Alaska Form F 3 – Fill Out and Use This PDF

The Alaska F 3 form is a comprehensive Personal History Statement required by the Alaska Police Standards Council (APSC) for assessing the suitability of applicants for the position of an APSC Certified Officer. It demands meticulous attention to detail, requiring applicants to provide a wide array of personal information, from basic identification details to an extensive list of relatives and references. For anyone seeking to apply, it's imperative to ensure the accuracy and completeness of the form's information, as discrepancies can lead to disqualification. To assist with your application process, click on the button below to fill out your form.

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Alaska Form F 3 PDF Details

Fulfilling the Alaska F-3 Form is a crucial step for applicants aspiring to become APSC Certified Officers, a process governed by the Alaska Police Standards Council regulations. This comprehensive Personal History Statement aids in the background investigation pivotal in evaluating an applicant's suitability for the esteemed position. Applicants are urged to ensure they're working with the latest version of the form, available on the APSC website, and are reminded of their responsibility to furnish all requested information accurately and completely. It's not just about filling out a form; it's an act of integrity, as inaccuracies or omissions can be severely penalizing, often more so than some histories of prior misconduct. Intriguingly, the form is sensitively designed with respect to privacy, especially concerning medical or disability-related information, adhering to federal laws like the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act. The explicit and thorough instructions emphasize the need for honesty and transparency in the application process, thereby underscoring the form's role not just as a procedural requirement but as a foundational step in establishing trust and accountability in candidates vying to uphold law and order in Alaska.

Question	Answer
Form Name	Alaska Form F 3
Form Length	28 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min
Other names	alaska f3 form, apsc f 3 form, alaska police standards council, alaska 3 form

Form Preview Example

Alaska Police Standards Council

PO Box 111200

Juneau, Alaska 99811

Instructions to the Applicant

The information you provide in this Personal History Statement will be used in the background investigation to assist in determining your suitability for the position of an APSC Certified Officer, in accordance with Alaska Police Standards Council (APSC) regulations.

•Please confirm this version is the most current version by checking APSC website: https://dps.alaska.gov/APSC/Agency-Forms

•It is your responsibility to complete this form and provide all required information.

•If filling out hardcopy, please fill out form in blue or black ink or type as indicated by the agency. Do not use pencil.

•You must respond to all items and questions. If a question does not apply to you, write “N/A” (not applicable) in the space provided for your response.

•If you need more space for any response, use the last page of this form (page 27) and identify the additional information by the question number.

•Send the completed form to your background investigator or the agency to which you are applying. Do NOT send the form to APSC.

Disqualification

There are very few automatic bases for rejection. Even issues of prior misconduct, such as prior illegal drug use, driving under the influence, theft, or even arrest or conviction are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent job-relevant information from their prospective employer.

BOTTOM LINE: You are responsible for providing complete, accurate, and truthful responses.

Disclosure of Medically-Related Information

In accordance with the U.S. Americans with Disabilities Act, and the Genetic Information Nondiscrimination Act (GINA), applicants are not expected or required to reveal any medical or other disability-related information about themselves or their family members in response to questions on this form.

I have read and I understand the above instructions.

Signature: _________________________________________________ Date: ________________________

APSC Form F-3

Page 2

SECTION 1: PERSONAL

1.YOUR FULL NAME

LAST

FIRST

MIDDLE

2.OTHER NAMES YOU HAVE USED OR BEEN KNOWN BY (INCLUDE MAIDEN NAME AND NICKNAMES)

3.ADDRESS WHERE YOU LIVE

NUMBER / STREET

APT / UNIT

N/A

CITY

STATE

ZIP

4.MAILING ADDRESS, IF DIFFERENT FROM ABOVE (FOR EXAMPLE, PO BOX)

5.CONTACT NUMBERS

CELL	WORK	HOME	OTHER	TYPE:

6. CONTACT EMAIL		7. LIST ALL OTHER EMAIL ADDRESSES (SEPARATED BY COMMAS)

• Attach a copy of birth certificate or passport or if applicable certification of naturalization (mandatory)

8. CITIZENSHIP

Are you a U.S. citizen?	Yes	No
IF NATURALIZED, provide your certificate number and date, place, and court naturalized

9.BIRTH PLACE (CITY / COUNTY / STATE / COUNTRY) 10. BIRTHDATE (MM/DD/YYYY) 11. SOCIAL SECURITY NUMBER 12. DRIVER’S LICENSE

NUMBER:

STATE:

EXPIRES:

13. PHYSICAL DESCRIPTION			EYE COLOR:
HEIGHT:	WEIGHT:	HAIR COLOR:

13.1SCARS, MARKS, AND TATOOS (include removed or altered tatoos)

SECTION 2: RELATIVES AND REFERENCES

14.IMMEDIATE FAMILY

•Provide all applicable information in the spaces below. • Mark “Deceased,” if appropriate. Mark "N/A" if a category is not applicable

•If more spaced is needed, use Section 15 or continue on page 27 – reference corresponding numbers.

14.A	Spouse / Domestic Partner / Boyfriend / Girlfriend / Significant			Other		Deceased			N/A
NAME			HOME ADDRESS (NUMBER / STREET / APT)		CITY		STATE	ZIP

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY		STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

		DATE OF MARRIAGE/REGISTRATION	BIRTHDATE (MM/DD/YYYY)	Is there, or has there ever been, a civil or criminal restraining or stay-away
		(MM/YYYY)
		(MM/YYYY)		order in effect involving you and this individual?				Yes	No

14.B	Former Spouse/Domestic Partner/Significant Other or Boyfriend/Girlfriend dated longer than three months					Deceased			N/A
NAME			HOME ADDRESS (NUMBER / STREET / APT)		CITY		STATE	ZIP

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY		STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

		DATE OF MARRIAGE/REGISTRATION	BIRTHDATE (MM/DD/YYYY)
		DATE OF DISSOLUTION	BIRTHDATE (MM/DD/YYYY)	Is there, or has there ever been, a civil or criminal restraining or stay-away
		DATE OF DISSOLUTION
		(MM/YYYY)							No
		(MM/YYYY)		order in effect involving you and this individual?				Yes	No
		(MM/YYYY)

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SECTION 2: RELATIVES AND REFERENCES continued

14.C Parents / Guardians

List ALL parents/guardians, living or deceased, including biological, adoptive, foster, step-parents, in-laws, etc.

