Az Post Form – Fill Out and Use This PDF

Arizona Peace Officer Standards and

Training Board

STATEMENT OF PERSONAL HISTORY AND

APPLICATION FOR CERTIFICATION

I.TO THE APPLICANT

Certification by the Arizona Peace Officer Standards and Training Board is required by state law, A.R.S. §41-1823.B, prior to a person being authorized to act in the capacity of a peace officer. To be considered for certification under the rules of AZ POST, you must complete this application and RETURN IT TO THE DEPARTMENT TO WHICH YOU ARE APPLYING.

II.A FALSE OR MISLEADING STATEMENT ON THIS FORM IS A CRIME UNDER A.R.S. §§ 13-2704, 13-2907.01 AND 39-

161 AND IS CAUSE TO DENY OR REVOKE PEACE OFFICER CERTIFICATION.

The existence of any of the following conditions may result in rejection from the selection process. These areas will be explored extensively during a background investigation including a polygraph examination:

a.Illegal drug use,

b.Participation in criminal activity or behavior,

c.Poor driving record,

d.Dishonesty/providing false information.

III. PUBLIC DISCLOSURE OF INFORMATION

Your Social Security Number is required by A.R.S. §25-320 and is requested for identification and record keeping purposes. AZ

POST does not disclose Social Security Numbers in response to public record requests.

IV. INSTRUCTIONS

Read every question carefully. Answer every question. If the question does not apply to you, write "DNA" in the answer space. Do not leave blank answer spaces. Please print clearly. When using the Continuation Sheet, please note the question number you are referring to. Applications that are incomplete or cannot be read will not be accepted.

V.PEACE OFFICER CODE OF ETHICS

I will exercise self-restraint and be constantly mindful of the welfare of others. I will be exemplary in obeying the laws of the land and loyal to the state of Arizona and my agency and its objectives and regulations. Whatever I see or hear of a confidential nature or that is confided to me in my official capacity will be kept secure unless revelation is necessary in the performance of my duty.

I will never take selfish advantage of my position and will not allow my personal feelings, animosities or friendships to influence my actions or decisions. I will exercise the authority of my office to the best of my ability, with courtesy and vigilance, and without favor, malice, ill will, or compromise. I am a servant of the people and I recognize my position as a symbol of public faith. I accept it as a public trust to be held so long as I am true to the law and serve the people of Arizona.

CERTIFICATION:

I hereby certify that I have read the above Code of Ethics and agree to abide by it.

SIGNATURE OF APPLICANT: _____________________________________________

DATE: _____________________

AZ POST Form PH (June 2011) Page 1 of 10

Arizona Peace Officer Standards and

Training Board

AUTHORIZATION FOR RELEASE OF INFORMATION

I,

, DO HEREBY AUTHORIZE any and all persons, employers, partnerships,

(print name)

corporations and all civilian and government entities, military agencies, law enforcement agencies, private, and city, county, state and federal entities to release, furnish and exchange any and all available information relating to me for the purpose of determining my suitability to be appointed and certified as a peace officer. This includes, but is not limited to, all information related to my employment, performance, disciplinary history, character, integrity, reputation, conduct, behavior and fitness for duty.

This authorizes release to the ARIZONA PEACE OFFICER STANDARDS AND TRAINING BOARD and the (agency)

_______________________________________________________________. This release is in addition to, and not

(print agency name)

intended to curtail or diminish the authorization and immunity provided by statute. I DO HEREBY RELEASE from any and all liability, all persons or entities disclosing information pursuant to this release.

Signature of Applicant:		Date:
Sworn and Subscribed To Before Me This:	Day of	.
By:
State of:	County of:
Signature of Notary Public:

AZ POST Form PH (June 2011) Page 2 of 10

18.PERSONAL REFERENCES: List at least three people who have known you for over one year, excluding relatives or former employers, who can answer questions concerning your past conduct and character as it applies to your meeting the minimum standards for appointment.

		Home		Work		Years
Name	Street Address, City, State, Zip Code	Telephone		Telephone
						Known
		No.		No.

