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Background interview: Date:		Time:

Report to :

LAPD Administrative Investigation Section Personnel Department Building

700 E. Temple Street, Room B-22

LOS ANGELES POLICE DEPARTMENT

Personal History Form for Police Officer Applicants

IMPORTANT INSTRUCTIONS

This application is a permanent record. All information must be typed or neatly printed by the applicant, using black ink only. Illegible or incomplete applications will not be accepted. Do not write in shaded areas.

Upon reporting to your appointment with the Administrative Investigation Section (Backgrounds), you must present your completed application (Personal History Form) as well as the original and a photo copy of the following documents:

DOCUMENTS			Candidate will
DOCUMENTS	Copy attached	N/A	provide by (date)
	Copy attached	N/A	provide by (date)
Valid motor vehicle operator’s license
Social Security card
Certified copy of your birth certificate
High school transcripts or diploma
Proof of auto insurance for all vehicles that you operate
Sealed college transcripts (for all institutions attended)
Certified copy of marriage certificate(s)
Military DD 214
Divorce decree(s)
Certificate of Naturalization or Application for citizenship
GED test score
Selective Service number
Bankruptcy records
Civil suit records
Name change records

LAW ENFORCEMENT TRAINING RECORDS (if applicable)

Academy certificate(s) and state law enforcement certificate(s)

Specialized law enforcement training course certificate(s)

Recent police report writing samples (minimum of five)

Prior to writing upon this application, a photocopy must be made in the event additional space is needed to include all the information required. Do not mail this application or the above requested documents. Applicants must complete all sections of the application. Failure to do so will delay your background investigation and/or delay your background interview.

LAPD PHF 12 - 97

IMPORTANT INSTRUCTIONS (continued)

It is mandatory that all information requested be supplied in the manner specified. Each question on this application must be answered; leave no blanks. If a question does not apply, enter DNA. An incomplete application will not be accepted.

1.Read the form carefully.

2.List zip codes and area codes for all requested addresses and telephone numbers.

3.Print full names of all references: first name, middle name, and last name. If the reference has no middle name or initial, indicate by printing NMI.

4.Complete all the information on educational background. List all high schools attended and/or graduated from and all colleges attended.

5.When listing residence information, begin with your present residence and go back for the last ten years or since age fifteen.

6.When listing employment information, begin with your present employer and list all other employers. List actual work addresses not corporate office addresses. Each month and year must be accounted for. Be sure each address is accurate and complete. List periods of military service, including the name of your station or assignment, and your residence if you lived off the base. If you resided at an address other than your permanent home address while attending school, list it.

7.List relatives in the order requested. For deceased relatives, indicate “deceased” next to their name.

8.If there is not sufficient space to include all information required, place a photocopy of that page

(8-1/2" X 11"), in proper sequence and complete the information.

9.Any false statements or omissions made on this questionnaire may cause your name to be removed from the eligibility list or be cause for immediate termination, if an appointment is made.

10.You are required to report within five days to the Los Angeles Police Department, Administrative Investigation Section (backgrounds) any changes to information on this Personal History Form. Failure to do so may cause your name to be removed from the eligibility list or be cause for immediate termination, if an appointment is made.

I have read and understand the instructions provided.

Applicant’s signature:

Date:

Note: Please allow the full day for this appointment as you will be photographed, fingerprinted and given an in-depth background investigation interview. Business attire is strongly recommended.

LOS ANGELES POLICE DEPARTMENT

Personal History Form for Police Officer Applicants

This document is for the exclusive use of the Administrative Investigation Section.

Personal

Full legal

Last

First

Middle

name

Sex

Height

Weight

Hair

Eyes

Social Security Number

Driver s License No.

State

Expiration Date

U.S. Citizen

Naturalized citizen

Legal Alien

Date applied for citizenship

Date of Birth

Place of Birth (city, county, state, and country)

List all names (aliases and nicknames) you have used or have been known by (include maiden name).

Last

First

Middle

Year(s) Used

List and describe all tattoos and where they are located.

List the current address where you physically reside (not a mailing address).

Number, Street, and Apt. no.

City

State

Zip Code

Name of the County where you reside.	9 Rent 9 Own 9	Parent 9	How long have you resided there?
	9 Rent 9 Own 9	Parent 9	Other
			Years:	Months:

List your residence and work phone numbers	Residence (area code)		Work (area code)
(include area codes and extension if applicable).