14.C.1 Parent / Guardian:	Mother	Father	Step-mother	Step-father	In-law		Other:		Deceased
NAME		HOME ADDRESS (NUMBER / STREET / APT)				CITY		STATE	ZIP

HOME PHONE

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE ZIP

WORK PHONE

CELL PHONE

14.C.2 Parent / Guardian:	Mother	Father	Step-mother	Step-father	In-law		Other:		Deceased
NAME		HOME ADDRESS (NUMBER / STREET / APT)				CITY		STATE	ZIP

HOME PHONE

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE ZIP

WORK PHONE

CELL PHONE

14.C.3 Parent / Guardian:		Mother	Father	Step-mother	Step-father	In-law		Other:

NAME			HOME ADDRESS (NUMBER / STREET / APT)				CITY

	HOME PHONE		MAILING ADDRESS (IF DIFFERENT)				CITY

Deceased

STATE ZIP

WORK PHONE

CELL PHONE


14.C.4 Parent / Guardian:		Mother	Father	Step-mother	Step-father	In-law		Other:		Deceased
NAME			HOME ADDRESS (NUMBER / STREET / APT)				CITY		STATE	ZIP

	HOME PHONE		MAILING ADDRESS (IF DIFFERENT)				CITY		STATE	ZIP

WORK PHONE

CELL PHONE

14.D Brothers / Sisters

List ALL LIVING siblings, including half-siblings, step-siblings, foster-siblings, etc.

N/A

14.D.1 Sibling:		Brother	Sister		Half-brother	Half-sister	Other:
NAME				AGE	HOME ADDRESS (NUMBER / STREET / APT)			CITY	STATE	ZIP

	HOME PHONE				MAILING ADDRESS (IF DIFFERENT)			CITY	STATE	ZIP

	WORK PHONE				CELL PHONE		EMAIL

14.D.2 Sibling:		Brother	Sister		Half-brother	Half-sister		Other:
NAME				AGE	HOME ADDRESS (NUMBER / STREET / APT)				CITY	STATE	ZIP

	HOME PHONE				MAILING ADDRESS (IF DIFFERENT)				CITY	STATE	ZIP

	WORK PHONE				CELL PHONE		EMAIL

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SECTION 2: RELATIVES AND REFERENCES continued

14.D.3

Sibling:

Brother

Sister

Half-brother

Half-sister

Other:

NAME

AGE

HOME ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP

WORK PHONE

CELL PHONE

14.D.4

Sibling:

Brother

Sister

Half-brother

Half-sister

Other:

NAME

AGE

HOME ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP

WORK PHONE

CELL PHONE

14.E Children

N/A

List ALL 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/guardian, if other than you.

14.E.1 Child:

Son

Daughter

Other:

Biological Parents:

NAME

AGE

CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

DATE OF BIRTH

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

14.E.2 Child:

Son

Daughter

Other:

Biological Parents:

NAME

AGE

CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

DATE OF BIRTH

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

14.E.3 Child:		Son	Daughter		Other:		Biological Parents:
NAME				AGE	CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

	DATE OF BIRTH				ADDRESS (NUMBER / STREET / APT)			CITY	STATE	ZIP

					CONTACT NUMBER	EMAIL

14.E.4 Child:		Son	Daughter		Other:		Biological Parents:

NAME				AGE	CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

	DATE OF BIRTH				ADDRESS (NUMBER / STREET / APT)			CITY	STATE	ZIP

					CONTACT NUMBER	EMAIL

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SECTION 2: RELATIVES AND REFERENCES continued

15.LIST OF REFERENCES

•List at least 5 people who know you well, such as close personal relationships, social and family friends, former spouses and significant others, teachers, military colleagues, and/or co-workers. Do NOT include relatives, employers, housemates, or any individuals listed elsewhere.

	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY
	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY
15.1

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY
				EMAIL
		WORK PHONE	CELL PHONE	EMAIL

STATE ZIP

How do you know this person?

How long have you known this person?

15.2	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP
15.2

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

How do you know this person?

How long have you known this person?

15.3	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP
	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP


		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

How do you know this person?

How long have you known this person?

15.4	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP
	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP


		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

		How do you know this person?			How long have you known this person?

15.5	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP
15.5

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

		How do you know this person?			How long have you known this person?

15.6

NAME OF REFERENCE

HOME ADDRESS (NUMBER / STREET / APT)

CITY

STATE ZIP

HOME PHONE

MAILING ADDRESS (NUMBER / STREET / SUITE)

CITY

STATE

ZIP

WORK PHONE

CELL PHONE

How do you know this person?

How long have you known this person?

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SECTION 2: RELATIVES AND REFERENCES continued
NAME OF REFERENCE	HOME ADDRESS (NUMBER / STREET / APT)	CITY	STATE	ZIP
15.7

HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

WORK PHONE	CELL PHONE	EMAIL

		How do you know this person?			How long have you known this person?

	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP
15.8

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

		How do you know this person?			How long have you known this person?

	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)		CITY	STATE	ZIP
15.9

		HOME PHONE	MAILING ADDRESS (NUMBER / STREET / SUITE)		CITY	STATE	ZIP

		WORK PHONE	CELL PHONE	EMAIL

		How do you know this person?			How long have you known this person?

15.10

NAME OF REFERENCE

HOME ADDRESS (NUMBER / STREET / APT)

CITY

STATE ZIP

HOME PHONE

MAILING ADDRESS (NUMBER / STREET / SUITE)

CITY

STATE ZIP

WORK PHONE

CELL PHONE

How do you know this person?

How long have you known this person?

SECTION 3: EDUCATION

•You will be required to furnish unopened official transcripts or other proof to support all of your educational claims before hire or certification.

•If more space is needed, continue your response on page 27.

16. CHECK APPLICABLE

MM/YYYY

High School Diploma:

MM/YYYY

GED:

WHAT LANGUAGE(S) DO YOU SPEAK?

