Form Post 2 251 – Fill Out and Use This PDF

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Form Post 2 251 PDF Details

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Question	Answer
Form Name	Form Post 2 251
Form Length	26 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min 30 sec
Other names	phs post ca, post personal history statement, california 251 02, ca phs post

Form Preview Example

	State of California – Department of Justice	Commission on
	PERSONAL HISTORY STATEMENT – PEACE OFFICER	Peace Officer Standards and Training (POST)
	PERSONAL HISTORY STATEMENT – PEACE OFFICER	860 Stillwater Road, Suite 100
	POST 2-251 (Rev 02/2018)	860 Stillwater Road, Suite 100
	POST 2-251 (Rev 02/2018)	West Sacramento, CA 95605-1630
		West Sacramento, CA 95605-1630

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 California Peace Officer, in accordance with POST Commission Regulation 1953.

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

∙Following instructions given by the hiring department, type or neatly print in black ink.

∙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 supplemental information page on the last page of this form (page 25) and identify the additional information by the question number.

∙Following instructions given by the hiring department, provide the completed form to your background investigator or the agency to which you are applying. Do NOT send the form to POST.

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, the Genetic Information Nondiscrimination Act (GINA), and the California Fair Employment and Housing Act, 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: ________________________

Page 1 of 26

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

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
3.	ADDRESS WHERE YOU LIVE
	NUMBER / STREET		APT / UNIT
	CITY		STATE	ZIP
4.	MAILING ADDRESS, IF DIFFERENT FROM ABOVE (FOR EXAMPLE, PO BOX)
4.

N/A

5.	CONTACT NUMBERS
	HOME (	)	WORK (	)	EXT	OTHER (	)	CELL	FAX

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

8. CITIZENSHIP

Are you a U.S. citizen?.......................................................................................................................................................................

IF NO, are you a resident alien who is eligible and has applied for U.S. citizenship? ..........................................................................

Yes Yes

No No

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
	HEIGHT:	WEIGHT:		HAIR COLOR:		EYE COLOR:

SECTION 2: RELATIVES AND REFERENCES

14. IMMEDIATE FAMILY

∙Provide all applicable information in the spaces below.

∙Mark “N/A” if a category is not applicable.

∙Mark “Deceased,” if appropriate.

∙If more space is needed, continue on page 25 – reference corresponding numbers.

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

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

()

WORK PHONE

CELL PHONE

(

)

(

)

DATE OF MARRIAGE/REGISTRATION

Is there, or has there ever been, a restraining or stay-away

(MM/YYYY)

order in effect involving you and this individual?

Yes

14.B Former Spouse / Former Registered Domestic Partner

Deceased

N/A

NAME

HOME ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS (NUMBER / STREET / SUITE)

CITY

STATE

ZIP

()

WORK PHONE				CELL PHONE			EMAIL
(	)		(		)

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

Page 2 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 2: RELATIVES AND REFERENCES continued

14.C Parents / Guardians / In-laws

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

14.C.1 Parent / Guardian / In-law:

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 / In-law:

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 / In-law:

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.4 Parent / Guardian / In-law:

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.5 Parent / Guardian / In-law:

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.6 Parent / Guardian / In-law:

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

(

)

(

)

Supplemental relatives information included on page 25

Page 3 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 2: RELATIVES AND REFERENCES continued

14.D Brothers / Sisters

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

14.D.1 Sibling:

Brother

Sister

Half-brother

Half-sister

Other:

N/A

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

(

)

(

)

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

(

)

(

)

Supplemental relatives information included on page 25

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:

NAME

AGE

CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

(

)

14.E.2

Child:

Son

Daughter

Other:

NAME

AGE

CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

(

)

Page 4 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 2: RELATIVES AND REFERENCES continued

14.E.3

Child:

Son

Daughter

Other:

NAME

AGE

CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

(

)

14.E.4

Child:

Son

Daughter

Other:

NAME

AGE

CUSTODIAL PARENT/GUARDIAN (IF OTHER THAN YOU)

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

(

)

Supplemental relatives information included on page 25

15.LIST OF REFERENCES

∙List 7-10 people who know you well, such as close personal relationships, social and family friends, 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	STATE	ZIP
	NAME OF REFERENCE		HOME ADDRESS (NUMBER / STREET / APT)	CITY	STATE	ZIP

15.1

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




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

15.3



		HOME PHONE		WORK 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

15.4



		HOME PHONE		WORK 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?