19.EXCLUDING FAMILY MEMBERS, LIST ALL PERSONS YOU HAVE LIVED WITH DURING THE PAST FIVE YEARS.

Use the Continuation Sheet if necessary.

	Name	Street Address, City, State, Zip Code	Home	Relationship
			Telephone No.

20.FAMILY REFERENCES: List all immediate relatives, (i.e., parents, siblings, spouse, ex-spouse(s) and all children). Use the Continuation Sheet if necessary.

Name

Relationship

Age

Street Address, City, State, Zip code

Telephone No.

AGENCY VERIFICATION:	INITIALS:	DATE:	INITIALS:
Personal References Contacted and Results Documented		Residences and Family References Listed

AZ POST Form PH (June 2011) Page 4 of 10

21. EMPLOYMENT HISTORY: Show all employment beginning with most recent employer. Use the Continuation Sheet if necessary.

Dates of Employment			Name and Address of Employer		Supervisor's Name
							Job Title/Duties	Reason for Leaving
From	To		(Street, City, State)		and Phone Number

22.LIST ALL COLLEGES OR UNIVERSITIES YOU HAVE ATTENDED (Beginning with the most recent):

	School	Dates	Course of Study	Degree Received or
		Attended		Total Credit Hours

23.RESIDENCES: List all residences during the past five years. Use the Continuation Sheet if necessary.

From

To

Street Address

City

State/County

AGENCY VERIFICATION:		INITIALS:	DATE:		INITIALS:
Employment Verified and Results Documented			Certificates or Degrees, Documentation in File
Residences Verified and Results Documented in File

AZ POST Form PH (June 2011) Page 5 of 10

24.POLICE CONTACTS: List all incidents in which you were cited, arrested, accused or charged with a crime other than traffic violations. Include incidents that occurred as a juvenile, any that were expunged, set aside, dismissed, referred to pre-trial diversion or pardoned. Provide a full explanation on the Continuation Sheet.

Date	Location	Police Agency	Original Charge	Disposition/Court Action

25.CIVIL ACTIONS List all civil actions in which you were a party, (i.e., divorces, bankruptcy, small claims court, lawsuits etc.):

Date	Location	Action or Proceeding	Disposition/Court Action

26.		CURRENT DRIVER'S LICENSE				27. PREVIOUS DRIVER'S LICENSE INFORMATION
						List all states/countries where you have been licensed:
State:			__ Expiration Date: ______________________________
					__________________		___________________		____________________
Current Drivers License Number: ____________________________________
					__________________		___________________		____________________
		Have you ever had your Driver’s License revoked or suspended? YES NO If YES, provide a full explanation on the Continuation Sheet.
28.

29.MOTOR VEHICLE OPERATION: List all moving violations for which you were cited. Use the Continuation Sheet if necessary:

Date	Location and Issuing Agency	Violation Charged	Collision Related	Court Disposition
			YES NO
			YES NO
			YES NO
			YES NO
			YES NO
			YES NO

AGENCY VERIFICATION:	INITIALS:	DATE:	INITIALS:
Police Contacts Queried and Results Documented in Files		Civil Actions Queried and Results Documented in Files
Motor Vehicle Records Queried and Results Documented in File

AZ POST Form PH (June 2011) Page 6 of 10

30.ILLEGAL/NON-MEDICAL USE OF OR CRIMINAL INVOLVEMENT WITH DRUGS/CONTROLLED SUBSTANCES:

In this section, disclose all illegal drug use (or criminal involvement) that was NOT for the purpose of treating or alleviating the symptoms of a medical condition.

Drug use for medical purposes will be disclosed in a different portion of the application process.

	HAVE YOU EVER SOLD, SMUGGLED		HAVE YOU EVER USED, TRIED		IF YES HOW		HOW MANY		DATE FIRST		DATE LAST
TYPE OF DRUG	OR TRANSPORTED FOR SALE OR						TIMES AFTER
			OR EXPERIMENTED WITH?		MANY TIMES?				USED		USED
	PERSONAL GAIN?						AGE 21?

