Personal History Statement

Personal Information

Name*

Prefix First Middle Last Suffix

Any other names you are known by?

Present Mailing Address*

Street Address Address Line 2 City State ZIP Code

Permanent Mailing Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Height (inches)*

Weight (lbs)*

Sex*

Male
Female

Date of Birth*

Place of Birth

City or Town*

County*

State*

State / Province / Region Country

Color of Eyes*

Color of Hair*

Marriage

Marital Status*

Date of Present Marriage*

Spouse's Full Name (maiden name if applicable)*

Spouse's Date of Birth*

Were you married before present marriage?*

Yes
No

All ex-wives or husbands must be listed*

Name	Address	Phone #

Name court(s) where divorce(s) obtained (if applicable)

Court	City	State

If widowed, what was cause of wife or husband's death?

Children & Family

Do you have children?*

Yes
No

Children*

Name of Child	Date of Birth	Address

List below full names of all immediate relatives such as father, mother, sister, brothers, stepsisters, stepbrothers. If deceased give date ofdeath in address space and mark deceased. Give mother's maiden name as her middle name.*

Name of Relative	Relationship	Date of Birth	Address

Special Skills Related to the Position Applied For

From (MO. YR.)	To (MO. YR.)	Address of Residence	City / State	Landlord

Name of College / University	Location (City / State)	Degrees Received	Major Field of Study

Name of Organization	Member From	To	Office Held

Location	Approx. Date	Nature of Violation	Penalty or Disposition

Date	Charge	Enforcement Agency	City & State	Disposition

Personal Information

Place of Birth

Marriage

Children & Family

References

Residences

Education

Work History

Driving Information

Attitudes

Career Objectives

Citizenship

Financial Status

Military Service

Miscellaneous

Certification

Name of High School	Location (City / State)	Diploma Received?