17.LIST HIGH SCHOOL(S) ATTENDED

NAME OF HIGH SCHOOL

17.1

PUBLIC/PRIVATE OR HOMESCHOOL?

CITY

FROM (MM/YYYY)

TO (MM/YYYY)

STATE

NAME OF HIGH SCHOOL

17.2

PUBLIC, PRIVATE, OR HOMESCHOOL?

CITY

FROM (MM/YYYY)

TO (MM/YYYY)

STATE

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APSC Form F-3

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SECTION 3: EDUCATION continued

18.LIST ALL COLLEGES AND UNIVERSITIES ATTENDED

	NAME OF COLLEGE/UNIVERSITY		FROM (MM/YYYY)	TO (MM/YYYY)	TOTAL UNITS COMPLETED
18.1							QTR SYSTEM	SEM SYSTEM
							QTR SYSTEM	SEM SYSTEM
		ADDRESS (NUMBER / STREET)				TYPE OF DEGREE EARNED

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

18.2

NAME OF COLLEGE/UNIVERSITY

ADDRESS (NUMBER / STREET)

FROM (MM/YYYY)

TO (MM/YYYY)

TOTAL UNITS COMPLETED

QTR SYSTEM SEM SYSTEM TYPE OF DEGREE EARNED

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

18.3

NAME OF COLLEGE/UNIVERSITY

ADDRESS (NUMBER / STREET)

FROM (MM/YYYY)

TO (MM/YYYY)

TOTAL UNITS COMPLETED

QTR SYSTEM SEM SYSTEM TYPE OF DEGREE EARNED

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

18.4

NAME OF COLLEGE/UNIVERSITY

ADDRESS (NUMBER / STREET)

FROM (MM/YYYY)

TO (MM/YYYY)

TOTAL UNITS COMPLETED

QTR SYSTEM SEM SYSTEM TYPE OF DEGREE EARNED

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

19.LIST ALL TRADE, VOCATIONAL, AND BUSINESS SCHOOLS / INSTITUTES ATTENDED

19.1

NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE

CITY

FROM (MM/YYYY)	TO (MM/YYYY)	DID YOU COMPLETE THE COURSE?
		Yes	No
STATE TYPE OF SCHOOL OR TRAINING

19.2

NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE

CITY

FROM (MM/YYYY)	TO (MM/YYYY)	DID YOU COMPLETE THE COURSE?
		Yes	No
STATE TYPE OF SCHOOL OR TRAINING

20. Have you ever taken an Arrest and/or Firearms Course?				Yes	No
IF YES, provide the following information:

	A. COURSE PRESENTER NAME	LOCATION (CITY / STATE)

	B. COURSE COMPLETION			COMPLETION DATE (MM/YYYY)
	Did you successfully complete the course?	Yes	No

21. Have you ever attended a Basic Law Enforcement Academy: Police, Corrections, Probation/Parole, Village Police			......................	Yes	No
IF YES, provide the following information:

21.1

NAME OF ACADEMY

LOCATION (CITY, STATE)

FROM (MM/YYYY)

TO (MM/YYYY)

NAME OF TRAINING OFFICER / ACADEMY COORDINATOR

DID YOU PASS/GRADUATE?

Yes No

CONTACT NUMBER

21.2

NAME OF ACADEMY

LOCATION (CITY, STATE)

FROM (MM/YYYY)

TO (MM/YYYY)

NAME OF TRAINING OFFICER / ACADEMY COORDINATOR

DID YOU PASS/GRADUATE?

Yes No

CONTACT NUMBER

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SECTION 3: EDUCATION continued

22.Have you ever been subject to any disciplinary action, including academic probation, civil fine, suspension, expulsion, or resignation

from any high school(s), college/university, business, trade school, or basic course/academy?

Yes

IF YES, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school, educational institution, or basic course. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.

SECTION 4: RESIDENCE HISTORY

23.LIST OF RESIDENCES

•List all residences during the last 10 years or since age 15.

•Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit/apt number). Do NOT use PO 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 unless you shared individual quarters.

•If more space is needed, continue your response on page 27.

ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT)				FROM (MM/YYYY)	TO (MM/YYYY)
23.1					Present
					Present
CITY	STATE	ZIP	IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)				CONTACT NUMBER
CITY	STATE	ZIP	EMAIL
Name(s) of those with whom you live:
FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)	TO (MM/YYYY)
23.2
CITY	STATE	ZIP	IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)				CONTACT NUMBER
CITY	STATE	ZIP	EMAIL
Name(s) of those with whom you lived:
Reason for moving:
FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)	TO (MM/YYYY)
23.3
CITY	STATE	ZIP	IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)				CONTACT NUMBER
CITY	STATE	ZIP	EMAIL
Name(s) of those with whom you lived:
Reason for moving:

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APSC Form F-3					Page 9
SECTION 4: RESIDENCE HISTORY continued
FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)	TO (MM/YYYY)
23.4
CITY	STATE	ZIP	IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)				CONTACT NUMBER
CITY	STATE	ZIP	EMAIL
Name(s) of those with whom you lived:
Reason for moving:
FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)	TO (MM/YYYY)
23.5
CITY	STATE	ZIP	IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
MAILING ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER (NUMBER / STREET / APT / PO BOX)				CONTACT NUMBER
CITY	STATE	ZIP	EMAIL
Name(s) of those with whom you lived:
Reason for moving:

24.LIST OF HOUSEMATES

•Provide contact information for all housemates listed in Question 23 with whom you have resided during the past 10 years or since age 15.

•Do NOT list anyone for whom you have already provided contact information.

•If more space is needed, continue your response on page 27.

