including legal drugs for which you do not have a prescription) at work? Yes No If yes, indicate the number of times and date last used. Do you now take or have you ever taken ANY medication other than under a doctor s prescription (with the exception of over - the-counter drugs)? Yes No 26

28 PART XIII MISCELLANEOUS 73. Do you belong to any organization and/or adhere to any belief which would in any way: A. Limit or prohibit your use of weapons or firearms? Yes No B. Restrict or prohibit you from working on particular days or hours? Yes No C. Restrict you from conforming to departmental standards of appearance and/or grooming which may from time to time be set? Yes No If you answered Yes to any of the above, explain in the Remarks Section (PART XIV). 74. Has the consumption of alcohol beverages ever affected your job performance with respect to attendance or carrying out your duties and responsibilities? Yes No If yes, give the number of times 75. Are you now or have you ever been a member of or espoused the basic tenets and beliefs of an organization that to your present knowledge seeks the overthrowing of the Government of the United States by force or violence or other unlawful means? Yes No If you answered Yes, give full details in the Remarks Section (PART XIV). 76. Have you ever been issued a permit to license to carry a handgun or other weapon on your person? Yes No If yes, give full details below. 77. List any special skills you possess which you believe may be applicable to the position for which you are applying (skills with machines or equipment, public speaking experience, membership in a professional, scientific, community or other such organization etc.) 78. A. Have you ever applied for a position with ANY federal, state, or local law enforcement agency or any fire department? Yes No B. Have you ever applied for ANY position with the federal, state, or local government for which a background investigation was initiated? Yes No C. If you have ever been denied employment by an organization covered in questions A or B, provide complete details in the space provided below with regard to ALL positions. Be sure to include the name and address of each organization applied to, the position(s) applied for, the date(s) of your application(s), and the reason(s) you were not employed in each instance (including a thorough explanation of why you were denied employment, if such was the case.) If additional space is needed, use Remarks Sections (PART XIV). 27

29 79. Family: List the order given, showing relationship, brothers, and sisters, even if deceased. (Include any others you have resided with or with whom a close relationship existed or exists.) A: Relationship Name and Date of Birth Present Address: City/State/Zip B: Others 28

30 80. List any family members and acquaintances who are currently employed by this Department or who have been employed by this Department in the past: 81. Foreign Language: Enter foreign language and indicate your knowledge of each by placing an X in the proper column. Language Reading Speaking Understanding Writing Excell Good Fair Excell Good Fair Excell Good Fair Excell Good Fair 82. Foreign Travel: Exclude trips of less than 30 days to Canada or Mexico and foreign travel as a direct result of U.S. Military duties From Dates Country Visited Purpose of Travel To 83. Are there incidents in your life not mentioned herein which may reflect upon your suitability to perform the duties which you may be called upon to take or which might require further explanation? Yes No 29

31 PART XIV REMARKS SECTION/CONTINUATION SHEETS 30

32 PART XIV REMARKS SECTION/CONTINUATION SHEETS 31

33 PART XIV REMARKS SECTION/CONTINUATION SHEETS 32

34 PART XIV REMARKS SECTION/CONTINUATION SHEETS 33

35 PART XIV REMARKS SECTION/CONTINUATION SHEETS 34

36 PART XIV REMARKS SECTION/CONTINUATION SHEETS 35

37 PART XIV REMARKS SECTION/CONTINUATION SHEETS 36

38 SIGNATURE PAGE If information should surface during any stage of this investigation which would disqualify you from further consideration, the investigation may be terminated immediately and you will be notified accordingly. On this day of 20, I have completed the foregoing Personal History Statement and understand the contents. The information given is correct to the best of my knowledge and belief and does not knowingly contain any material misrepresentation of fact. I understand that any material misrepresentation of fact given by me will be cause for rejection before appointment or dismissal from the department after appointment. (Full Legal Signature) 37