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PERSONAL HISTORY STATEMENT - Civilian 1/18/18 January 2018 Schertz Police Department PERSONAL HISTORY STATEMENT Civilian Staff Name: ________________________________________ Date of Birth: ____________________________________ Position Applied For: ______________________________ Date: __________________________________________ 2 INSTRUCTIONS These instructions are provided to help you properly complete the Personal History Statement. It is essential that you read these directions and that all provided information be accurate in all respects. The provided information will be used as the basis for a background investigation that will determine your eligibility for employment. 1. Your Personal History Statement must be printed legibly in ink by you and no other person. Answer all questions to the best of your ability. 2. If a section or question does not apply to you, write N/A in the space provided. If it does apply, you are responsible for locating the correct information. Upon completing the Personal History Statement, re-check each section to ensure that all requested information has been provided. 3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is correct and in proper sequence before you begin. 4. Accurate information concerning traffic citations and accidents can be obtained by contacting the driver’s license authority in any state that has issued you a driver’s license. 5. You are responsible for obtaining correct names, addresses and telephone numbers. If you are not sure of an address or telephone number, personally verify it. 6. If there is insufficient space to provide the requested information, you shall attach extra sheets to the Personal History Statement. Be sure to reference the relevant section and question number on the attached sheets. 7. An accurate and complete Personal History Statement will help expedite the background investigation. Any and all willful omissions or falsifications will result in your removal from the applicant process, possibly resulting in a permanent disqualification. 8. The Authority for Release of Information and Waiver form on the last page MUST be notarized PRIOR to submitting the Personal History Statement. 9. After submission, it is the responsibility of each applicant to notify the Schertz Police Department of any changes to their Personal History Statement. Failure to do so will result in your termination from the process. By signing on the line below, I verify that I have read and understand the directions. ___________________________________ ____________________ Signature Date 3 PERSONAL HISTORY STATEMENT APPLICANT IDENTIFICATION (The information provided in this section is for identification purposes only) Name ____________________________________________________________________ (last) (first) (middle) Address __________________________________________________________________ (number) (street) ___________________________________________________________________ (city) (state) (zip code) Home Phone # ________________________ Cell Phone # __________________________ E-mail Address ____________________________________________________________ Date of Birth _______________________________________________________________ (month) (day) (year) Place of Birth ______________________________________________________________ (city) (county) (state) Social Security Number ___________________________________ Nickname(s), Maiden Name or Other Name by Which You Have Been Known _____________________________________________________________________ Scars, Tattoos or Other Distinguishing Marks _____________________________________ _____________________________________________________________________ Race _______ Sex _________ Blood Type _____________________ Driver’s License Number __________________________ State ________________ Are You a U.S. Citizen? YES______________ NO _____________ 4 List any foreign languages that you speak: ___________________________________________ Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group or combination of persons which is totalitarian, fascist, communist, or subversive, or which has adopted, or shows a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States, or which seeks to alter the form of Government of the United States by unconstitutional means? Yes ______ No ________ If yes, explain fully: _________________________________ ______________________________________________________________________________ ______________________________________________________________________________ RESIDENCES List all addresses (including city, county, state and zip code) where you have lived for the past 10 years, beginning with your present address. List dates by month and year. If you were renting, list the name of the landlord or , if you were in an apartment complex, list the name of the complex and the apartment manager’s name. Provide phone numbers for landlords and apartment complexes. Attach extra sheets if necessary. From: To: Address: ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ 5 ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ ______ ______________________________________________________ ______________________________________________________ ______________________________________________________ Excluding relatives, provide the name and current address and phone numbers (home, cell, work) of any roommate/person that you lived with for more than 30 days. Include the time period which you lived with this person(s): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6 Have you ever been evicted or asked to move out? Yes________ No _________ If yes, explain: _________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If renting / leasing a residence, have you ever lost your deposit? Yes ________ No ________ If yes, explain: _________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________ WORK HISTORY How many times have you been fired or asked to resign from a job: ___________ List the names of the jobs you were either fired or asked to resign from : ______________________________________________________________________________ ______________________________________________________________________________ How many times have you quit a job without giving sufficient notice, at least two weeks, or the time required by the employer? ___________ List the names of the jobs you did not give sufficient notice of leaving and why: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7 Beginning with your present or most recent job, in chronological order, list all employment since the age of 17, including part-time, self-employment, temporary or seasonal occupations and all periods of unemployment. Indicate month and year for the beginning and end of each job or period of unemployment. For periods of self-employment, list what type of work you were engaged in, along with the name, addresses and phone numbers of customers and/or suppliers who can verify your self- employment. For periods of part-time employment or unemployment, indicate what else you were doing during that time period. 