31.IF YOU ANSWERED YES ON ANY OF THE AREAS IN QUESTION #30, PROVIDE A FULL EXPLANATION ON THE CONTINUATION SHEET. INCLUDE, IF APPLICABLE, THE FOLLOWING:

Applicant Meets Drug Standards/Does Not Meet Standards Yes No	ACIC/ACCH Checked
Criminal History Check Completed and Documentation in File	NCIC/III Checked

AZ POST Form PH (June 2011) Page 7 of 10

	35. Do you have prior peace officer certification/employment in Arizona or any other state(s)?					YES NO
	If YES provide the following information:		Dates of Employment
	Name of Agency				City		State
			From	To

a. If prior Arizona certified, attach verification of most current AZ POST continuing and proficiency training and firearms qualifications.

YES NO

YES NO

YES NO

YES NO

37.CERTIFICATION:

I hereby certify under penalty of law that the entries on this statement and the attached Continuation Sheet are true, complete and correct to the best of my knowledge and belief. These entries are made in good faith. I understand that a false or misleading statement on this form constitutes a violation of the law and is cause to deny, suspend or revoke peace officer certification.

SIGNATURE OF APPLICANT: ________________________________________________________			DATE: ___________________________________
AGENCY VERIFICATION:	INITIALS:	DATE:		INITIALS:
Previous Agencies Applied To Queried and Results Documented		Certification History Verified and Results Documented in File
Training and Firearms Requirements Documentation in File		Valid Certification Verified and Documentation in File
Improper Conduct Researched and Documentation in File		Fingerprint Card Submitted - AZ DPS
Signature and Date Completed		Fingerprint Card Submitted - FBI

AZ POST Form PH (June 2011) Page 8 of 10

Arizona Peace Officer Standards and

Training Board

STATEMENT OF PERSONAL HISTORY AND

APPLICATION FOR CERTIFICATION

Continuation Sheet

Please state the applicable question number for each entry made on this page. Use the space provided to complete answers for previously asked questions or for necessary explanation and clarification.

Question Explanation, Clarification, etc.

Number

AZ POST Form PH (June 2011) Page 9 of 10

AGENCY VERIFICATION OF APPLICANTS

QUALIFICATIONS AND DOCUMENTATION

Page 1	Code of Ethics read, signed and dated.	(Please initial)
Page 2	Authorization for Release of Information fully completed and notarized.
Page 3	Agency Verification completed and results documented in file.
Page 4	Agency Verification completed and results documented in file.
Page 5	Agency Verification completed and results documented in file.
Page 6	Agency Verification completed and results documented in file.
Page 7	Agency Verification completed and results documented in file.
Page 8	Agency Verification completed and results documented in file.
Applicant meets minimum qualifications and documentation is complete and in file.
Applicant does not meet minimum qualifications.		Application Process Terminated
Reason for Disqualification:

Medical Examination completed and in file and applicant meets standards.

Medical Examination completed and in file and applicant does not meet standards.

ME and MH forms properly completed and in file.

F.B.I./D.P.S. record checks completed and in file and no record found.

F.B.I./D.P.S. record checks completed and in file and reflects arrest record.

F.B.I./D.P.S. Fingerprint check has been submitted, no return yet.

NCIC/III/ACIC/ACCH records check completed and in file and no record found.

NCIC/III/ACIC/ACCH records check completed and in file and record found.

Polygraph completed and report in file and applicant passed.

Polygraph completed and report in file and applicant failed.

Applicant meets all requirements and may be employed.

Applicant does not meet all requirements.Application Process Terminated

Reason for Disqualification:

AGENCY CERTIFICATION:

I hereby certify that I have reviewed this application for completeness and the required documentation in accordance with R13-4- 106(C)(7) and hereby attest that this person meets minimum qualifications for appointment, has not engaged in conduct or a pattern of conduct that would jeopardize public trust in the law enforcement profession, is of good moral character and have completed this report to document that finding.

NAME OF REVIEWER: ___________________________________________ TITLE: _________________________________

(Printed)

SIGNATURE OF REVIEWER:____________________________________________ DATE: _____________________________

AZ POST Form PH (June 2011) Page 10 of 10