NAME OF HOUSEMATE		CONTACT NUMBER
24.1
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY	STATE	ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL
NAME OF HOUSEMATE		CONTACT NUMBER
24.2
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY	STATE	ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL
NAME OF HOUSEMATE		CONTACT NUMBER
24.3
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY	STATE	ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL
NAME OF HOUSEMATE		CONTACT NUMBER
24.4
CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY	STATE	ZIP
NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL

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SECTION 4: RESIDENCE HISTORY continued

24.5	NAME OF HOUSEMATE				CONTACT NUMBER
24.5

		CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY			STATE	ZIP

		NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL

	NAME OF HOUSEMATE				CONTACT NUMBER
24.6

		CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY			STATE	ZIP

		NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL

	NAME OF HOUSEMATE				CONTACT NUMBER
24.7

		CURRENT ADDRESS IF DIFFERENT (NUMBER / STREET / APT)	CITY			STATE	ZIP

		NATURE OF RELATIONSHIP (E.G., RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY, ETC.)		EMAIL


25. Have you ever been evicted or asked to leave a residence?							Yes	No

26. Have you ever left a residence with unpaid damage, owing rent, utilities, or other household expenses?							Yes	No


If you answered “YES” to Questions 25 and/or 26, explain (include when, where, and circumstances):

SECTION 5: EXPERIENCE AND EMPLOYMENT

27.JOB EXPERIENCE

•List ALL jobs you have had in last 10 years, including part-time, temporary, self-employment, and volunteer. (Begin with your most current.)

•If you have military experience, including guard or reserve duty, enter your military base, assignments, or unit of assignment. A separate block is used for each change of duty station and/or deployment.

•List ALL periods of unemployment in excess of 30 days. If more space is needed, continue your response on page 27.

•If you cannot locate the information, explain all efforts your have made to find it on page 27.

27.1

NAME OF CURRENT EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

JOB TITLE / RANK

DUTIES / ASSIGNMENTS

TYPE OF

EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS AND PHONE NUMBER

REASON FOR WANTING TO LEAVE

Is there any reason this employer may make negative statements about you if contacted?

Yes

IF YES, explain:

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SECTION 5: EXPERIENCE AND EMPLOYMENT continued

27.2

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

27.3

NAME OF EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

JOB TITLE / RANK

DUTIES / ASSIGNMENTS

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS AND PHONE NUMBER

REASON FOR LEAVING

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

FROM (MM/YYYY)

TO (MM/YYYY)

27.4

Student

Between jobs

Leave of absence

Travel

Other:

NAME OF EMPLOYER OR MILITARY UNIT				FROM (MM/YYYY)		TO (MM/YYYY)
27.5
ADDRESS (NUMBER / STREET / SUITE / OR BASE)			SUPERVISOR
CITY	STATE	ZIP	CONTACT NUMBER				EXT
JOB TITLE / RANK			EMAIL
DUTIES / ASSIGNMENTS		TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
		FT	PT	Temp	Self-employed		Volunteer
NAMES OF CO-WORKERS AND PHONE NUMBER		REASON FOR LEAVING

27.6

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

NAME OF EMPLOYER OR MILITARY UNIT			FROM (MM/YYYY)		TO (MM/YYYY)
27.7
ADDRESS (NUMBER / STREET / SUITE / OR BASE)		SUPERVISOR
CITY	STATE ZIP	CONTACT NUMBER				EXT
JOB TITLE / RANK		EMAIL
DUTIES / ASSIGNMENTS	TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
	FT	PT	Temp	Self-employed		Volunteer
NAMES OF CO-WORKERS AND PHONE NUMBER	REASON FOR LEAVING

27.8

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

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APSC Form F-3

Page 12

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

27.9

NAME OF EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

JOB TITLE / RANK

DUTIES / ASSIGNMENTS

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS AND PHONE NUMBER

REASON FOR LEAVING

27.10

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

FROM (MM/YYYY)

TO (MM/YYYY)

Student

Between jobs

Leave of absence

Travel

Other:

NAME OF EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

27.11

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

JOB TITLE / RANK

DUTIES / ASSIGNMENTS

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS AND PHONE NUMBER

REASON FOR LEAVING

27.12

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

NAME OF EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

27.13

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

JOB TITLE / RANK

DUTIES / ASSIGNMENTS

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS AND PHONE NUMBER

REASON FOR LEAVING

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

FROM (MM/YYYY)

TO (MM/YYYY)

27.14

Student

Between jobs

Leave of absence

Travel

Other:

Ver. 11/22/2019

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	APSC Form F-3						Page 13

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

27.15	NAME OF EMPLOYER OR MILITARY UNIT					FROM (MM/YYYY)		TO (MM/YYYY)
27.15

	ADDRESS (NUMBER / STREET / SUITE / OR BASE)				SUPERVISOR

	CITY	STATE	ZIP		CONTACT NUMBER				EXT

	JOB TITLE / RANK				EMAIL

	DUTIES / ASSIGNMENTS			TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
				FT	PT	Temp	Self-employed		Volunteer

	NAMES OF CO-WORKERS AND PHONE NUMBER			REASON FOR LEAVING

27.16

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

27.17	NAME OF EMPLOYER OR MILITARY UNIT					FROM (MM/YYYY)		TO (MM/YYYY)
	NAME OF EMPLOYER OR MILITARY UNIT					FROM (MM/YYYY)		TO (MM/YYYY)


	ADDRESS (NUMBER / STREET / SUITE / OR BASE)				SUPERVISOR

	CITY	STATE	ZIP		CONTACT NUMBER				EXT

	JOB TITLE / RANK				EMAIL

	DUTIES / ASSIGNMENTS			TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
				FT	PT	Temp	Self-employed		Volunteer

	NAMES OF CO-WORKERS AND PHONE NUMBER			REASON FOR LEAVING

27.18

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

	NAME OF EMPLOYER OR MILITARY UNIT					FROM (MM/YYYY)		TO (MM/YYYY)
	NAME OF EMPLOYER OR MILITARY UNIT					FROM (MM/YYYY)		TO (MM/YYYY)
27.19

	ADDRESS (NUMBER / STREET / SUITE / OR BASE)				SUPERVISOR

	CITY	STATE	ZIP		CONTACT NUMBER				EXT

	JOB TITLE / RANK				EMAIL

	DUTIES / ASSIGNMENTS			TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)
				FT	PT	Temp	Self-employed		Volunteer

	NAMES OF CO-WORKERS AND PHONE NUMBER			REASON FOR LEAVING

	PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)					FROM (MM/YYYY)	TO (MM/YYYY)
	PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)					FROM (MM/YYYY)	TO (MM/YYYY)
27.20	Student	Between jobs	Leave of absence	Travel	Other:
	Student	Between jobs	Leave of absence	Travel	Other:

