STATE OF ARKANSAS
COMMISSION
ON
LAW ENFORCEMENT STANDARDS
IN TRAINING
PERSONAL HISTORY STATEMENT
PERSONAL STATEMENT HISTORY
__________________________________________________________________________________
Law Enforcement Agency Month Day Year
Position: Full Time _____ Part Time ____ Reserve _____ Jail _____
INSTRUCTIONS: Fill out this questionnaire completely and accurately. All statements in your questionnaire are subject to verification. Incorrect statements may bar or remove you from employment. If space provided is inadequate, and additional pages and identify information by item number. If a question does not apply to you, indicate by writing N/A in the answer blank. Type or print legibly in ink all responses.
PERSONAL
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1. Name: First Middle Last Social Security #
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Nicknames or Aliases
____________________________________________
2. Height Weight
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3. Present Address Street & Number City State Zip Code
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Permanent Address Street & Number City State Zip Code
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Home Telephone Number Business
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4. Date of Birth Place of Birth
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5. Citizenship: US Born US Naturalized Other: Specify
6. List organizations, clubs and associations of which you are or have been a member, or which you are or have been associated. __________________________________________________________________________________
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7. List hobbies and/or special skills.
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MARITAL
8. Marital Status (check one)
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Single Married Divorced Engaged Separated Widowed
9. Name of Spouse or Fiancé:
__________________________________________________________________________________
10. If married, are you living with your spouse? Yes ______ No ______
If not, state reasons:
__________________________________________________________________________________
__________________________________________________________________________________
11. Have you ever been separated or divorced? Yes ______ No ______
If yes, give date and location of court jurisdiction.
__________________________________________________________________________________
__________________________________________________________________________________
12. Give the following information concerning your spouse's parents:
Father:_____________________________________________________________________________
Name Address
Mother:____________________________________________________________________________
Name Address
13. List below every child born to you:
NAME BIRTH DATE PLACE OF BIRTH WITH WHOM RESIDES
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
14. Are you supporting all children born to you, adopted by you and stepchildren?
Yes ______ No ______ If no, give details.
__________________________________________________________________________________
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15. Have you ever been involved as a defendant in a paternity proceeding?
Yes ______ No ______ If yes, give date and court or jurisdiction:
__________________________________________________________________________________
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16. Give the names of five responsible persons, other than relatives or past employers, who could provide information about your character, ability, experience, personality and other qualities.
Name Address Telephone
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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
17. List your parents, brothers and sisters:
Name Address Telephone
Father_____________________________________________________________________________
Mother____________________________________________________________________________
Bro/Sis____________________________________________________________________________
Bro/Sis____________________________________________________________________________
Bro/Sis____________________________________________________________________________
18. Has any member of your immediate family ever been arrested for or convicted of a felony offense? Yes ______ No ______ If yes, complete the following:
Date Location Charge Disposition
__________________________________________________________________________________
__________________________________________________________________________________
FINANCIAL
19. Do you have life insurance and/or hospitalization insurance? Yes ______ No ______
20. Have you a savings account? Yes ______ No ______
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Bank City & State
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Bank City & State
21. Have you a checking account? Yes ______ No ______
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Bank City & State
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Bank City & State
22. Do you own or have an interest in any business dealing in alcohol? Yes ____ No ____
If yes, give name, location, and type of business:
___________________________________________________________________________________
___________________________________________________________________________________
23. do you own or are you buying your own home? Yes ______ No ______
Is there a mortgage on the property? Yes ______ No ______
24. Do you own or are you buying other real estate? Yes ______ No ______
If yes, give name of agency holding the property.
___________________________________________________________________________________
Bank or Company City & State
25. List motor vehicles that you own or are buying or leasing:
Make Model Year Amount Owed
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___________________________________________________________________________________
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26. What income other than salary do you have at present? Include spouse's salary?
___________________________________________________________________________________
___________________________________________________________________________________
27. List Credit References:
___________________________________________________________________________________
Name of Firm Amount Owed
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Street Address Street Address
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Name of Firm Amount Owed
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Street Address Street Address
___________________________________________________________________________________
Name of Firm Amount Owed
___________________________________________________________________________________
Street Address Street Address
___________________________________________________________________________________
Name of Firm Amount Owed
___________________________________________________________________________________
Street Address Street Address
___________________________________________________________________________________
Name of Firm Amount Owed
___________________________________________________________________________________
Street Address Street Address
___________________________________________________________________________________
Name of Firm Amount Owed
___________________________________________________________________________________
Street Address Street Address
28. What is your total indebtedness at present? ___________________________________________________________________________________
29. Have your creditors treated you fairly? Yes ______ No ______ If not, explain:
___________________________________________________________________________________
___________________________________________________________________________________
30. Have you ever been sued? Yes ______ No ______ If yes, give details:
___________________________________________________________________________________
___________________________________________________________________________________
RESIDENCES
31. List addresses for past 10 years starting with present address at top.
From Mo/Yr To Mo/Yr Address/Residence City & State Landlord
___________________________________________________________________________________
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___________________________________________________________________________________
___________________________________________________________________________________
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WORK HISTORY
32. Are you now or have you ever been engaged in any business as an owner, partner, or corporate board member? Yes ______ No ______ If yes, give details below:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
33. If you have ever been discharged or forced to resign because of misconduct for unsatisfactory service, give details:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
34. Have your employers always treated you fairly? Yes ______ No ______
If no, explain:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
35. Do you object to wearing a uniform? Yes ______ No ______
36. Do you object to working nights? Yes ______ No ______
37. Do you object to working shifts? Yes ______ No ______
38. List all jobs you have held in the last ten years. Put your present or most recent job first. If you need more space, you may attach additional sheets. Include military service in proper time sequence and temporary part-time jobs.