1. From: ______________ To: ______________ Company Name or Employer: ______________________________________________ Address (street, city, state and zip): ___________________________________________ _______________________________________________________________________ Phone Number: _______________________Website:____________________________ Job Title: __________________________ Full or Part Time: ____________________ Starting Salary: $ ___________ per hour Ending Salary: $ ____________ per hour Duties Performed: ________________________________________________________ _______________________________________________________________________ Supervisor’s Full Name: ___________________________________________________ Full Name of Co-Workers: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Did you quit or resign from this job or were you fired or laid off? ___________________ Reasons for quitting, resigning or being fired? _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8 2. From: ______________ To: ______________ Company Name or Employer: ______________________________________________ Address (street, city, state and zip): ___________________________________________ _______________________________________________________________________ Phone Number: _______________________Website:____________________________ Job Title: __________________________ Full or Part Time: ____________________ Starting Salary: $ ___________ per hour Ending Salary: $ ____________ per hour Duties Performed: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Supervisor’s Full Name: ___________________________________________________ Full Name of Co-Workers: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Did you quit or resign from this job or were you fired or laid off? ___________________ Reasons for quitting, resigning or being fired? _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 9 3. From: ______________ To: ______________ Company Name or Employer: ______________________________________________ Address (street, city, state and zip): ___________________________________________ _______________________________________________________________________ Phone Number: _______________________Website:____________________________ Job Title: __________________________ Full or Part Time: ____________________ Starting Salary: $ ___________ per hour Ending Salary: $ ____________ per hour Duties Performed: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Supervisor’s Full Name: ___________________________________________________ Full Name of Co-Workers: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Did you quit or resign from this job or were you fired or laid off? ___________________ Reasons for quitting, resigning or being fired? _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 10 4. From: ______________ To: ______________ Company Name or Employer: ______________________________________________ Address (street, city, state and zip): ___________________________________________ _______________________________________________________________________ Phone Number: _______________________Website:____________________________ Job Title: __________________________ Full or Part Time: ____________________ Starting Salary: $ ___________ per hour Ending Salary: $ ____________ per hour Duties Performed: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Supervisor’s Full Name: ___________________________________________________ Full Name of Co-Workers: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Did you quit or resign from this job or were you fired or laid off? ___________________ Reasons for quitting, resigning or being fired? _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 11 5. From: ______________ To: ______________ Company Name or Employer: ______________________________________________ Address (street, city, state and zip): ___________________________________________ _______________________________________________________________________ Phone Number: _______________________Website:____________________________ Job Title: __________________________ Full or Part Time: ____________________ Starting Salary: $ ___________ per hour Ending Salary: $ ____________ per hour Duties Performed: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Supervisor’s Full Name: ___________________________________________________ Full Name of Co-Workers: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Did you quit or resign from this job or were you fired or laid off? ___________________ Reasons for quitting, resigning or being fired? _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 12 6. From: ______________ To: ______________ Company Name or Employer: ______________________________________________ Address (street, city, state and zip): ___________________________________________ _______________________________________________________________________ Phone Number: _______________________Website:____________________________ Job Title: __________________________ Full or Part Time: ____________________ Starting Salary: $ ___________ per hour Ending Salary: $ ____________ per hour Duties Performed: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Supervisor’s Full Name: ___________________________________________________ Full Name of Co-Workers: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Did you quit or resign from this job or were you fired or laid off? ___________________ Reasons for quitting, resigning or being fired? _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13 MILITARY SERVICE 1. Have you served in the U.S. Armed Forces? No ______ Yes ______ If yes, answer the following: What Branch? ______________________________________ DATES: (month/year) From: To: Location: a. ________ ________ _______________________________________________ b. ________ ________ _______________________________________________ c. ________ ________ _______________________________________________ d. ________ ________ _______________________________________________ Commanding Officer/Job Duties Each Location: Commanding Officer: Job Duties: a. ______________________ _______________________________________________ b. ______________________ _______________________________________________ c. ______________________ _______________________________________________ d. ______________________ _______________________________________________ 2. Highest Rank You Achieved in the Service: ___________________________________ Rank at Discharge: ___________________________________________ Type of Discharge: ___________________________________________ 14 3. Was ANY disciplinary action ever taken against you while you were in the military? (Such disciplinary action would include Court Martial, Captain’s Mast, Article 15, Restriction to Barracks, Letters of Reprimand, Etc.) Yes __________ No __________ If yes, provide the following information: Article or Section Number: _________________________________________________ Charge: _______________________ Date: ____________ Commanding Officer at the Time: ___________________________________________ (full name and rank) Where were you stationed at the time? ________________________________________ Disposition (What happened as a result of the charge?) ___________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7. If you received a discharge other than Honorable, give complete details: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8. Selective Service Registration Information: Where Registered:_________________________________________________________ Date Registered: _______________ Registration Number:________________________ 15 EDUCATIONAL HISTORY Include ALL colleges, universities and high schools attended. High Schools: 1. Name: _________________________________________________________________ From: ________________ To: _______________ Complete Address: _______________________________________________________ _______________________________________________________________________ Phone Number: _________________________________________________________ Graduated? Yes______ No______ If yes, give date: ________________________________________________________ List extra-curricular activities you participated in: ______________________________ List any offices you held (President, Student Council, Honor Society): ______________________________________________________________________ 2. Name: _____________________________________________________________ From: ________________ To: _______________ Complete Address: _______________________________________________________ _______________________________________________________________________ Phone Number:__________________________________________________________ Graduated? Yes______ No______ If yes, give date: ________________________________________________________ List extra-curricular activities you participated in: ______________________________ List any offices you held (President, Student Council, Honor Society): ______________________________________________________________________ 16 Colleges or Universities: 1. Name: _________________________________________________________________ Complete Address and Phone Number of Registar: _______________________________________________________________________ _______________________________________________________________________ Dates From: ________________ To: _______________ Hours Completed: ______________ Major/Minor: _____________________________ Degree, if any, and Date Degree Received: ____________________________________ GPA _____________ 2. Name: _________________________________________________________________ Complete Address and Phone Number of Registar: _______________________________________________________________________ _______________________________________________________________________ Dates From: ________________ To: _______________ Hours Completed: ______________ Major/Minor: _____________________________ Degree, if any, and Date Degree Received: ____________________________________ GPA _____________ 3. Name: _________________________________________________________________ Complete Address and Phone Number of Registar: _______________________________________________________________________ _______________________________________________________________________ Dates From: ________________ To: _______________ Hours Completed: ______________ Major/Minor: _____________________________ Degree, if any, and Date Degree Received: ____________________________________ GPA _____________ 17 Were you ever on academic or scholastic suspension or probation? Yes _______ No________ If yes, when and why? __________________________________________________________ ____________________________________________________________________________ List other schools attended (trade, vocational, business, etc.). Give the name , telephone number and complete mailing address of the school, dates attended, course of study and other pertinent information. Include copies of certificates received. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ ARRESTS, DETENTION AND LAW SUITS. 1. Have you ever been arrested, charged with a criminal offense, questioned as a possible suspect in a criminal investigation or otherwise detained by the police for any reason other than a traffic violation? Yes: __________ No: ___________ If yes, complete the following: A. Offense, Charge, or Reason for Detention: _______________________________ Police Agency: ___________________________________________________ City and State: ____________________________________________________ Date:_________________ What happened to the case? ___________________ _________________________________________________________________ _________________________________________________________________ 18 B. Offense, Charge, or Reason for Detention: _______________________________ Police Agency: ___________________________________________________ City and State: ____________________________________________________ Date:_________________ What happened to the case? ___________________ _________________________________________________________________ _________________________________________________________________ C. Offense, Charge, or Reason for Detention: _______________________________ Police Agency: ___________________________________________________ City and State: ____________________________________________________ Date:_________________ What happened to the case? ___________________ _________________________________________________________________ _________________________________________________________________ 2. Are you presently under indictment or charges for a criminal offense? Yes: _________ No: __________ If yes, give complete details, including location:________________________________ _______________________________________________________________________ 3. Are you or have you ever been on probation or parole? Yes: _________ No:_________ If yes, give complete details, including location: ________________________________ _______________________________________________________________________ 4. Have you ever been involved as a respondent or plaintiff in a law suit? Yes:_________ No:_________ If yes, give complete details, including location and court docket number: ___________ _______________________________________________________________________ 19 5. How many of your immediate or close relatives have ever been arrested?