27.3 Please list your hobbies and sports, include your length of participation and level of proficiency:

Ver. 11/22/2019

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APSC Form F-3

Page 14

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

28.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

29.	Have you ever been fired, released from probation, or asked to resign from any place of employment?			Yes	No

30.	Were you ever involved in a physical/verbal altercation with a supervisor, co-worker, or customer?			Yes	No

31.	Have you ever quit without giving notice?			Yes	No

32.	Have you ever resigned in lieu of termination?			Yes	No

33.	Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.)				No
	by a co-worker, superior, subordinate or customer?			Yes	No

34.	Were you ever the subject of a written complaint at work?			Yes	No

35.	Have you ever been counseled at work due to lateness or absences?			Yes	No

36.	Did you ever receive an unsatisfactory performance review?			Yes	No

37.	Have you ever sold, released, given away, or used for your own purposes legally confidential information?			Yes	No

38.	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? _		_ Days

39.	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?
40.	Has your work performance ever been affected by your use of alcohol or drugs?			Yes	No
	IF YES, when?	Name of employer:

41.	In the past three years, have you been warned by an employer about your drinking or drug habits and their impact				No
	on your performance?			Yes	No
	IF YES, when?	Name of employer:

41.1Have you taken any money or items from a work place or other place (this includes from siblings, parents, friends, businesses,

or other entities, etc.)		Yes		No

If you answered “YES” to any of Questions 28–41.1, explain (include when, where, and circumstances (value if applicable) – reference corresponding numbers).

Ver. 11/22/2019

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APSC Form F-3	Page 15

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

42. Have you ever applied for any position at a law enforcement or corrections agency (city, county, state, village/tribal, or federal)? Yes		No

•If you answered “YES” to Question 42, 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 27.

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

42.1

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

42.2

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

42.3

ADDRESS (NUMBER / STREET)

BACKGROUND

INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

Ver. 11/22/2019

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APSC Form F-3

Page 16

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

42.4

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

42.5

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

42.6

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

42.7

NAME OF LAW ENFORCEMENT OR CORRECTIONS AGENCY

DATE APPLIED (MM/YYYY)

ADDRESS (NUMBER / STREET)

BACKGROUND

INVESTIGATOR’S NAME (IF KNOWN)

CITY

STATE

ZIP

CONTACT NUMBER

EXT

POSITION APPLIED FOR

CHECK EACH STEP IN THE PROCESS THAT YOU COMPLETED, AND YOUR STATUS:

STEP:

Application

Written

Physical Ability

Oral

Polygraph/CVSA

Background

Chief’s Oral

Conditional Offer

STATUS:

Hired

On Eligibility List

Withdrawn

List Expired

Disqualified, Reason:

42.8

Have you ever applied for certification or been certified as a law enforcement officer?

Yes

If yes, list name and location of certification authority, date of issue, and date of expiration (if applicable).

42.9

Have you ever had a law enforcement certification revoked, suspended, or have been disqualified for certification?

Yes

If yes, state name of certification authority, date of decision, and reason(s).

Ver. 11/22/2019

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APSC Form F-3

Page 17

SECTION 6: MILITARY EXPERIENCE

•You will be required to furnish your DD-214, NGB-22, or other proof to support all your military claims.

43.	Are you required to register for the Selective Service?	Yes	No
	IF YES, and you have registered, provide your Selective Registration number and date of registration:
	IF NO, explain:

44.	Have you ever attempted to enlist or served in the military?	Yes	No

45.	If you answered “YES” to Question 44, include the following service information:

BRANCH OF SERVICE

FROM (MM/YYYY)

TO (MM/YYYY)

TYPE OF DISCHARGE
Entry Level	Honorable	General	OTH (Other than Honorable)	Bad Conduct	Dishonorable
Separation Code (1–4) if applicable – refer to your DD-214:

If denied entry, declined, or otherwise disallowed from enlistment, list reason:

46.Are you currently participating in one of the following?

Military Reserve

National Guard

IF CHECKED, date obligation ends (MM/DD/YY):

47.Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s mast,

	office hours, article 15, company punishment, counseling statement)?	Yes	No

48.	Were you ever denied a security clearance, or had a clearance revoked, suspended, or downgraded?	Yes	No

49.	Have you ever taken military property without permission for personal use, to sell, or to give away?	Yes	No

	If you answered “YES” to any of Questions 47–49, explain (include dates and circumstances).

SECTION 7: FINANCIAL

50.INCOME AND EXPENSES

•For each of the following questions (50A, B, C), fill in the amounts to the nearest dollar.

•For Question 50C: Estimate your monthly living expenses. Include housing, utilities, credit cards or other loan payments, food, gas and car maintenance, entertainment, etc., as well as any other obligations you may have.

		A) From your employer(s), what is your take-home monthly income?		$	per month

		B) Do you have other sources of income? (IF YES, fill in amount and explain.)	Yes	No $	per month
		Explain:

		C) How much do you spend each month?		$	per month


51.	.........................................................................................Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)?				Yes	No

52.	Have any of your bills ever been turned over to a collection agency?				Yes	No

53.	Have you ever had purchased goods repossessed?				Yes	No

54.	Have your wages or Alaska permanent fund dividend ever been garnished?				Yes	No

55.	Have you ever been delinquent on income or other tax payments?				Yes	No

56.	Have you ever failed to file income tax or cheated/lied on an income tax form?				Yes	No

Ver. 11/22/2019

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	APSC Form F-3	Page 18
F-3: PERSONAL HISTORY STATEMENT – APSC Officer

SECTION 7: FINANCIAL continued
57.	Have you ever had an employment bond refused?	Yes	No

58.	Have you ever avoided paying any lawful debt by moving away?	Yes	No

59.	Have you ever defaulted on (failed to pay) a loan or failed to pay any citation/ticket?	Yes	No

60.	Have you ever borrowed money to pay for a gambling debt?	Yes	No
	If yes, do you currently have any outstanding debts as a result of gambling?	Yes	No

61.	Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)?	Yes	No

62.	Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)?	Yes	No

63.	Have you written three or more bad checks (including insufficient fund checks or on a closed account) in a one-year period?	.... Yes	No

If you answered “YES” to any of Questions 51–63, explain (include when, where, and why – reference corresponding numbers).