Page 5 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 2: RELATIVES AND REFERENCES continued

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

15.5



		HOME PHONE		WORK 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
15.6
15.6

		HOME PHONE		WORK 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
	NAME OF REFERENCE			HOME ADDRESS (NUMBER / STREET / APT)			CITY	STATE	ZIP
15.7


		HOME PHONE		WORK 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		WORK 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		WORK 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

15.10

		HOME PHONE		WORK 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?

Supplemental references information included on page 25

Page 6 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 3: EDUCATION

∙NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims in Section 3.

∙If more space is needed, continue your response on page 25.

16. CHECK APPLICABLE		MM/YYYY
High School Diploma:	/

MM/YYYY

High School Equivalency Test:

MM/YYYY

California High School Proficiency Certificate:

17.LIST HIGH SCHOOL(S) ATTENDED

	NAME OF HIGH SCHOOL		FROM (MM/YYYY)	TO (MM/YYYY)
	NAME OF HIGH SCHOOL		FROM (MM/YYYY)	TO (MM/YYYY)
17.1			/	/
			/	/

		CITY		STATE

	NAME OF HIGH SCHOOL		FROM (MM/YYYY)	TO (MM/YYYY)

17.2			/	/
			/	/

		CITY		STATE

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

ADDRESS (NUMBER / STREET)

DEGREE EARNED

YES

NO TYPE:

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

NAME OF COLLEGE/UNIVERSITY

FROM (MM/YYYY)

TO (MM/YYYY)

TOTAL UNITS COMPLETED

18.2

QTR SYSTEM

SEM SYSTEM

ADDRESS (NUMBER / STREET)

DEGREE EARNED

YES

NO TYPE:

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

NAME OF COLLEGE/UNIVERSITY

FROM (MM/YYYY)

TO (MM/YYYY)

TOTAL UNITS COMPLETED

18.3

QTR SYSTEM

SEM SYSTEM

ADDRESS (NUMBER / STREET)

DEGREE EARNED

YES

NO TYPE:

CITY

STATE

ZIP

MAJOR / AREA OF STUDY

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

	NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE		FROM (MM/YYYY)			TO (MM/YYYY)	DID YOU COMPLETE THE COURSE?
	NAME OF TRADE, VOCATIONAL, OR BUSINESS SCHOOL/INSTITUTE		FROM (MM/YYYY)			TO (MM/YYYY)	DID YOU COMPLETE THE COURSE?
19.1			/			/	Yes	No
			/			/	Yes	No

		CITY		STATE	TYPE OF SCHOOL OR TRAINING

Supplemental education information included on page 25

LIST ALL POST BASIC COURSES ATTENDED

20. Have you ever taken a PC832 (Arrest and/or Firearms) Course?	Yes
IF YES, provide the following information:

A. COURSE PRESENTER NAME

LOCATION (CITY / STATE)

B. COURSE COMPLETION
Did you successfully complete the course?	Yes

COMPLETION DATE (MM/YYYY)

Page 7 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 3: EDUCATION continued

21. Have you ever attended a POST Basic Course/Academy: Regular, Modular, Specialized Investigators’, Reserve, or Dispatcher?						Yes	No
	IF YES, provide the following information:

	NAME OF COURSE PRESENTER/ACADEMY		FROM (MM/YYYY)	TO (MM/YYYY)	DID YOU PASS/GRADUATE?
21.1			/	/		Yes	No
			/	/		Yes	No

	LOCATION (CITY, STATE)	NAME OF TRAINING OFFICER / ACADEMY COORDINATOR			CONTACT NUMBER
					(	)

	NAME OF COURSE PRESENTER/ACADEMY		FROM (MM/YYYY)	TO (MM/YYYY)	DID YOU PASS/GRADUATE?
21.2			/	/		Yes	No
			/	/		Yes	No

	LOCATION (CITY, STATE)	NAME OF TRAINING OFFICER / ACADEMY COORDINATOR			CONTACT NUMBER
					(	)

Supplemental POST basic course information included on Page 25

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

from any high school(s), college/university, business, trade school, or POST 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 POST basic course academy. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.