_____________ Provide information on who, what for, when, and where: _______________________________________________________________________ _______________________________________________________________________ 6. How many of your close friends have been arrested? _________ Provide information on who, what for, when and where: _______________________________________________________________________ _______________________________________________________________________ TRAFFIC RECORD. 1. Has your driver’s license, in any state, ever been suspended or revoked or in danger of suspension or revocation? Yes: _________ No: ___________ If yes, give complete details: _______________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2. List all states in which you have held a driver’s license: State __________ D.L. # __________________________________________ State __________ D.L. # __________________________________________ State __________ D.L. # __________________________________________ 20 3. List the following information concerning your auto insurance: Company: _______________________________________________________________ Agent Name:_____________________ Phone Number: _________________________ Mailing Address: _________________________________________________________ _______________________________________________________________________ Policy Number: __________________ Expiration Date: ________________________ If the policy is in someone else’s name, what name is it under and why? _____________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 4. Excluding parking tickets, list ALL traffic citations you have received (including tickets which have been dismissed or that were dismissed by Defensive Driving) : Date Charge (If speeding, include how fast/speed limit) Where was Ticket Issued? Issuing Agency Disposition (fine, dismissed, etc.) 21 5. List ALL traffic accidents in which you have been involved: Date Exact Location Investigating Agency What Happened? 22 MARITAL AND FAMILY HISTORY Are you currently: Single: ______ Engaged: ______ Married: ______ Separated: ______ Divorced: _______ Widowed: ______ If engaged, complete the following information on your fiancé: Name: ____________________________________________________________________ Date of Birth: ______________________ Mailing Address: ___________________________________________________________ ____________________________________________________________ Home Phone: _______________ Work Phone: _________________________________ Employer Name and Address: _________________________________________________ _________________________________________________ Occupation: _______________________________________________________________ If married, complete the following information on your spouse: Name: ___________________________________________________________________ Date of Birth: ______________________ Social Security Number: _____________________________________________________ Mailing Address: ___________________________________________________________ ____________________________________________________________ Home Phone: _______________ Work Phone: _________________________________ Employer Name and Address: _________________________________________________ _________________________________________________ _________________________________________________ 23 Occupation: _______________________________________________________________ Date of Marriage: ____________________ City and State where married: _________________________________________________ If ever divorced, annulled or widowed, indicate which: _____________________________ Former Spouse’s Full (Maiden) Name: __________________________________________ Date of Birth: ____________________ Complete Current Address: ___________________________________________________ ___________________________________________________ Phone Number: ____________________________________________________________ Date of Marriage: _______________________________ City and State where married: _________________________________________________ If divorced or annulled, date of court order or decree: ______________________________ Where was the order or decree issued (court, city, county and state): ___________________________________________________________________________ (Attach extra sheets and provide all of the above information for EVERY former marriage.) Have you ever assaulted your spouse, former spouse or significant other? Yes:____ No:____ Has your spouse, former spouse or significant other ever assaulted you? Yes:____ No:____ Have you ever been ordered by a court to pay child support or alimony? Yes:____ No:____ If yes, provide the following information: To Whom Paid ___________________________ Amount ___________________________ To Whom Paid ___________________________ Amount ___________________________ To Whom Paid __________________________ Amount ___________________________ 24 How paid? (direct, court clerk, etc. If paid through court clerk, give complete name and mailing address of the office to which it is sent.): ______________________________________________________________________________ ______________________________________________________________________________ List all children related to you or your spouse including natural, adopted, step-children or foster children: Full Name Relation Date of Birth Complete Address Supported by Whom 25 List all other dependents: Full Name Relation Complete Address and Phone Date of Birth Have you or your spouse ever been investigated for child abuse or neglect? Yes____ No____ If yes, give complete details: ___________________________________________________ ___________________________________________________________________________ List other relatives in the following order: Father, Mother (include maiden name), Brothers, Sisters and any In-Laws: (indicate if deceased) Full Name Relation Complete Address And Phone Number Date of Birth 26 Full Name Relation Complete Address And Phone Number Date of Birth FINANCIAL INFORMATION At what age did you become financially self-supporting? ________________________ What is your current monthly salary or wages:_________________________________ List all other sources of income (including spouse’s income) along with the amount and how often money is received from that source: ___________________________________________________________________________ ___________________________________________________________________________ If you own any real estate, give the complete address (including county) of