SECTION 8: LEGAL

Disclosure of Arrests and Convictions

•This section requires you to report detentions, arrests, and convictions, including diversion programs, suspended imposition of sentences, and offenses that may have been pardoned or expunged. As an officer applicant, you are required to disclose this information.

•If more space is needed, continue your response on page 27.

64.Have you EVER been detained by law enforcement for investigation, arrested, indicted, charged, or convicted of any misdemeanor or felony offense in this state or any other legal jurisdiction (including offenses in the Uniform Code

of Military Justice)?	Yes	No
IF YES, explain each incident:

64.1

CHARGE

EXPLANATION AND DISPOSITION

APPROX DATE (MM/YYYY)

ARRESTING OR DETAINING AGENCY

64.2

CHARGE

EXPLANATION AND DISPOSITION

APPROX DATE (MM/YYYY)

ARRESTING OR DETAINING AGENCY

Ver. 11/22/2019

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APSC Form F-3

Page 19

SECTION 8: LEGAL continued

64.3

CHARGE

EXPLANATION AND DISPOSITION

APPROX DATE (MM/YYYY)	ARRESTING OR DETAINING AGENCY

65. Have you ever been placed on court probation or parole?

Yes

66.Were you ever required to appear before a juvenile court for an act which would have been a crime if

committed as an adult?

Yes

67.Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity,

	support, etc.)?	Yes	No

68.	Have the police ever been called to your home for any reason?	Yes	No

69.	Have you or your spouse/partner ever been referred to Child Protective Services?	Yes	No

70.	Have you ever been the respondent of an emergency protective order/restraining order/stalking/stay-away order?	Yes	No

71.Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf was required

to make payment to the other party?

Yes

72.Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or other state

or federal assistance?

Yes

73.Have you ever been required to repay any welfare payments, unemployment compensation, Alaska permanent fund

dividend, or other state or federal assistance?	Yes	No

74. Have you ever filed a false insurance or workers’ compensation claim?	Yes	No

If you answered “YES” to any of Questions 65–74, explain (include court case or document, dates, and circumstances – reference corresponding numbers).

Involvement in Criminal Acts – Part 1

75.Have you committed any of the following acts at any time in your life?

•You MUST include any acts committed at any time after you were first employed in law enforcement, including as a reserve officer, Police Explorer/Police Cadet.

•NOTE: You may NOT withhold any information regarding your involvement in any of the following acts, even if federal or state law relieved you from reporting the detention, arrest, or conviction that arose from it.

75.1	.................................................................................................................................................Animal abuse and/or neglect	Yes	No

75.2	Annoying, obscene, or harassing contacts by telephone or other electronic communication device; including “sexting”		No
75.2	or sending/receiving/sharing personally intimate photos of self or others	Yes
		Yes

Ver. 11/22/2019

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	APSC Form F-3	Page 20

SECTION 8: LEGAL continued
	Assault, Battery (use of force or violence upon another or placing another in fear),or accused of assault or battery		Yes	No
75.3			Yes	No

75.4	..........................................................Brandishing a weapon or discharging a firearm in violation of city, state, or federal laws		Yes	No

75.5	........................................................................................................................Carrying a concealed weapon without a permit		Yes	No

75.6	.............................................................................................................................Contributing to the delinquency of a minor		Yes	No

75.7	Defrauding an innkeeper or theft of services (not paying for food, a room at a hotel/motel or campground, or taxi service)	...	Yes	No

75.8	.............................................................................Driving or operating a vehicle under the influence of alcohol and/or drugs		Yes	No

75.9	...............................................Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself)		Yes	No

75.10	......................................................................................................................................................Filing a false police report		Yes	No

75.11	..................................................................................................................................................Hit & run collision (no injuries)		Yes	No

75.12	........................................................................................................................................................................Illegal gambling		Yes	No

75.13	............................................................................Illegal hunting and/or fishing (for example, without a license, out of season)		Yes	No

75.14	.............................................................................................Impersonating a peace officer (pretending to be a police officer)		Yes	No

75.15	................................................................................................................Indecent exposure and/or lewd or obscene conduct		Yes	No

75.16	..............................................................................................................................................Intentionally writing a bad check		Yes	No

75.17	.........................................................................................Joyriding (using a car or other vehicle without owner’s permission)		Yes	No

75.18	........Peeping (including, but not limited to, looking through a window or opening with the intent to invade someone’s privacy)		Yes	No

75.19	..................................................................................Petty theft (value up to $250, including shoplifting/switching price tags)		Yes	No

75.20	....................................................................................................................Possession or consumption of alcohol as a minor		Yes	No

75.21	......................................Possession of falsified or altered identification, including use of another person’s ID (for any reason)		Yes	No

75.22	...................................................Possession of stolen property (including, but not limited to, vehicles, credit/debit cards, etc.)		Yes	No

75.23	Prostitution or solicitation of prostitution (including, but not limited to, patronizing illegal massage parlors; include legalized			No
75.23	prostitution, whether inside the U.S. or not)		Yes
	prostitution, whether inside the U.S. or not)		Yes
75.24	.......................................................................................................................................................................Reckless driving		Yes	No

75.25	.......................Resisting arrest and/or delaying or obstructing an officer (including, but not limited to, running from the police)		Yes	No

75.26	.............................................................................................................................................................................Trespassing		Yes	No

75.27	..............................................Vandalism (including, but not limited to, “tagging,” malicious mischief, and/or property damage)		Yes	No

75.28	.............................................................................................................................Any other act amounting to a misdemeanor		Yes	No

•If you answered “YES” to ANY of the item(s) in Question 75, fully explain circumstances, including dates, names of individuals involved, and resolution. Reference the corresponding number (e.g., 75.5) for each explanation.

•If more space is needed, continue your response on page 27.

Ver. 11/22/2019

Initial here to verify you have provided complete and accurate information:

APSC Form F-3

Page 21

SECTION 8: LEGAL continued

Involvement in Criminal Acts – Part 2

76.At any time in your life, have you EVER committed any of the following acts?

NOTE: You may NOT withhold any information regarding your involvement in any of the following acts, even if federal or state law relieved you from reporting the detention, arrest, or conviction that arose from it.