23.Since the age of 18, have you cheated on an exam, or assisted another person in cheating on an exam, or participated in cheating on any POST exam? .........................................................................................................................................................

IF YES, explain circumstances.

Yes

SECTION 4: RESIDENCE HISTORY

24.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/dormitory). 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 25.

ADDRESS WHERE YOU NOW LIVE (NUMBER / STREET / APT)

24.1

CITY

STATE

ZIP

FROM (MM/YYYY)

TO (MM/YYYY)

/Present

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

Name(s) of those with whom you live:

Page 8 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 4: RESIDENCE HISTORY continued

	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)
	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)

24.2					/			/
					/			/

	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
						CONTACT NUMBER
						(	)

CITY

STATE

ZIP

Name(s) of those with whom you lived:

Reason for moving:

	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)
	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)

24.3					/			/




	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

Name(s) of those with whom you lived:

Reason for moving:

	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)
	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)

24.4					/			/



	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

Name(s) of those with whom you lived:

Reason for moving:

	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)
	FORMER ADDRESS (NUMBER / STREET / APT)				FROM (MM/YYYY)			TO (MM/YYYY)
24.5					/			/
24.5



	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

Name(s) of those with whom you lived:

Reason for moving:

Supplemental residence information included on page 25

Page 9 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 4: RESIDENCE HISTORY continued

25.LIST OF HOUSEMATES

∙Provide contact information for all housemates listed in Question 24 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 25.


	NAME OF HOUSEMATE			CONTACT NUMBER

25.1				(	)
				(	)

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

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

	NAME OF HOUSEMATE				CONTACT NUMBER
	NAME OF HOUSEMATE				CONTACT NUMBER

25.2					(	)



		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

25.3					(	)



		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
25.4					(	)
25.4


		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
25.5					(	)
25.5


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

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

Supplemental housemate information included on page 25

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

27. Have you ever left a residence owing rent, utilities, or other household expenses?								Yes	No

If you answered “YES” to Questions 26 and/or 27, explain (include when, where, and circumstances):

Page 10 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

______________________________________________________________________________________________________

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 5: EXPERIENCE AND EMPLOYMENT

28.JOB EXPERIENCE

∙List ALL jobs you have had, including part-time, temporary, self-employment, and volunteer. (Begin with your current or most recent.)

∙If you have military experience, including reserve duty, enter your military base, assignments, or unit of assignment.

∙List ALL periods of unemployment in excess of 30 days.

∙If more space is needed, continue your response on page 25.

NAME OF CURRENT EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

28.1

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

Would there be a problem if we contact your current employer?

Yes

IF YES, explain:

__________________________________________________________________________________________________

28.2

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)

28.3

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

28.4

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)	TO (MM/YYYY)
/	/

Page 11 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

NAME OF EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

28.5

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

28.6

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)

28.7

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

28.8

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)

28.9

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

Page 12 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

FROM (MM/YYYY)

TO (MM/YYYY)

28.10

Student

Between jobs

Leave of absence

Travel

Other:

NAME OF EMPLOYER OR MILITARY UNIT

FROM (MM/YYYY)

TO (MM/YYYY)

28.11

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

28.12

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)

28.13

ADDRESS (NUMBER / STREET / SUITE / OR BASE)

CONTACT NUMBER

EXT

(

)

CITY

STATE

ZIP

JOB TITLE / RANK

TYPE OF EMPLOYMENT (CHECK ALL THAT APPLY)

Temp

Self-employed

Volunteer

DUTIES / ASSIGNMENTS

REASON FOR LEAVING

SUPERVISOR

CONTACT NUMBER

EXT.

(

)

NAMES OF CO-WORKERS

CONTACT NUMBER

EXT.

(

)

(

)

28.14

PERIOD OF UNEMPLOYMENT (CHECK APPLICABLE)

Student

Between jobs

Leave of absence

Travel

Other:

FROM (MM/YYYY)

TO (MM/YYYY)

Supplemental employment information included on Page 25

29.Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling,

reprimands, suspensions, reductions in pay, reassignments, or demotions.)..................................................................................