the property along with the value and the name and mailing address of the mortgagor: ___________________________________________________________________________ ___________________________________________________________________________ 27 Have you ever declared bankruptcy? Yes ________ No __________ If yes, state why and provide a copy of court records: _______________________________ List all current checking accounts, along with the full name, address and phone number of the financial institution: a._________________________________________________________________________ b._________________________________________________________________________ c._________________________________________________________________________ d._________________________________________________________________________ List all current savings accounts along with the full name, address and phone number of the financial institution: a._________________________________________________________________________ b._________________________________________________________________________ c._________________________________________________________________________ List all checking or saving accounts you have had in the last three years that are now inactive. Provide the full name, address and phone number of the financial institution: a.________________________________________________________________________ b.________________________________________________________________________ c.________________________________________________________________________ d.________________________________________________________________________ Have you ever had a check returned? Yes ______ No ______ If yes, list the date(s), number(s) of checks, and describe the circumstances of the return(s): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 28 Did you know that any of these checks would be returned when you wrote them? Yes: ______ No: ______ List all individuals, companies or others to whom you are indebted (Include rent, mortgages, vehicle payments, charge accounts, credit cards, loans, child support payments, alimony, utilities and any other debts or payments): a. ________________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment b. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment c. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment d. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment 29 e. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment f. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment g. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment h. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment 30 i. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment j. _______________________________________________________________________ Name of Creditor Mailing Address Phone Number ________________________________________________________________________ Type of Account Reason for Debt or Item Purchased _________________________________________________________________________ Account Number Total Balance Monthly Payment 14. Total Indebtedness $_____________ Total Monthly Payments $___________________ 15. Have you been turned down for credit within the last five years? Yes ______ No ______ If yes, list the company name, date and reason for denial: __________________________ _________________________________________________________________________ _________________________________________________________________________ 16. How many items have been repossessed from you? __________ Provide the circumstances for each item: ________________________________________ __________________________________________________________________________ 31 MEMBERSHIP IN ORGANIZATIONS 1. List the following information regarding your past or present membership in all groups, clubs, organizations (professional, fraternal, social, etc.): a. ________________________________________________________________________ Name and Address Type of Dates of Organization Organization Involved b. ________________________________________________________________________ Name and Address Type of Dates of Organization Organization Involved c. ________________________________________________________________________ Name and Address Type of Dates of Organization Organization Involved d. ________________________________________________________________________ Name and Address Type of Dates of Organization Organization Involved e. ________________________________________________________________________ Name and Address Type of Dates of Organization Organization Involved PERSONAL DECLARATIONS 1. Describe in your own words the frequency and extent of your use of alcoholic beverages: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ 32 2. Have you ever used marijuana or any other drug not prescribed by a physician? Yes _______ No ________ If yes, explain your marijuana or drug use including when and how many times used along with the date last used. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3. Have person(s) used marijuana or other illegal drugs in your presence? If so, provide details including date(s), location(s), name(s), etc.:_________________________________ _________________________________________________________________________ 4. Have you ever sold, give or delivered drugs or narcotics to anyone? If yes, explain: Yes ________ No ________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 5. Have you ever received drugs or narcotics from anyone? If yes, explain: Yes ________ No ________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 33 6. As an adult, have you ever stolen or shoplifted anything; that is, have you taken anything from an employer, store or person that didn’t belong to you? Yes _____ No ______ If yes, give specifics according to the example. WHAT? HOW LONG AGO? TOTAL VALUE? FROM WHOM? (EXAMPLE) Sweater 1 yr. 3 months $36.00 Store ________________________________________________________________________ a.________________________________________________________________________ b.________________________________________________________________________ c.________________________________________________________________________ 7. Have you ever purchased items that you knew or suspected were stolen? Yes ____ No ____ If yes, provide the following: WHAT? HOW LONG AGO? TOTAL VALUE? a.______________________________________________________________________ b.______________________________________________________________________ c.______________________________________________________________________ 8. Have you ever borrowed anything that you intentionally did not return? Yes ____ No____ If yes, provide the following: WHAT? HOW LONG AGO? TOTAL VALUE? a.______________________________________________________________________ b.