76.1	.........................................................................................................Arson (intentionally destroying property by setting a fire)	Yes	No

76.2	Felony Assault (struck or threatened to strike someone with an instrument likely to cause great bodily	Yes	No
76.2	injury or death, caused a person injury by using a dangerous instrument, or been accused of felony assault?

76.3	............................................................................................................................................................Blackmail or extortion	Yes	No

76.4	..................................................................................Burglary (entering a structure or vehicle to commit theft or other crime)	Yes	No

76.5	.....................................................Child molestation (performing unlawful acts with a child, inappropriate touching of a child)	Yes	No

76.6	.............................................................................................................Elder abuse and/or neglect (physical and/or financial)	Yes	No

76.7	........................................................................................Embezzlement (theft of money or other valuables entrusted to you)	Yes	No

76.8	................................................................................................................................................................Felony drunk driving	Yes	No

76.9	....................................................................Rape (including sexual contact, penetration without consent, or statutory rape)	Yes	No

76.10	...............................................................Forgery (falsifying any type of document, check certificate, license, currency, etc.)	Yes	No

76.11	.....................................................................................................Fraudulent use of a credit, ATM, debit, and/or check card	Yes	No

76.12	................................................................................................................................Theft (value of over $250, or any firearm)	Yes	No

76.13	............................................................................................................................................................Hit & run (with injuries)	Yes	No

76.14	.............................................................................................................................................................................Hate crime	Yes	No

76.15	........................................................................................................................................................................Illegal sex acts	Yes	No

76.16	.....................................................................................................................................................................Insurance fraud	Yes	No

76.17	.........................................................................................................Murder, homicide, manslaughter, or attempted murder	Yes	No

76.18	........................................................................................................................................................Perjury (lying under oath)	Yes	No

76.19	......................................................................................................................Possession of an explosive/destructive device	Yes	No

76.20	........................................................................................Robbery (theft from another person using a weapon, force, or fear)	Yes	No

76.21	...................................................................................................................................................................................Stalking	Yes	No

76.22	.....................................................................................................................................Theft of a vehicle and/or vehicle parts	Yes	No

76.23	..................................................................Viewing and/or possessing child pornography (including distributing or creating)	Yes	No

76.24	................................................................................Bigamy or Polygamy, married to more than one person at the same time	Yes	No

76.25	......................................................................................................................................Any other act amounting to a felony	Yes	No

76.26	Have you ever been an inmate or resident in any type of correctional institution (halfway house, jail, prison, juvenile center,	Yes	No
	etc)?

Ver. 11/22/2019

Initial here to verify you have provided complete and accurate information:

APSC Form F-3

Page 22

SECTION 8: LEGAL continued

•If you answered “YES” to ANY of the item(s) in Question 76, fully explain circumstances, including dates, names of individuals involved, and resolution. Reference the corresponding number (e.g., 76.3) for each explanation.

•If more space is needed, continue your response on page 27.

Illegal Use of Drugs

•For the purpose of responding to the following questions, “illegal drugs” include the unauthorized or illegal use of prescription medications

or over-the-counter drugs; the illegal use of “controlled substances,” and includes the illegal use of any substance for the purpose of getting “high.”

•Your responses should include — but not be limited to — your use of any of the following:


 Amphetamines / Methamphetamines (Uppers, Speed, Crank, etc)	 Marijuana (with or without a prescription)
 Barbiturates (Downers)	 Mescaline
 Cocaine / Crack Cocaine	 Morphine
 Designer Drugs (Ecstasy, Synthetic Heroin, Spice, etc.)	 PCP / Angel Dust
 GHB (Date Rape Drug)	 Quaaludes
 Hallucinogens (Peyote, LSD, Mushrooms)	 Steroids
 Hashish / Hashish Oil	 Tetrahydrocannabinal (THC)
 Heroin / Opium	 Glue, paint, or any substance containing toluene

77. Within the past twelve months, have you used any drug(s) indicated above or any other illegal substances?		Yes	No
IF YES, give details including drug(s) used, most recent date used, and circumstances:

78.Prior to the past twelve months:

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 YOU CHECKED BOX 2, give details including drug(s) used, most recent date used, and circumstances:

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APSC Form F-3

Page 23

SECTION 8: LEGAL continued

79.Have you EVER engaged in any of the activities listed below involving drugs, narcotics or illegal substances, including marijuana and/or prescription drugs without a prescription, and the licensed cultivation, manufacture, transportation, or sale of marijuana or marijuana products:

Sold

Manufactured

Delivered

Purchased

Given

Furnished

Cultivated

Transported

Held for Another

IF ANY ITEM IS CHECKED, give details including drug(s) involved, over what time period(s), and circumstances.

80.During the past five years, have you associated with friends, acquaintances, housemates, or family members who

have illegally used drugs or narcotics, and/or illegally used prescription medications?	Yes	No
IF YES, explain:_

SECTION 9: MOTOR VEHICLE OPERATION

81.Current Driver’s License:

STATE OF ISSUE LICENSE NUMBER

EXPIRATION DATE (MM/DD/YYYY)

NAME UNDER WHICH LICENSE WAS GRANTED

82.List other states where you have been licensed to operate a motor vehicle:

STATE OF ISSUE LICENSE NUMBER (IF KNOWN)

TYPE OF LICENSE

NAME UNDER WHICH LICENSE WAS GRANTED

83. Have you ever been refused a driver’s license by any state?	Yes	No
IF YES, explain (include when, where, and circumstances):

84. Has your driver’s license ever been suspended or revoked?	Yes	No
IF YES, explain (include when, where, and circumstances):

85.List your current liability insurance on your vehicle(s).