Yes

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

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

32.	Have you ever quit without giving proper notice?	Yes	No

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

34.Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.)

by a co-worker, superior, subordinate or customer?.......................................................................................................................

Yes

Page 13 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

35. Were you ever the subject of a written complaint at work that resulted in disciplinary action against you?......................................

Yes

36. Have you ever been counseled at work due to lateness or absences?...........................................................................................

Yes

37. Did you ever receive an unsatisfactory performance review? .........................................................................................................

Yes

38. Have you ever sold, released, or given away legally confidential information? ...............................................................................

Yes

39. Have you ever called in sick when you were neither sick nor caring for a sick family member? ......................................................

Yes

IF YES, how many sick days have you used in the past five years which were not due to illness? _

_ Days

40.While working (i.e. on duty), have you ever engaged in sexual intercourse or the unwarranted touching of the intimate body parts of another person while working (i.e. on duty)? (NOTE: Do not include lawful contact such as pat searches in law enforcement duties and/or training.)...............................................................................................................................................

Yes

41.While working (i.e. on duty), have you ever sent photographs of yourself or others, showing nudity or depicting sexual acts, to co-workers or other persons without prior authorization and/or consent? (NOTE: Do not include lawful exchange of investigative content and/or evidence pursuant to official law enforcement investigations.)............................................................

Yes

If you answered “YES” to any of Questions 29–41, explain (include when, where, and circumstances – reference corresponding numbers).

_______________________________________________________________________________________________________

Supplemental employment information included on Page 25

42. In the past three years, have you missed days or been late to work due to drug or alcohol consumption? .....................................

If YES, how often?

Yes

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

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

45. Have you ever applied for any position at this or any other law enforcement agency (city, county, state, or federal)?....................

Yes

∙If you answered “YES” to Question 45, 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 25.

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.1

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

Withdrew

Disqualified

List Expired

Other (explain)

Page 14 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.2

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

Withdrew

Disqualified

List Expired

Other (explain)

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.3

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

Withdrew

Disqualified

List Expired

Other (explain)

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.4

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

Withdrew

Disqualified

List Expired

Other (explain)

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.5

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

Withdrew

Disqualified

List Expired

Other (explain)

Page 15 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 5: EXPERIENCE AND EMPLOYMENT continued

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.6

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

Withdrew

Disqualified

List Expired

Other (explain)

NAME OF LAW ENFORCEMENT AGENCY

DATE APPLIED (MM/YYYY)

45.7

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

Withdrew

Disqualified

List Expired

Other (explain)

Supplemental employment information is included on Page 25

SECTION 6: MILITARY EXPERIENCE

46. Are you required to register for the Selective Service?

Yes

IF YES, have you registered?

Yes

IF NO, explain:

47. Have you ever served in the military?

Yes

48.If you answered “YES” to Question 47, include the following service information:

BRANCH OF SERVICE

TYPE OF DISCHARGE

FROM (MM/YYYY)

TO (MM/YYYY)

Entry Level

Honorable

General

OTH (Other than Honorable)

Re-entry Code (1–4) if applicable – refer to your DD-214:

Bad Conduct

Dishonorable

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

Military Reserve

National Guard

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

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

	office hours, company punishment)?	Yes	No

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

52.	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 50-52, explain (include dates and circumstances).

_______________________________________________________________________________________________________

Supplemental military information included on Page 25

Page 16 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 7: FINANCIAL

53.INCOME AND EXPENSES

∙For each of the following questions (53A and B), fill in the amounts to the nearest dollar.

∙For Question 53A: Provide your total monthly disposable income. Include money from investments, rental income, alimony, side businesses, etc.

∙For Question 53B: 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)	...........................................................................................What is your total monthly disposable income?	$	per month

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

54. Have you ever filed for or declared bankruptcy (Chapter 7, 11 or 13)? .........................................................................................

Yes

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

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

57.	Have your wages ever been garnished?	Yes	No

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

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

60.	Have you ever had an employment bond refused?	Yes	No

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

62.	Have you ever defaulted on (failed to pay) a loan?	Yes	No

63.	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

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

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

66.	Have you written three or more bad checks in a one-year period?	Yes	No

If you answered “YES” to any of Questions 54-66, explain (include when, where, and why – reference corresponding numbers).