______________________________________________________________________ 9. Do you have any beliefs or precepts that would prevent you from fully performing your duties including working weekends, evenings, nights and holidays? Yes _____ No ______ 34 10. As you know, we will investigate your past. When we interview employers, friends, and neighbors, we almost always find someone who questions the applicant’s acceptability for the position they are applying for. What type of reservations might people have about you? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 11. List all places where you have turned in an application for employment in the last 6 months: a. __________________________________________________________________________ Agency Full Address and Phone Number __________________________________________________________________________ Date Applied Status – If not hired, why not? b. __________________________________________________________________________ Agency Full Address and Phone Number __________________________________________________________________________ Date Applied Status – If not hired, why not? c. __________________________________________________________________________ Agency Full Address and Phone Number __________________________________________________________________________ Date Applied Status – If not hired, why not? d. __________________________________________________________________________ Agency Full Address and Phone Number __________________________________________________________________________ Date Applied Status – If not hired, why not? 35 e. __________________________________________________________________________ Agency Full Address and Phone Number __________________________________________________________________________ Date Applied Status – If not hired, why not? 12. Are there any incidents in your life or details not mentioned herein which may influence this agency’s evaluation of your suitability for employment? Yes ________ No ________ If yes, explain: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 13. How do you spend your spare time? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 14. What are your hobbies? ______________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 36 REFERENCES. List five persons who know you well enough to provide current information about you. DO NOT LIST RELATIVES, CURRENT ROOMMATES, GIRL/BOYFRIENDS, FIANCEE, FORMER EMPLOYERS OR FORMER SUPERVISORS WHO ARE ALREADY LISTED IN YOUR WORK HISTORY. 1. ___________________________________________________________________________ Name Complete Address ___________________________________________________________________________ Home Phone Work Phone ___________________________________________________________________________ Place of Employment ___________________________________________________________________________ Occupation Years Known 2. ___________________________________________________________________________ Name Complete Address ___________________________________________________________________________ Home Phone Work Phone ___________________________________________________________________________ Place of Employment ___________________________________________________________________________ Occupation Years Known 3. ___________________________________________________________________________ Name Complete Address ___________________________________________________________________________ Home Phone Work Phone ___________________________________________________________________________ Place of Employment ___________________________________________________________________________ Occupation Years Known 37 4. ___________________________________________________________________________ Name Complete Address ___________________________________________________________________________ Home Phone Work Phone ___________________________________________________________________________ Place of Employment ___________________________________________________________________________ Occupation Years Known 5. ___________________________________________________________________________ Name Complete Address ___________________________________________________________________________ Home Phone Work Phone ___________________________________________________________________________ Place of Employment ___________________________________________________________________________ Occupation Years Known I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statement and answers to questions. I am fully aware that any such willful misrepresentations, omissions or falsifications may be grounds for immediate rejections or termination of employment. ____________________________________________ ____________________ Signature of Applicant Date 38 Authority for Release of Information and Waiver I, ____________________________ do hereby authorize a review of full disclosure of all records concerning myself to any duly authorized agent of the City of Schertz, whether the said records are of a public, private or confidential nature. I understand that such request could result, directly or indirectly, in the release of negative information, any part of which could be included in my personal history profile. The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; financial or credit institutions, including records of loans; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me; the results of any polygraph examinations and the records and 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 have, or have had an interest. I hereby waive the attorney-client privilege of confidentiality for any attorney with whom I hold such privilege. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or part, upon its release authorization will be considered in determining my suitability for employment by the City of Schertz. I understand that all materials pertaining to this background investigation become the property of the City of Schertz and will not be returned to me. I also certify that any person(s) who may furnish such information concerning me shall not be held legally accountable for giving this information in anyway; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature. __________________________________ ______________________________ Full Name (Print, include maiden name) Date of Birth __________________________________ ______________________________ Address Social Security Number __________________________________ ______________________________ City/State/ Zip Code Phone (include area code) __________________________________ Signature of Applicant Subscribed and sworn to before me this ________ day of ___________________, _______. _____________________________________________