Apd 5 – Fill Out and Use This PDF

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POLICE DEPARTMENT

APD-5

CITY OF NEW YORK

Personal History of: ,

Applicant for appointment as: Police Officer

Exam Number:

List Number:

Social Security No.:

APPLICANT PROCESSING DIVISION

INSTRUCTIONS FOR THE ONLINE PERSONAL HISTORY QUESTIONNAIRE

(APD-5 BOOKLET)

The following is a list of instructions, information and documents that an eligible candidate for the position of New York City Police Officer should have available to them prior to registering and obtaining a password on the website to complete the online Personal History Questionnaire (APD-5 Booklet). The documents listed will be presented to your investigators at the first initial interview when the investigation process commences.

Birth Certificate - an official copy with a raised seal. If no record of your birth is on file at the Department of Health or the Bureau of Vital Statistics of the State in which you were born, obtain a statement from the agency attesting to the fact.

Name Change – obtain records of name change, if applicable.

Naturalization Certificate – foreign born candidates. Police Officers must be U.S. Citizens at the time of appointment.

High School Diplomas, High School Equivalency Diploma, or Armed Forces GED Certificate (the record of scores you obtained in the individual tests must be presented), Diplomas and Degrees from Colleges attended. Official Transcripts from all colleges you attended either part time or full time must be obtained.

Marriage Certificate – if married. Certificate must be issued by a governmental agency. Birth Certificates of Children – if any.

Registered Domestic Partnership or Civil Union - Certificate must be issued by a governmental Agency.

Divorce - records of divorce, annulment or legal separation, if applicable.

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Social Security Card - A Detail Earnings Report for a fee obtained from the Social Security Administration for the employments you had since leaving high school is required.

Motor Vehicle Driver’s License – Certificate of Motor Vehicle Registration – for any vehicle owned by you or your spouse. A DMV abstract from the Department of Motor Vehicles would be helpful for summons records.

Selective Service Registration - and classification cards (male candidates only) to register, obtain or check on a registration via the internet go to www.sss.gov.

Original Discharge or Separation papers for all military service (DD214 member 4 page).

W-2 Forms - Withholding tax certificates and copies of income tax returns for the past five years (especially for self employment).

Employments – all dates of employments and contact information since leaving high school (Detailed Social Security Earnings Report).

Unemployment – all dates of unemployment since leaving high school with a notarized letter obtained from persons other than yourself stating that they financially supported you.

Disability Benefits – Worker’s Compensation – provide all records.

Membership Cards – all labor union, fraternal or social organizations to which you belong.

Debts – Judgments – Garnishees – provide all records.

Proof of Residence – two (2) proofs of residence (rent stub, utility bill, etc. for current address).

Court Dispositions – transcripts and/or dispositions from the Court Clerk of the court of trial for any arrest in which you were the defendant. Proof of payment for any summonses you received (other than traffic summonses).

Licenses – any licenses held by you (both past and present) from a government agency (pistol, rifle, hack, liquor, etc.).

DISCLOSURE NOTICE

This is an acknowledgement that the information provided above has been read, reviewed and understood by the candidate completing the Personal History Questionnaire. The items and documents listed above will ensure that you have access to authentic and accurate information for the processing of your investigation. Failure to truthfully disclose authentic, accurate information and/or presenting false documentation can result in your disqualification from the investigation process of becoming a New York City Police Officer.

Agree Disagree

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I. Personal Data

b. List below any other name, alias, or nickname by which you have ever been known (including maiden name, if you are a married female) with reason for such use:

N/A

c. Do you have any tattoos, brands, body piercings, or other body art? null

If yes, include the location and complete description, including symbolized meaning, and reason for getting same: N/A

5. Citizenship: Citizen of the U.S.A.? null

a. What country were you born in? Not Available

b. If not born in the U.S.A., date entered U.S.A.: N/A

c. Are you a naturalized citizen of the U.S.A.? null

d. Do you have a dual citizenship with another country? null

If yes, what country? Not Available

When was it obtained? N/A

How was it obtained? N/A

6. Do you have a U.S. Resident Alien Card? null

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If yes, how was it obtained? (Lottery, etc.)