_______________________________________________________________________________________________________

Page 17 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 8: LEGAL

Disclosure of Arrests and Convictions

∙This section requires you to report detentions, arrests, and convictions, including diversion programs that were not successfully completed, and in some cases, offenses that may have been pardoned. As a peace officer applicant, you are required to disclose this information, unless specifically exempted by state or federal law. It is strongly recommended that you consult with an attorney before omitting any information.

∙If more space is needed, continue your response on page 25.

67.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)? ......................................................................................................................................................................

IF YES, explain each incident:

Yes

	CHARGE	APPROX DATE (MM/YYYY)	ARRESTING OR DETAINING AGENCY
	CHARGE	APPROX DATE (MM/YYYY)	ARRESTING OR DETAINING AGENCY

67.1		/
		/

	DISPOSITION OR PENALTY
	____________________________________________________________________________________________________
	____________________________________________________________________________________________________
	____________________________________________________________________________________________________

	CHARGE	APPROX DATE (MM/YYYY)	ARRESTING OR DETAINING AGENCY
67.2		/
		/

	DISPOSITION OR PENALTY
	____________________________________________________________________________________________________
	____________________________________________________________________________________________________
	____________________________________________________________________________________________________

Supplemental disclosure information included on Page 25

68.	Have you ever been placed on court probation?			Yes	No

69.	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	No

70.	Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity,
	support, etc.)?			Yes	No

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

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

73.	Have you ever been the subject of an emergency protective order/restraining order/stay-away order?			Yes	No

74.	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	No

75.	Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or other state
	or federal assistance?			Yes	No

76.	Have you ever been required to repay any welfare payments, unemployment compensation, or other state or
	federal assistance?			Yes	No

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

If you answered “YES” to any of Questions 68-77, explain (include court case or document, dates, and circumstances – reference corresponding numbers). If more space is needed, continue your response on page 25.

______________________________________________________________________________________________________

Page 18 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

Page 19 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 8: LEGAL continued

Involvement in Criminal Acts – Part 1

78.Have you committed any of the following acts within the past seven (7) years? (You do NOT have to report any acts committed prior to age 15.)

∙You MUST include any acts committed at any time after you were first employed in law enforcement, including as a 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.


	Animal abuse and/or neglect	Yes	No
78.1	Animal abuse and/or neglect	Yes	No

	Annoying, obscene, or harassing contacts by telephone or other electronic communication device	Yes	No
78.2		Yes	No

	Battery (use of force or violence upon another)	Yes	No
78.3	Battery (use of force or violence upon another)	Yes	No

78.4	Brandishing a weapon (any type of weapon)	Yes	No

78.5	Carrying a concealed weapon without a permit	Yes	No

	Contributing to the delinquency of a minor	Yes	No
78.6	Contributing to the delinquency of a minor	Yes	No

	Defrauding an innkeeper (not paying for food or room at a hotel/motel, campground, etc.)	Yes	No
78.7		Yes	No

	Driving a vehicle or operating a boat/vessel while under the influence of alcohol and/or drugs	Yes	No
78.8		Yes	No

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

78.10	Filing a false police report	Yes	No

78.11	Hit & run collision (no injuries)	Yes	No

78.12	Illegal gambling	Yes	No

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

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

	Indecent exposure and/or lewd or obscene conduct	Yes	No
78.15	Indecent exposure and/or lewd or obscene conduct	Yes	No

78.16	Intentionally writing a bad check	Yes	No

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

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

	Petty theft (value up to $950, including shoplifting/switching price tags)	Yes	No
78.19		Yes	No

	Possession of alcohol as a minor (under the age of 21)	Yes	No
78.20	Possession of alcohol as a minor (under the age of 21)	Yes	No

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

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

78.23	Prostitution or solicitation of prostitution (including, but not limited to, patronizing illegal massage parlors)	Yes	No

	Reckless driving	Yes	No
78.24	Reckless driving	Yes	No

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

78.26	Trespassing	Yes	No

Page 20 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 8: LEGAL continued

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

	Any other act amounting to a misdemeanor	Yes	No
78.28	Any other act amounting to a misdemeanor	Yes	No

∙ If you answered “YES” to ANY of the item(s) in Question 78, fully explain circumstances, including dates, names of individuals involved, and resolution. Reference the corresponding number (e.g., 78.5) for each explanation.