(1) Title of present or last position___________________________________________
Starting Salary____________________ Last Salary ____________________________
Name and title of supervisor _______________________________________________
No. employees supervised by you __________________________________________
Employer____________________________ Address__________________________
Duties________________________________________________________________
Date Employed _______________________ Date separated_____________________
Full time________ Years _____ Months _____
Part time________ Years _____ Months _____
If part time, number of hours worked per week _____________________
Reason for leaving______________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(2) Title of present or last position _________________________________________
Starting Salary____________________ Last Salary ___________________________
Name and title of supervisor ______________________________________________
No. employees supervised by you __________________________________________
Employer____________________________ Address__________________________
Duties_______________________________________________________________
Date Employed _______________________ Date separated____________________
Full time________ Years _____ Months _____
Part time________ Years _____ Months _____
If part time, number of hours worked per week _____________________
Reason for leaving______________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(3) Title of present or last position _________________________________________
Starting Salary____________________ Last Salary ___________________________
Name and title of supervisor ______________________________________________
No. employees supervised by you __________________________________________
Employer____________________________ Address__________________________
Duties_______________________________________________________________
Date Employed _______________________ Date separated____________________
Full time________ Years _____ Months _____
Part time________ Years _____ Months _____
If part time, number of hours worked per week _____________________
Reason for leaving______________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(4) Title of present or last position _________________________________________
Starting Salary____________________ Last Salary ___________________________
Name and title of supervisor ______________________________________________
No. employees supervised by you __________________________________________
Employer____________________________ Address__________________________
Duties_______________________________________________________________
Date Employed _______________________ Date separated____________________
Full time________ Years _____ Months _____
Part time________ Years _____ Months _____
If part time, number of hours worked per week _____________________
Reason for leaving______________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
39. Have you previously submitted an application for employment with this agency?
Yes ______ No ______ Approximate date: _______________________
MILITARY SERVICE
40. Were you ever in the U.S. Military Service or any other military organization?
Yes ______ No ______ Branch of Service: _______________________________
Unit __________ Date of Enlistment ____________ Date of Discharge _______________
Service Number _____________________ Highest Rank _________________________
41. List medals and decorations: ____________________________________________
______________________________________________________________________
42. Type of Discharge: ____________________________________________________
43. If you are presently a member of the National Guard or any military reserve, give the unit, location, and describe your obligation:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
44. List all schools attended:
______________________________________________________________________
Name of Grade School
______________________________________________________________________
Location
______________________________________________________________________
From Mo/Yr To Mo/Yr Year Completed
______________________________________________________________________
Name of High School
______________________________________________________________________
Location
______________________________________________________________________
From Mo/Yr To Mo/Yr Year Completed
______________________________________________________________________
Name of College or University
______________________________________________________________________
Location
______________________________________________________________________
From Mo/Yr To Mo/Yr Year Completed
45. Did you either graduate from high school or pass the high school equivalency test?
Yes ______ No ______
46. List college degrees received and major field of each. Include incomplete courses:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
47. Were you ever expelled from any school or were you ever disciplined by any school official? Yes ______ No ______ If yes, explain:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
ARREST AND MILITARY DISCIPLINARY
Answer all of the following questions completely and accurately. Any falsifications or misstatements of fact may be sufficient to disqualify you. (Exclude minor traffic violations.)
48. Have you ever been arrested or detained by police? Yes ______ No ______
If yes, give details below:
Crime Charged: ______________________________________________________
Police Agency: ________________________ Date: _________________________
Disposition of Case: ___________________________________________________
Crime Charged: ______________________________________________________
Police Agency: ________________________ Date: _________________________
Disposition of Case: ___________________________________________________
Crime Charged: ______________________________________________________
Police Agency: ________________________ Date: _________________________
Disposition of Case: ___________________________________________________
49. Have you ever been placed on probation? Yes ______ No ______
If yes, give details below:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
50. Have you ever been required to pay a fine in excess of $25.00?
Yes ______ No ______ If yes, give details below:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
51. Have you ever been reported as a missing person or a runaway?
Yes ______ No ______ If yes, give complete details, including jurisdiction, dates and outcome:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
52. Were you ever court-martialed, tried on charges, or were you the subject of a summary court, deck court, captain's mast or company punishment, or any other disciplinary action while a member of the armed forces? Yes ______ No ______ If yes, explain below:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
53. List any disciplinary action taken against you in the National Guard or other reserve unit?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
54. If you have ever been fingerprinted by a police agency other than for an arrest, give details below. Your answers will be checked with the F.B.I. and other agencies.