N/A

Expiration Date: N/A

Alien Registration No.: N/A

7. Do you now have, or have you ever had a US passport? null

a. Have you ever reported a passport lost or stolen? null

If yes, describe the circumstances of the loss to include the date, location, and police report number.

b. Do you now have or have you ever had a foreign passport? null

c. Have you ever applied for a travel visa to travel to or from another country? null

d. Has a visa ever been denied? null

8. Have you traveled to countries outside of the U.S.A.? null

If yes, what countries outside of the U.S.A. have you traveled to? Include dates and how long you were in the country:

9.Marital Status: null

Spouse/Registered Domestic Partner(s):

Initial here to indicate that you have provided complete and accurate information for this section:_____________

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II. Residence Record

10.Starting with your present address and working back, list each address (including temporary addresses) at which you have resided. Please include military and college (campus and/or off-campus) addresses. All foreign addresses must be included:

a. Do you own or co-own any Real Estate?: null

b. All Residence telephone number(s) ever used: (Area Code)____-_________

c. All Cell phone number(s) ever used: (Area Code) ____-_________ N/A

d. All email address(es) ever used: N/A

e. Do you have an account on a social networking website, such as MySpace, Facebook, or Twitter? null

If yes, indicate address(es): N/A

Initial here to indicate that you have provided complete and accurate information for this section:_____________

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III. Family Record

11. Do you have any children? null

If yes, list below all of your living or deceased children, including natural, adopted, and/or foster care. Include any other children who have ever resided with you. Provide the name and contact information of the other parent or guardian:

a. What provisions have you made for the support of the children listed above? N/A

b. Do any of your children receive child support or other supportive income? (Social Security, disability, etc.)?

null

If yes, explain:

N/A

Initial here to indicate that you have provided complete and accurate information for this section:_____________

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IV. Family Record and References

12.List the full names of biological mother and father; stepmothers/ stepfathers; grandfathers; grandmothers; father-in-law; mother-in-law, living or deceased. The complete address for each must be listed (include city and state):

12a. List the full names of all biological brothers and sisters; half-brothers/half-sisters; stepbrothers/stepsisters; uncle; aunt; great aunt; great uncle; first cousin; nephew; niece; fiancé or fiancée, living or deceased:

12b. List any person(s) who has (have) ever resided with you, whether they are related to you or not (include females’ maiden names). The complete address for each must be listed (include city and state):

12c. List 5-6 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere:

Initial here to indicate that you have provided complete and accurate information for this section:_____________

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V. Foreign Contacts

13. a. Do you speak, read, write, or understand a foreign language? null

If yes, list language(s) and educational level of proficiency:

N/A

b. How often is each language used? N/A

c. With whom is each language used? N/A

d. Is this person inside or outside of the United States? null

If outside, list country:

N/A

VI. Education Record

14.List all schools, including foreign schools you have attended beginning with the 9th grade:

a. List any other schools attended, including but not limited to, trade, vocation, business, professional and occupational licenses, training courses, internships, certificate programs, etc. List the dates of attendance:

N/A

b. High school diploma from an accredited U.S. Institution? null

G.E.D.?

null

If yes, enter information below:

G.E.D.-Issuing State: NA

Date Issued: N/A

Other: N/A

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c. Were you ever the subject of any disciplinary action at any educational institution which you attended?

null

If yes, explain (School name, disposition date, etc.):

N/A

Initial here to indicate that you have provided complete and accurate information for this section:_____________

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VII. Employment Record

15.Have you ever been fired or suspended from any job, or has any form of disciplinary action been taken against you by any employer?

null

If yes, explain: N/A

a. List below, starting with your current employment, or unemployment – and working back, each period of employment and unemployment you have had. Include within the sequence any period of active military service. If you were discharged from any employment, or asked to resign, so state under “Reason for leaving employment”. DO NOT LEAVE ANY TIME PERIODS UNACCOUNTED FOR.

16.If you listed any period(s) of unemployment, state how you were supported during that time:

N/A

17.Are you currently employed by the New York City Police Department?

null

If yes, enter information below:

Current Title: N/A

Supervisor's Name: N/A

Telephone Number: N/A

Command: N/A

a. Have you ever applied for any position or taken any civil service examinations for any position with any City, Municipal, Village, Town, Country, State, and/or Federal Authority?

null

This includes if you have been interviewed without an examination. If “yes,” state name of agency concerned, position/title, year of exam, list position (if any), and current status:

N/A

b. Have you ever been employed by any City, Municipal, Village, Town, County, State, Federal Authority and/or Foreign Government?

null

If yes, state name of agency concerned:

N/A

c. Are you employed by and/or do you have an interest in an individual or organization

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