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HomeMy WebLinkAboutPersonal History Statement - FillablePERSONAL HISTORY STATEMENT Page 1 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 1: PERSONAL 1. YOUR FULL NAME LAST FIRST MIDDLE NUMBER / STREET APT / UNIT CITY STATE ZIP HOME WORK EXT OTHER CELL FAX PAGER HOME BUSINESS 7. If you were born outside of the United States, 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 – – NO.STATE EXP HEIGHT WEIGHT HAIR COLOR EYE COLOR SECTION 2: RELATIVES AND REFERENCES •Provide all applicable information in the spaces below. •Mark “N/A” if a category is not applicable or if the individual is deceased. •If more space is needed, continue your response on page 25. N/A A. Father NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) ( ) ( ) N/A B. Step-father NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) ( ) ( ) N/A C. Mother NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) ( ) ( ) PERSONAL HISTORY STATEMENT Page 2 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 2: RELATIVES AND REFERENCES continued 13. IMMEDIATE FAMILY continued N/A D.Step-mother NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE N/A E. Spouse / Registered Domestic Partner NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) N/A F. Father-in-law NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) N/A G. Mother-in-law NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) N/A H. Former Spouse(s) / Former Registered Domestic Partner(s) 1) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) ( ) PERSONAL HISTORY STATEMENT Page 3 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 2: RELATIVES AND REFERENCES continued 13. IMMEDIATE FAMILY continued N/A I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc. M F UNDER AGE 18 M F UNDER AGE 18 ( ) ( ) ( ) M F UNDER AGE 18 M F UNDER AGE 18 ( ) ( ) ( ) M F UNDER AGE 18 M F UNDER AGE 18 N/A J. Children List all of your 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 or guardian, if other than you. M F ( ) M F ( ) PERSONAL HISTORY STATEMENT Page 4 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 2: RELATIVES AND REFERENCES continued 13. IMMEDIATE FAMILY (Section J. Children) continued 3) NAME CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) M F ( ) M F ( ) M F ( ) M F ( ) List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere. ( ) ( ) ( ) HOW LONG HAVE YOU KNOWN THIS PERSON? ( ) ( ) HOW LONG HAVE YOU KNOWN THIS PERSON? ( ) ( ) ( ) HOW LONG HAVE YOU KNOWN THIS PERSON? PERSONAL HISTORY STATEMENT Page 5 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 2: RELATIVES AND REFERENCES (Section 14. References) continued D) NAME HOME ADDRESS (NUMBER / STREET / APT) CITY STATE ZIP HOME PHONE ( ) ( ) ( ) ( ) ( ) HOW LONG HAVE YOU KNOWN THIS PERSON? HOW LONG HAVE YOU KNOWN THIS PERSON? ( ) ( ) ( ) HOW LONG HAVE YOU KNOWN THIS PERSON? HOW LONG HAVE YOU KNOWN THIS PERSON? PERSONAL HISTORY STATEMENT Page 6 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims. 15.Check applicable: High School Diploma from an accredited U.S. institution GED California High School Proficiency Certificate 16.List high schools attended: A) NAME FROM TO DID YOU GRADUATE? Yes No Yes No 17.List all colleges or universities attended: A) NAME FROM TO TOTAL UNITS EARNED TYPE OF DEGREE EARNED EARNED EARNED 18.List any trade, vocational, or business schools/institutes attended: THE COURSE? Yes No THE COURSE? Yes No THE COURSE? Yes No 19.Have you ever attended a Crime Justice Basic Academy? .................................................................................................................................................. Yes No If yes, provide the following information: A) ACADEMY NAME FROM TO DID YOU GRADUATE? Y N ( ) PERSONAL HISTORY STATEMENT Page 7 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 3: EDUCATION continued 20. Have you ever been placed on academic discipline, suspended, or expelled from any high school, college/university, business or trade school? ............................................................................................................................................................. Yes No If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances. SECTION 4: RESIDENCE 21. LIST OF RESIDENCES •List all residences during the last ten years or since age 15. Provide complete addresses (include markers such as Street, Drive, Road, East, West,etc., and unit or apartment number). Do not use P.O. 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 unlessyou shared individual quarters. •If more space is needed continue on page 25. Present CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER ( ) Names of those with whom you live: ( ) Names of those with whom you lived: Reason for moving: ( ) Names of those with whom you lived: Reason for moving: PERSONAL HISTORY STATEMENT Page 8 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 4: RESIDENCE continued 21. LIST OF RESIDENCES continued D) FORMER ADDRESS (NUMBER / STREET / APT) FROM TO CITY STATE ZIP IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT) CONTACT NUMBER ( ) Names of those with whom you lived: Reason for moving: ( ) Names of those with whom you lived: Reason for moving: ( ) Names of those with whom you lived: Reason for moving: ( ) Names of those with whom you lived: Reason for moving: PERSONAL HISTORY STATEMENT Page 9 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 4: RESIDENCE continued 22.Provide contact information for all housemates listed in Question 21 with whom you have resided during the past 10 years, or since the age of 15. DONOT list anyone for whom you have already provided contact information. If more space is needed, continue your response on page 25. ( ) ( ) ( ) ( ) ( ) ( ) 23. Have you ever been evicted or asked to leave a residence? ......................................................................................................... .. Yes No 24. Have you ever left a residence owing rent? ..................................................................................................................................... Yes No Questions 23 and/or 24 PERSONAL HISTORY STATEMENT Page 10 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 5: EXPERIENCE AND EMPLOYMENT 25. JOB EXPERIENCE •List ALL jobs you have had, including part-time, temporary, self-employment and volunteer. (Begin with your most current. If more space is neededcontinue your response on page 25.) •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. F-T P-T Temp Self-employed Volunteer 1) 2) Would there be a problem if we contact your current employer? Yes No B) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other