Personal History Statement

1Personal Information

2References

3Residences

4Education

5Work History

6Driving Information

7Attitudes

8Career Objectives

9Citizenship

10Financial Status

11Military Service

12Miscellaneous

13Certification

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*
MM slash DD slash YYYY
Place of Birth
City or Town*
County*
State*
State / Province / Region Country
Color of Eyes*
Color of Hair*
Marriage
Marital Status*
- Single
- Married
- Widowed
- Divorced
- Estranged
Date of Present Marriage*
MM slash DD slash YYYY
Spouse's Full Name (maiden name if applicable)*
Spouse's Date of Birth*
MM slash DD slash YYYY
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

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References
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. Please list complete mailing address, zip code and telephone number.
References
Name

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

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Residences
List addresses for past 20 years starting with present address at top*
From (MO. YR.) To (MO. YR.) Address of Residence City / State Landlord

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Education
List all High Schools attended*
Name of High School Location (City / State) Diploma Received?
List all College's / University's attended*
Name of College / University Location (City / State) Degrees Received Major Field of Study
List any languages other than English which you can understand or speak.

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Attitudes
What are your feelings about the use of deadly force if it became necessary in the performance of official duties?*
What are your feelings about drug / alcohol usage?*

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Career Objectives
Explain briefly your reasons for applying for this position?*
Do you know of anything that would disqualify you for appointment as a Correctional Officer or would prevent you from fully discharging the duties of such a position?*
- Yes
- No
Explain*

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Citizenship
Are you a citizen of the United States or do you have a valid appropriate permit to work in the United States issued by the U.S. Department of Justice or U.S. Department of Labor?*
- Yes
- No
(Upon employment, proof of citizen status or work authorization will be required)
Applicants for Law Enforcement Positions - Are you a U.S. Citizen?
- Yes
- No

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Military Service
WERE YOU EVER IN THE US MILITARY SERVICE OR ANY OTHER MILITARY ORGANIZATION?*
- Yes
- No
Branch of Service*
Unit*
Date of Enlistment*
MM slash DD slash YYYY
Date of Discharge
MM slash DD slash YYYY
Service No. (if different from social security number)
Highest Rank*
Selective service status / Draft board number
Draft Board Address
Present draft status or classification
Date of classification
MM slash DD slash YYYY
List medals and decorations
Type of Discharge
If you are presently a member of the National Guard or any military reserve give the unit, location, and describe your obligation
What is your reserve obligation?
What special training did you receive in the armed services that would be relevant to this position?
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
Please explain*
List any disciplinary action taken against you in the National Guard or other reserve unit

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Certification
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.
Date*
MM slash DD slash YYYY
Signature of Applicant*

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Name of Organization	Member From	To	Office Held

Location	Approx. Date	Nature of Violation	Penalty or Disposition

Date	Charge	Enforcement Agency	City & State	Disposition

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 Relative	Relationship	Date of Birth	Address

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

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