∙ If more space is needed, continue your response on page 25.

______________________________________________________________________________________________________

Supplemental legal information included on Page 25

Involvement in Criminal Acts – Part 2

79.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.

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

79.2	Assault with a deadly weapon (struck or threatened to strike someone with an instrument likely to cause great bodily	Yes	No
79.2	injury or death)
	injury or death)
79.3	Blackmail or extortion	Yes	No

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

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

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

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

79.8	Felony drunk driving (involving injuries)	Yes	No

79.9	Felony illegal sex acts	Yes	No

	Forcible rape	Yes	No
79.10	Forcible rape	Yes	No

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

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

79.13	Grand theft (value of over $950, automobile, any firearm)	Yes	No

79.14	Hit & run (with injuries)	Yes	No

79.15	Hate crime	Yes	No

	Insurance fraud	Yes	No
79.16	Insurance fraud	Yes	No

79.17	Murder, homicide, attempted murder, or assault with intent to commit murder	Yes	No

	Perjury (lying under oath)	Yes	No
79.18	Perjury (lying under oath)	Yes	No

79.19	Possession of an explosive/destructive device	Yes	No

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

Page 21 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 8: LEGAL continued

79.21

Stalking .................................................................................................................................................................................

Yes

79.22

Theft of a vehicle and/or vehicle parts ...................................................................................................................................

Yes

79.23

Viewing and/or possessing child pornography .......................................................................................................................

Yes

79.24

Any other act amounting to a felony .......................................................................................................................................

Yes

∙If you answered “YES” to ANY of the item(s) in Question 79, fully explain circumstances, including dates, names of individuals involved, and resolution. Reference the corresponding number (e.g., 79.3) for each explanation.

∙If more space is needed, continue your response on page 25.

______________________________________________________________________________________________________

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; it also includes the illegal use of any other 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)

Barbiturates (Downers)

Cocaine / Crack Cocaine

Designer Drugs (Ecstasy, Synthetic Heroin, etc.)

GHB (Date Rape Drug)

Hallucinogens (Peyote, LSD, Mushrooms)

Hashish / Hashish Oil

Heroin / Opium

Marijuana (with or without a prescription)

Mescaline

Morphine

PCP / Angel Dust

Quaaludes

Steroids

Tetrahydrocannabinal (THC)

Glue, paint, or any substance containing toluene

80.Within the past six months, have you used any drug(s) as indicated above? .............................................................................

IF YES, give details including drug(s) used, most recent date used, and circumstances:

Yes

______________________________________________________________________________________________________

81.Prior to the past six 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:

_____________________________________________________________________________________________________

Page 22 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 8: LEGAL continued

82.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?

Yes

No If YES, indicate which activities (mark all that apply):

Sold

Manufactured

Purchased

Furnished

Cultivated

Carried or Held for Another

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

_____________________________________________________________________________________________________

83.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:

_____________________________________________________________________________________________________

Supplemental drug information included on Page 25

SECTION 9: MOTOR VEHICLE INFORMATION

84.Current Driver’s License:

STATE OF ISSUE	LICENSE NUMBER	EXPIRATION DATE (MM/DD/YYYY)
		/	/

NAME UNDER WHICH LICENSE WAS GRANTED

85.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

86. Have you ever been refused a driver’s license by any state?	Yes
IF YES, explain (include when, where, and circumstances):

______________________________________________________________________________________________________

87. Has your driver’s license ever been suspended or revoked?	Yes
IF YES, explain (include when, where, and circumstances):

____________________________________________________________________________________________________

Page 23 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 9: MOTOR VEHICLE INFORMATION continued

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

	TYPE OF COVERAGE			VEHICLE MAKE		YEAR (YYYY)		VEHICLE LICENSE
	TYPE OF COVERAGE			VEHICLE MAKE		YEAR (YYYY)		VEHICLE LICENSE
88.1	Insured	Bonded	Cash Deposit
	Insured	Bonded	Cash Deposit

	INSURANCE COMPANY				POLICY NUMBER				EXPIRATION DATE (MM/DD/YYYY)
										/	/

	ADDRESS (NUMBER/STREET)			CITY		STATE	ZIP		CONTACT NUMBER

									(	)