FROM TO ( ) F-T P-T Temp Self-employed Volunteer 1) 2) D) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other FROM TO ( ) F-T P-T Temp Self-employed Volunteer 1) 2) PERSONAL HISTORY STATEMENT Page 11 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 5: EXPERIENCE AND EMPLOYMENT continued 25. JOB EXPERIENCE continued F) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other ( ) F-T P-T Temp Self-employed Volunteer 1) X 2) H) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other F-T P-T Temp Self-employed Volunteer 2) J) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other FROM TO ( ) F-T P-T Temp Self-employed Volunteer 1) X 2) L) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other FROM TO PERSONAL HISTORY STATEMENT Page 12 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 5: EXPERIENCE AND EMPLOYMENT continued 25.JOB EXPERIENCE continued M) NAME OF EMPLOYER OR MILITARY UNIT FROM TO ADDRESS (NUMBER / STREET OR BASE) SUPERVISOR CITY STATE ZIP CONTACT NUMBER ( ) EXT JOB TITLE EMAIL DUTIES / ASSIGNMENTS F-T P-T Temp Self-employed Volunteer 1) 2) N) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other FROM TO ( ) F-T P-T Temp Self-employed Volunteer 1) 2) P) PERIOD OF UNEMPLOYMENT Check applicable: Student Between jobs Leave of absence Travel Other ( ) F-T P-T Temp Self-employed Volunteer 1) X 2) 26.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 27.Have ever you ever been fired, released from probation, or asked to resign from any place of employment? ................................. Yes No 28.Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer? .............................................. Yes No PERSONAL HISTORY STATEMENT Page 13 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 5: EXPERIENCE AND EMPLOYMENT continued 29.Have you ever quit without giving proper notice? ........................................................................................................................... Yes No 30.Have you ever resigned in lieu of termination? .............................................................................................................................. Yes No 31.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 32.Were you ever the subject of a written complaint at work? ............................................................................................................ Yes No 33.Have you ever been counseled at work due to lateness or absences? .......................................................................................... Yes No 34.Did you ever receive an unsatisfactory performance review? ........................................................................................................ Yes No 35.Have you ever sold, released, or given away legally confidential information? ............................................................................... Yes No 36.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? If you answered yes to any of Questions 26–36, explain (include when, where and circumstances; indicate corresponding number): 37.In the past three years, have you missed days or been late to work due to drug or alcohol consumption? .................................... Yes No If yes, how often? 38.Has your work performance ever been affected by your use of alcohol or drugs? .......................................................................... Yes No 39.In the past three years, have you been warned by an employer about your drinking or drug habits and their impact onyour performance? ........................................................................................................................................................................ Yes No 40.Have you ever applied to any other law enforcement agency (city, county, state or federal)? ............................................................................ Yes No •If yes, 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 25. ( ) STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer STATUS: Hired On List Withdrawn Disqualified PERSONAL HISTORY STATEMENT Page 14 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 5: EXPERIENCE AND EMPLOYMENT continued 40.ever continued STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer STATUS: Hired On List Withdrawn Disqualified ( ) Check each step in the process that you completed, and your status: STEPS: Application Written Physical agility Oral Polygraph/CVSA Background Chief’s oral Conditional job offer STATUS: Hired On List Withdrawn Disqualified SECTION 6: MILITARY EXPERIENCE 41.Are you required to register for the Selective Service? .................................................................................................................. Yes No If yes, have you registered? .......................................................................................................................................................... Yes No If no, explain: 42. BRANCH OF SERVICE From To 44.TYPE OF DISCHARGE: Entry Level Honorable General OTH (Other than Honorable) Bad Conduct Dishonorable Re-entry Code (1–4) if applicable – refer to your DD-214: 45.Are you currently participating in one of the following?Military Reserve If checked, date obligation ends: 46.Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s mast,office hours, company punishment)? .............................................................................................................................................. Yes No 47.Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded? ......................................... Yes No If you answered yes to Questions 46 and/or 47, explain (include dates and circumstances): PERSONAL HISTORY STATEMENT Page 15 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 7: FINANCIAL 48. INCOME AND EXPENSES For each of the following questions fill in the amounts to the nearest dollar. A) From your employer(s), what is your take-home monthly income?................................................................$ per month B) Do you have income other than from your salary or wages? ............................................................................................................. Yes No If yes, fill in amount: ................................................................................................................................$ per month Explain: C) How much do you spend each month? .........................................................................................................$ per month Estimate your monthly living expenses; include housing, utilities, credit cards or other loan payments, food, gas and 49. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)?............................................................................................... Yes No 50. Have any of your bills ever been turned over to a collection agency?................................................................................................. Yes No 51. Have you ever had purchased goods repossessed? .......................................................................................................................... Yes No 52. Have your wages ever been garnished? ............................................................................................................................................ Yes No 53. Have you ever been delinquent on income or other tax payments? ................................................................................................... Yes No 54. Have you ever failed to file income tax or cheated/lied on an income tax form? ................................................................................. Yes No 55. Have you ever had an employment bond refused? ............................................................................................................................ Yes No 56. Have you ever avoided paying any lawful debt by moving away? ....................................................................................................... Yes No 57. Have you ever defaulted on (failed to pay) a loan? ............................................................................................................................ Yes No 58. 59. Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)? .............. Yes No 60. Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)? ..................... Yes No 61. Have you written three or more bad checks in a one-year period? ..................................................................................................... Yes No If you answered yes to any of Questions 49–61, explain (include when, where, and why; indicate corresponding number): PERSONAL HISTORY STATEMENT Page 16 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 8: LEGAL Disclosure of Arrests and Convictions As an applicant for a peace officer position, you are required to disclose any of the following which occurred on or after your 15th birthday, even if the records were sealed, expunged, dismissed or pardoned: •ALL detentions or arrests, whether they resulted in a conviction or not •ALL convictions •ALL diversion programs that were not successfully completed 62. Either as an adult or a juvenile, have you EVER been detained for investigation, held on suspicion, questioned, fingerprinted, arrested, indicted, criminally charged, or convicted of any misdemeanor orfelony offense in this state or in any other legal jurisdiction (including offenses punishable underthe Uniform Code of Military Justice)? .............................................................................................................................. Yes No If yes, explain each incident. 63.Have you ever been placed on court probation as an adult?........................................................................................................... Yes No 64.committed as an adult? .................................................................................................................................................................. Yes No 65.support, etc.)? ................................................................................................................................................................................ Yes No 66.Have the police ever been called to your home for any reason? ..................................................................................................... Yes No 67.Have you or your spouse/partner ever been referred to Child Protective Services? ........................................................................ Yes No PERSONAL HISTORY STATEMENT Page 17of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 8: LEGAL continued 68.Have you ever been the subject of an emergency protective order/restraining order/stay-away order? .......................................... Yes No 69.Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf wasrequired to make payment to the other party? ................................................................................................................................ Yes No 70.Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or otherstate or federal assistance? ............................................................................................................................................................ Yes No 71.Have you ever filed a false insurance or workers’ compensation claim? ......................................................................................... Yes No If you answered yes to any of Questions 63–71, explain (include court case or document, dates, and circumstances; indicate corresponding number): 72.UNDETECTED ACTS – PART 1 At any time have you ever committed any of the following misdemeanors? A) Annoying / obscene phone calls ...................................................................................................................................................... Yes No B) Battery (use of force or violence upon another) ............................................................................................................................... Yes No C) Brandishing a weapon (any type of weapon) ................................................................................................................................... Yes No D) Carrying a concealed weapon without a permit ................................................................................................................................ Yes No E) Contributing to the delinquency of a minor ....................................................................................................................................... Yes No F) Defrauding an innkeeper (not paying for food or room at a hotel/motel) ........................................................................................... Yes No G) Driving under the influence of alcohol and/or drugs ......................................................................................................................... Yes No H) Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) ....................................................... Yes No I) Hit & run collision (no injuries) ......................................................................................................................................................... Yes