Agency _________________ Date ___________ Purpose _______________________
Agency _________________ Date ___________ Purpose _______________________
Agency _________________ Date ___________ Purpose _______________________
55. Can you operate a motor vehicle? Yes ______ No ______
56. Do you possess a valid operator's license from the State of Arkansas?
Yes ______ No ______
57. Do you possess an operator's license issued by any state other than Arkansas?
Yes ______ No ______
If yes, give state and number: _____________________________________________
58. Was your license ever suspended or revoked? Yes ______ No ______
If yes, state which and give reasons:
__________________________________________________________________________________
__________________________________________________________________________________
59. Was your license ever restored? Yes ______ No ______ When?
__________________________________________________________________________________
60. Have you ever been refused an operator's license by any state?
Yes ______ No ______
61. Have your driving privileges ever been restricted? Yes ______ No ______
__________________________________________________________________________________
__________________________________________________________________________________
62. Has a motor vehicle being driven by you ever been involved in an accident?
Yes ______ No ______ If yes, give complete details for each accident whether collision or non collision: ____________________________________________________________
Date:______________ Police Investigation:______________ Yes ______ No ______
Location: ______________________ Cause of accident: _________________________
Date:______________ Police Investigation:______________ Yes ______ No ______
Location: ______________________ Cause of accident: _________________________
Date:______________ Police Investigation:______________ Yes ______ No ______
Location: ______________________ Cause of accident: _________________________
63. List any convictions for minor traffic violations:
Location Approx. Date Nature of Violation Penalty or Disposition
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
ATTITUDES
64. What do you consider to be the current social problems of greatest concern?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
65. What are your experiences and beliefs concerning alcoholic beverages?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
66. What are your experiences and beliefs concerning the use of marijuana and/or other mind altering drugs?
__________________________________________________________________________________
__________________________________________________________________________________
67. What are your feelings about the use of deadly force if it became necessary in the performance of official duties?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
CAREER OBJECTIVES
68. Explain briefly your reasons for applying for this position:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I hereby certify that all statements made in this questionnaire are true and complete and understand that any misstatements of material facts will subject me to disqualification or dismissal.
Signature:
__________________________________ By signing this employment application, I certify that I am in compliance with the Military Selective Act.
SWORN AND SUBSCRIBED BEFORE ME
_____________________________________
NOTARY PUBLIC, THIS _____________ day
of_______________ 20 __________________
My commission expires:___________________
NOTICE-False swearing is a Class A misdemeanor.
Punishable under Arkansas Code 5-53-103
SALINE COUNTY SHERIFF'S OFFICE
% PERSONNEL
321 N. MAIN STREET
BENTON, AR 72015
Phone: 303-5609
Fax: 303-5747
AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT
To the Saline County Sheriff's Office to whom I am an applicant for employment, I understand that I must provide true and correct information regarding the following:
NAME______________________ DATE OF BIRTH___________________________
ADDRESS_____________________________________________________________
TELEPHONE NUMBER__________________________________________________
SOCIAL SECURITY NUMBER____________________________________________
In so furnishing, I willingly release the Saline County Sheriff's Office to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied. It is in the public's interest that all relevant information concerning my personal and employment history be disclosed to the above department. I hereby authorize any representative of the Saline County Sheriff's Office bearing this release to obtain any information in your files pertaining to my employment records and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorize agent of the Saline County Sheriff's Office, whether said records are of public, private, or confidential nature. The intent of this authorization is to give my consent for a full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the Saline County Sheriff's Office to consider in determining my suitability for employment in that department. It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.
I consent to your release of any and all public private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently has, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential, and/or sealed.
I hereby release you, your organization, and all others from liability or damages that may result from furnishing the information request, including any liability or damage pursuant to any state or federal laws. I hereby release you, as the custodian of such records of _______ organization, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information, or of the Saline County Sheriff's Office regardless of any agreement I may have made with you previously to the contrary. The law enforcement organization requesting the information pursuant to this release will discontinue processing my application if you refuse to disclose the information request.
For an in consideration to the Saline County Sheriff's Office acceptance and processing of my application for employment, I agree to hold the _______, its agents and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision weather or not to employee me with the Saline County Sheriff's Office. I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.
I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regard to access and disclosure of records, and I waive those rights with the understanding that information furnished will be used by the Saline County Sheriff's Office in conjunction with employment procedures.
A photocopy or FAX copy of this release form will be valid as an original thereof, even though the said photocopy or FAX copy does not contain an original writing of my signature.
This waiver is valid for a period of _______ from the date of my signature.
Should there be any questions as to the validity of this release, you may contact me at the address listed on this form
I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form.
I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims, damages, loses and expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request.
______________________________________
Signature of Applicant
Sworn and Subscribed before me ___________________________________
Notary Public, this _______ day of _______ 20_____.
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