85.1

TYPE OF COVERAGE

Insured

INSURANCE COMPANY

Bonded

Cash Deposit

VEHICLE MAKE

POLICY NUMBER

YEAR (YYYY)

VEHICLE LICENSE

EXPIRATION DATE (MM/DD/YYYY)

ADDRESS (NUMBER/STREET)

CITY

STATE ZIP

CONTACT NUMBER

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APSC Form F-3

Page 24

SECTION 9: MOTOR VEHICLE OPERATION continued

	TYPE OF COVERAGE		VEHICLE MAKE
85.2	Insured	Bonded	Cash Deposit
	Insured	Bonded	Cash Deposit
	INSURANCE COMPANY		POLICY NUMBER

YEAR (YYYY)

VEHICLE LICENSE

EXPIRATION DATE (MM/DD/YYYY)

ADDRESS (NUMBER/STREET)

CITY

STATE ZIP

CONTACT NUMBER

85.3

TYPE OF COVERAGE

VEHICLE MAKE

YEAR (YYYY)

VEHICLE LICENSE

Insured

Bonded

Cash Deposit

INSURANCE COMPANY

POLICY NUMBER

EXPIRATION DATE (MM/DD/YYYY)

ADDRESS (NUMBER/STREET)

CITY

STATE

ZIP

CONTACT NUMBER

86. List ALL violation citations (including traffic tickets) you have received within the past seven years,

regardless if they were reduced or expunged.

86.1

NATURE OF VIOLATION

LOCATION (STREET)

CITY

STATE

DATE VIOLATION OCCURRED (MM/YYYY)

ACTION TAKEN

Not Guilty

Fined

Traffic School

Dismissed

86.2

NATURE OF VIOLATION

LOCATION (STREET)

CITY

STATE

DATE VIOLATION OCCURRED (MM/YYYY)

ACTION TAKEN

Not Guilty

Fined

Traffic School

Dismissed

86.3

NATURE OF VIOLATION

LOCATION (STREET)

CITY

STATE

DATE VIOLATION OCCURRED (MM/YYYY)

ACTION TAKEN

Not Guilty

Fined

Traffic School

Dismissed

87.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:

..................................................88. Have you been involved as the driver in a motor vehicle accident within the past seven years?							Yes	No
IF YES, give details below.

	DATE OF ACCIDENT (MM/YYYY)		LOCATION (STREET)	CITY				STATE
88.1

	POLICE REPORT		LAW ENFORCEMENT AGENCY AND CASE/INCIDENT NUMBER	AT FAULT?		WAS THE ACCIDENT?
	Yes	No		Yes	No	Injury	Non-injury

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	APSC Form F-3					Page 25

SECTION 9: MOTOR VEHICLE OPERATION continued
	DATE OF ACCIDENT (MM/YYYY)		LOCATION (STREET)	CITY				STATE
88.2

	POLICE REPORT		LAW ENFORCEMENT AGENCY AND CASE/INCIDENT NUMBER	AT FAULT?		WAS THE ACCIDENT?
	Yes	No		Yes	No	Injury	Non-injury

88.3	DATE OF ACCIDENT (MM/YYYY)		LOCATION (STREET)	CITY				STATE
88.3

	POLICE REPORT		LAW ENFORCEMENT AGENCY AND CASE/INCIDENT NUMBER	AT FAULT?		WAS THE ACCIDENT?
	Yes	No		Yes	No	Injury	Non-injury

89.Have you ever driven a vehicle without being lawfully licensed and/or without having auto insurance, as required by

law?			Yes
	IF YES, GIVE REASON	FROM (MM/YYYY)	TO (MM/YYYY)

90. Have you ever been refused automobile liability insurance or a bond, or had them cancelled?

Yes

IF YES, GIVE REASON

DATE (MM/YYYY)

INSURANCE COMPANY

SECTION 10: OTHER TOPICS

91. Have you ever been issued, refused, or required to relinquish a permit to carry a concealed weapon?

Yes

92.Are you now, or have you ever been, a member or associate of 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

93.	Have you ever hit or physically overpowered a spouse or romantic partner?	Yes	No

94.	Since the age of 15, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act?	Yes	No

95.Are you now, or have you ever been, a member or affiliated with any organization or association which advocated the overthrow of the United States government by force, violence, or other unconstitutional means, or which has the policy of advocating or approving acts of force or violence to deny

other persons their rights under the Constitution of the United States or of this state?	Yes	No

95.1 Have you ever pushed, punched, slapped, shoved, threatened, or injured someone or been injured yourself, in a domestic violence incident?
	Yes	No

If you answered “YES” to any of Questions 91–95.1, give details including dates and circumstances – reference corresponding numbers).

Ver. 11/22/2019

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APSC Form F-3	Page 26

SECTION 11: CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION
96. I,	authorize release of all information pertaining to me from the records of credit bureaus, educational

institutions, military services, law enforcement agencies and present and past employers, to my prospective employer and the Alaska Police Standards Council. I also authorize the Alaska Police Standards Council to release to any law enforcement agency, information which the council obtains regarding my qualifications to be a police, corrections, probation/parole, village police, or municipal corrections officer.

I hereby certify that I have personally completed and initialed each page of this form and any attached supplemental page(s), and that all statements made are true and complete to the best of my knowledge and belief. I understand that any misstatement of material fact may subject me to disqualification; or, if I have been appointed, may disqualify me from continued employment.

I further agree and consent in advance to being summarily discharged without cause or hearing if any of the information that I have provided contains any misrepresentation or falsification or if any requested information has been knowingly omitted. I acknowledge that information on this form will be used by the council to determine my eligibility and qualifications for employment, training, and certification.

A photocopy or electronic copy of this authorization is as valid as the original.

This authorization does not expire unless the Alaska Police Standards Council is notified in writing.

I swear and affirm, under penalty of Perjury (AS 11.56.200) and/or Unsworn Falsification (AS 11.56.210), that the information provided in this Personal History Statement is true and accurate to the best of my knowledge.

Done aton the day of, _.

(City), (State)

______________________________________

Applicant

Sworn and Subscribed before me
This	day of	,	.

_______________________________________

Notary Public in and for the state of ___________

My commission expires ____________________

Use the following page to continue any of your responses. Be sure to reference corresponding numbers.

Ver. 11/22/2019

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APSC Form F-3

Page 27

ADDITIONAL COMMENTS

•Use this space to provide information that does not fit elsewhere on this form (e.g., additional family members, schools, residences, employers, explanations to questions, etc.). Reference the corresponding questions and/or specific items.

•You may print copies of this page as needed. If you are filling in this page online, continue on the next page.

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APSC Form F-3

Page 28

ADDITIONAL COMMENTS

•This page is a continuation of page 27.

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