No J) Hunting/fishing without a license ...................................................................................................................................................... Yes No K) Illegal gambling ............................................................................................................................................................................... Yes No L) Impersonating a peace officer (pretending to be a police officer) ..................................................................................................... Yes No M)Indecent exposure (including flashing or mooning) .......................................................................................................................... Yes No N)Joyriding (using a car or other vehicle without owner’s permission) ................................................................................................. Yes No O) Petty theft (value up to $400, including shoplifting/switching price tags) ........................................................................................... Yes No P)Possession of alcohol as a minor ..................................................................................................................................................... Yes No PERSONAL HISTORY STATEMENT Page 18 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 8: LEGAL continued 72. UNDETECTED ACTS – PART 1 continued Q) Possession of falsified or altered identification, including use of another person’s ID (for any reason) ............................................. Yes No R)Possession of stolen property (including vehicles) ........................................................................................................................... Yes No S) Prostitution or soliciting a prostitute .................................................................................................................................................. Yes No T) Resisting arrest (including running from the police) .......................................................................................................................... Yes No U)Trespassing ..................................................................................................................................................................................... Yes No V)Vandalism (including “tagging,” malicious mischief and/or property damage) ................................................................................... Yes No W) Intentionally writing a bad check ...................................................................................................................................................... Yes No X)Filing a false police report ................................................................................................................................................................ Yes No Y)Any other act amounting to a misdemeanor within the past seven years .......................................................................................... Yes No If you answered yes to any item(s) in Question 72, fully explain circumstances, including date(s), names of individuals involved, and resolution. Indicate the corresponding letter (72-A, etc.) for each explanation. 73. UNDETECTED ACTS – PART 2 At any time in your life have you ever committed any of the following? A)Arson (intentionally destroying property by setting a fire) ................................................................................................................. Yes No B)Assault with a deadly weapon .......................................................................................................................................................... Yes No C)Theft of a vehicle and/or vehicle parts .............................................................................................................................................. Yes No D)Burglary (entering a structure or vehicle to commit theft or other crime) ........................................................................................... Yes No E)Child molestation (performing unlawful acts with a child) ................................................................................................................. Yes No F) Accessing and/or possessing child pornography .............................................................................................................................. Yes No PERSONAL HISTORY STATEMENT Page 19 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 8: LEGAL (Question 73) continued G) Elder abuse/neglect ......................................................................................................................................................................... Yes No H)Embezzlement (theft of money or other valuables entrusted to you) ................................................................................................ Yes No I) Felony drunk driving (involving injuries) ........................................................................................................................................... Yes No J)Forcible rape or other act of unlawful intercourse ............................................................................................................................. Yes No K)Forgery (falsifying any type of document, check certificate, license, currency, etc.).......................................................................... Yes No L) Hit & run (with injuries) ..................................................................................................................................................................... Yes No M)Hate crime ....................................................................................................................................................................................... Yes No N)Insurance fraud ................................................................................................................................................................................ Yes No O) Grand theft (value of over $400, or any firearm) ............................................................................................................................... Yes No P)Murder, homicide, or attempted murder ........................................................................................................................................... Yes No Q) Perjury (lying under oath) ................................................................................................................................................................. Yes