	TYPE OF COVERAGE			VEHICLE MAKE		YEAR (YYYY)		VEHICLE LICENSE

88.2	Insured	Bonded	Cash Deposit
	Insured	Bonded	Cash Deposit

	INSURANCE COMPANY				POLICY NUMBER				EXPIRATION DATE (MM/DD/YYYY)

										/	/

	ADDRESS (NUMBER/STREET)			CITY		STATE	ZIP		CONTACT NUMBER

									(	)

	TYPE OF COVERAGE			VEHICLE MAKE		YEAR (YYYY)		VEHICLE LICENSE

88.3	Insured	Bonded	Cash Deposit
	Insured	Bonded	Cash Deposit

	INSURANCE COMPANY				POLICY NUMBER				EXPIRATION DATE (MM/DD/YYYY)

										/	/

	ADDRESS (NUMBER/STREET)			CITY		STATE	ZIP		CONTACT NUMBER
									(	)

89. Have you received any traffic citations, excluding parking citations, within the past seven years.

Yes

No If YES, give details below.

	NATURE OF VIOLATION			LOCATION (STREET)		CITY		STATE
	NATURE OF VIOLATION			LOCATION (STREET)		CITY		STATE

89.1

	DATE VIOLATION OCCURRED		ACTION TAKEN
	Month:	Year:	Not Guilty		Fined	Traffic School	Dismissed

	NATURE OF VIOLATION			LOCATION (STREET)		CITY		STATE

89.2

	DATE VIOLATION OCCURRED		ACTION TAKEN
	Month:	Year:	Not Guilty		Fined	Traffic School	Dismissed

	NATURE OF VIOLATION			LOCATION (STREET)		CITY		STATE

89.3

	DATE VIOLATION OCCURRED		ACTION TAKEN
	Month:	Year:	Not Guilty		Fined	Traffic School	Dismissed

90.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:

______________________________________________________________________________________________________

91. Have you been involved as the driver in a motor vehicle accident within the past seven years?

Yes

IF YES, give details below.

DATE OF ACCIDENT (MM/YYYY)

LOCATION (STREET)

CITY

STATE

91.1

POLICE REPORT

LAW ENFORCEMENT AGENCY

AT FAULT?

WAS THE ACCIDENT?

Yes

Injury

Non-injury

DATE OF ACCIDENT (MM/YYYY)

LOCATION (STREET)

CITY

STATE

91.2/

POLICE REPORT		LAW ENFORCEMENT AGENCY	AT FAULT?		WAS THE ACCIDENT?
Yes	No		Yes	No	Injury	Non-injury

Page 24 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 2/2018)

SECTION 9: MOTOR VEHICLE INFORMATION continued

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

91.3/

	POLICE REPORT		LAW ENFORCEMENT AGENCY	AT FAULT?		WAS THE ACCIDENT?
	Yes	No		Yes	No	Injury	Non-injury


92. Have you ever driven a vehicle without auto insurance, as required by law?					Yes	No

IF YES, GIVE REASON

FROM (MM/YYYY)

TO (MM/YYYY)

93. 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

Supplemental motor vehicle information included on page 25

SECTION 10: OTHER TOPICS

94.	Have you ever been refused a permit to carry a concealed weapon?	Yes	No

95.	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

96.	Other than in self-defense, have you ever used force or violence against another person with whom you have had a dating,
	romantic or intimate relationship with, or who resided in the same household as you?	Yes	No

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

98.	Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, 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

If you answered “YES” to any of Questions 94–98, give details including dates and circumstances – reference corresponding numbers).

_______________________________________________________________________________________________________

SECTION 11: CERTIFICATION

99.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.

Signature in Full: 

Date:

Use the following page to continue your responses, if/as appropriate. Be sure to review all responses carefully and

provide additional information, as necessary. Reference corresponding question/item numbers.

Page 25 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

PERSONAL HISTORY STATEMENT – PEACE OFFICER

POST 2-251 (Rev 02/2018)

SUPPLEMENTAL INFORMATION

∙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, text will flow to additional pages automatically.

Page 26 of 26

Initial this page to indicate that you have provided complete and accurate information: _____

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