No R)Possession of an explosive/destructive device ................................................................................................................................. Yes No S)Robbery (theft from another person using a weapon, force, or fear) ................................................................................................. Yes No T) Stalking ............................................................................................................................................................................................ Yes No U)Blackmail or extortion....................................................................................................................................................................... Yes No V)Any other act amounting to a felony ................................................................................................................................................. Yes No any Question 73 resolution. Indicate the corresponding letter (73-A, etc.) for each explanation. PERSONAL HISTORY STATEMENT Page 20 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 8: LEGAL continued Questions 74 and 75 ask about your current and past recreational drug use. This covers the use of any drug, including the unauthorized use of prescription drugs or over-the-counter drugs. Your answers should include, but not be limited to, your use of any of the following drugs: –Amphetamines / Methamphetamines (Uppers, Speed, Crank, etc) –Barbiturates (Downers) –Cocaine / Crack Cocaine –Designer Drugs (Ecstasy, Synthetic Heroin, etc.) –GHB (Date Rape Drug) –Glue –Hallucinogens (Peyote, LSD, Mushrooms) –Hashish / Hashish Oil –Heroin / Opium –Marijuana –Mescaline –Morphine –PCP / Angel Dust –Quaaludes –Steroids –Tetrahydrocannabinal (THC) 74. Within the past 10 years, have you used any drug(s) as indicated above? ..................................................... Yes No If yes, give details, including drug(s) used and circumstances: 75.Prior to the past 10 years (check all that apply): 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 checked, give details including drug(s) used, most recent date used, and circumstances. ever Sold Manufactured Purchased Furnished Cultivated Carried or held for another If you checked any items above, give details including drug(s) involved, over what time period(s), and circumstances. PERSONAL HISTORY STATEMENT Page 21 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 9: MOTOR VEHICLE OPERATION 77. CURRENT DRIVER’S LICENSE NUMBER STATE OF ISSUE EXPIRATION DATE NAME UNDER WHICH LICENSE WAS GRANTED 78.LIST OTHER STATES WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE: State of issue Type of license Name under which license was granted and license number, if known 79. Have you ever been refused a driver’s license by any state? ...................................................................................................... Yes No If yes, explain (include when, where, and circumstances): 80. Has your driver’s license ever been suspended or revoked? ...................................................................................................... Yes No If yes, explain (include when, where, and circumstances): 81.List your current liability insurance on your vehicle(s): Insured Bonded Cash Deposit ( ) Insured Bonded Cash Deposit ( ) Insured Bonded Cash Deposit ( ) Insured Bonded Cash Deposit PERSONAL HISTORY STATEMENT Page 22 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 9: MOTOR VEHICLE OPERATION continued 82. List all traffic citations, excluding parking citations, you have received within the past seven years: Month Year Not Guilty Fined Traffic School Dismissed Month Year Not Guilty Fined Traffic School Dismissed Month Year Not Guilty Fined Traffic School Dismissed D)Has a traffic citation ever resulted in a warrant or caused your driver’s 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: 83.Have you been involved as the driver in a motor vehicle accident within the past seven years? ................................................ Yes No If yes, give details. LOCATION (NUMBER / STREET / APT) CITY STATE ZIP YES NO INJURY NON- LOCATION (NUMBER / STREET / APT) CITY STATE ZIP YES INJURY NON- LOCATION (NUMBER / STREET / APT) CITY STATE ZIP YES NO INJURY NON- 84.Have you ever driven a vehicle without auto insurance, as required by law? ............................................................................. Yes No DATE 85.Have you ever been refused automobile liability insurance or a bond, or had them cancelled? ................................................. Yes No DATE PERSONAL HISTORY STATEMENT Page 23 of 23 Initial this page to indicate that you have provided complete and accurate information: _____ SECTION 9: MOTOR VEHICLE OPERATION continued Use this space for additional information you would like to include regarding your driving record. SECTION 10: OTHER TOPICS 86.Have you ever been refused a permit to carry a concealed weapon? ........................................................................................ Yes No 87.Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other groupthat advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality,gender, sexual preference, or disability? ................................................................................................................................... Yes No 88.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 89.Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or other 90.Have you ever hit or physically overpowered a spouse or romantic partner? ............................................................................. Yes No If you answered yes to any of Questions 86–90, give details including dates and circumstances; indicate corresponding number. SECTION 11: CERTIFICATION 91.I hereby certify that I have personally completed and initialed each page of this form and any supplemental page(s) attached, and thatall statements made are true and complete to the best of my knowledge and belief. I understand that any misstatement of material factmay subject me to disqualification; or, if I have been appointed, may disqualify me from continued employment. PERSONAL HISTORY STATEMENT Page 24 of 26 Initial this page to indicate that you have provided complete and accurate information: _____ ADDITIONAL SPACE •Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g., additional family members, schools,residences, employers, explanations to questions, etc.) •Identify the corresponding question and specific item being referenced.