Pager or beeper (area code)

Cellular phone (optional)

List a mailing address if unable to obtain mail at your residence

Mailing Address

City

State

Zip Code

LAPD PHF 12 - 97

Family Members and Relatives

During the background investigation, your family and other relatives will be asked to comment upon your suitability for the position of peace officer. Supply the appropriate information in the spaces provided. If a category is not applicable, print N/A in the box provided for the name. If deceased, so indicate.

Name

Residence Address (include zip codes). If same as yours write

“same”.

Telephone (Include area code)

Father

Home

Occupation

Work

Mother	Home

Mother’s maiden name	Work

Occupation

Stepfather	Home

Occupation	Work

Stepmother	Home

Occupation	Work

Father-in-law	Home

Occupation	Work

Mother-in-law	Home

Occupation	Work

Brother	Home	Age

Occupation	Work


Brother	Home	Age

Occupation	Work


Brother	Home	Age

Occupation	Work


Brother	Home	Age

Occupation	Work


Brother	Home	Age

Occupation	Work
Occupation

	Home	Age
Sister

Occupation	Work


Sister	Home	Age

Occupation	Work


Sister	Home	Age

Occupation	Work


Sister	Home	Age

Occupation	Work


Sister	Home	Age

Occupation	Work

Family Members and Relatives (continued)

Stepbrother

Occupation

Home

Work

Age

Stepbrother	Home	Age

Occupation	Work


Stepsister	Home	Age

Occupation	Work


Stepsister	Home	Age

Occupation	Work

List five other family members and relatives (uncles, aunts, cousins, etc.)

Name

Relationship

Occupation

Name

Relationship

Occupation

Home

Work

Home

Work

Age

Name

Relationship	Home	Age

Occupation	Work


Name
Relationship	Home	Age

Occupation	Work


Name

Relationship	Home	Age

Occupation	Work

Children

List all of your children (include step-children, adopted children, etc.)

Sex

Relationship to you

Living with you

Name

Male

Female

Date of birth

Natural

Step

Adopted

Foster

Yes

Marital Status

9Single

9Married

9Widowed

9Separated

9Annulled

9Divorced

Full name of spouse	Maiden name	Other names spouse has used		Date of birth		Age

Date of marriage	Place of marriage (city, county, state, and country)

Spouse’s employer		Occupation or position			How long employed

Current address of spouse, if not living with you		Home phone (area code)	Work phone (area code)

If divorced, widowed, or had an annulment, provide the following information.

Full name of former spouse	Maiden name	Other names spouse has used	Date of birth	Age

Date of marriage

Place of marriage (city, county, state, and country)

Former spouse’s employer

Occupation or position

How long employed

Current address of former spouse or last known address

Home phone (area code)

Work phone (area code)

Date filed for divorce

City, county, and state of divorce

Is divorce final

9 Yes

9 No

Full name of former spouse

Maiden name

Other names spouse has used

Date of birth

Age

Date of marriage

Place of marriage (city, county, state, and country)

Former spouse’s employer

Occupation or position

How long employed

Current address of former spouse or last known address

Home phone (area code)

Work phone (area code)

Date filed for divorce

City, county, and state of divorce

Is divorce final

9 Yes

9 No

Have you ever been ordered by court to pay child support?

9 Yes

9 No

If yes, what is or was the monthly amount

9 Yes

9 No

Have you ever been required to pay alimony?

If yes, what is or was the monthly amount

Have you ever been delinquent in child support payments or alimony payments?

9 Yes

9 No

If yes, explain below.

Residences

List all of your residences during the last ten years or since age fifteen. Begin with your most current residence. When listing military bases, include nearest city, state, and zip code. When listing addresses, include Street, Avenue, Drive, Court, North, South, East, West. Include unit number or apartment number, where applicable.

Current address

City, state, and zip code

Since (month/year)

With whom do you live

Address

City, state, and zip code

From (month/year)

To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving

Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving


Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving


Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving

Residence (continued)

Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving

Address

City, state, and zip code

From (month/year)

To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving

Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving


Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving


Address	City, state, and zip code	From (month/year)	To (month/year)

With whom did you live

If rented, give name, complete address, and phone number of person who collected the rent

Reason for moving

Cohabitants (roommates)

List those individuals with whom you have resided during the last ten years, excluding family members.

Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known

Full name	Age	Home phone (area code)	Work phone (area code)
Full name			Work phone (area code)

Current address (include zip code)		Occupation		Years known

Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known


Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known


Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known


Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known


Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known


Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known


Full name	Age	Home phone (area code)	Work phone (area code)

Current address (include zip code)		Occupation		Years known

Experience and Employment

Beginning with your most current employment, list every job, including military service. Account for all time periods. Jobs include self-employment, part-time jobs, full-time jobs, temporary work, volunteer work, and internships. You must list all employment regardless of the length of employment. Addresses must be complete and accurate. Zip codes are required. If you have periods of unemployment, list those periods in sequence in the spaces specifically provided. Start with your most current employment.

Do you object to our contacting your present employer(s) prior to your being accepted? 9 Yes	9 No
If yes, please explain

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Work schedule (for example: Monday through Friday, 9 to 5, etc.)

How long employed there?

9 Present employment

Job title or position

9 Full time

9 Part-time

Salary

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name			Work or home phone (area code)

List another supervisor			Work or home phone (area code)

List a co-worker			Work or home phone (area code)

9 Unemployed	From:	To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

9 Present employment

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Present employment

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

9 Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed From:

To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Experience and Employment (continued)

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Dates of employment

Name of employer

Work phone (area code)

From

Month / year

Complete address

Job title or position

9 Full time

9 Part-time

Salary

How long employed there?

9 Volunteer

9 Internship

9 Temporary

Describe your duties

Reason for leaving (be specific)

Supervisor’s name

Work or home phone (area code)

List another supervisor

Work or home phone (area code)

List a co-worker

Work or home phone (area code)

Unemployed

From:

To:

Experience and Employment (continued)

Have you ever held employment under another name? 9 Yes		9 No
If yes, list the names used, the employer, and the dates of employment.

Name used	Employer		From (month/year)		to (month/year)




Have you ever been terminated (fired) or asked to resign from a job or position in lieu of termination?			9 Yes	9	No

If yes, start with most recent, and list the following information, giving details. If more space is needed, please explain under the general information section at the end of this application.

Date	Employer

Details





Date	Employer

Details





Date	Employer

Details





Date	Employer

Details

Have you ever had any extended work absences for any reason other than medical or earned vacations? (Leave of absence,

suspensions, layoffs, etc.).9 Yes 9 No

If yes, list the dates, name of employer, and details.

Date	Employer

Details

Experience and Employment (continued)

Have you ever been investigated by your employer or supervisor for improper conduct, illegal activities, sexual harassment, or equal employment violations?

9 Yes 9 No

If yes, please provide the following information.

Date

Employer

Details and results of investigation

Have you ever been suspended by an employer, or received a formal written reprimand, or verbal warning, or verbal counseling?

9 Yes 9 No If yes, please explain.

Date

Employer

Circumstances

Date

Employer

Circumstances

Date

Employer

Circumstances

Date

Employer

Circumstances

Date

Employer

Circumstances

Have you ever held a full-time or part-time position with peace officer powers? (Prior police experience includes police officer, police reserve, or military police)

9 Yes 9 No

If yes, list dates, employer/agency, rank ,and duties. Start with the most recent.

Date	Employer / agency
Duties / assignments
Duties / assignments

Rank

Date	Employer / agency

Duties / assignments

Rank

Experience and Employment (continued)


Have you ever attended a police academy or a law enforcement training center? 9 Yes								9	No
If yes, please provide the following information.

Name and address of training site							Date started			Date ended

Was the training	9	Full-time		9	Part-time?	List the total number of hours of the training course.

Did you complete the training?			9	Yes	9 No
If no, explain the reason.




Name and address of training site							Date started			Date ended

Was the training	9	Full-time		9	Part-time?	List the total number of hours of the training course.

Did you complete the training?			9	Yes	9 No

If no, explain the reason.

Have you ever been a police cadet or explorer? 9 Yes	9 No
If yes, please provide the following information.

Agency		Date started	Date ended

Agency		Date started	Date ended

Agency		Date started	Date ended

Prior Los Angeles Police Department applications

Have you ever applied to the Los Angeles Police Department before (for any position)? 9 Yes 9 No

If yes, please provide the date, the position, and results. Check all boxes that apply. Do not include this application.

Date applied

Position

9	Submitted application only 9 Took written test			9	Failed written test	9 Oral interview taken	9 Failed oral interview	9 Took PAT
9	Failed PAT	9	Submitted Personal History Form	9	Background investigation conducted 9 Background pending 9 Took polygraph
9	Disqualified	9	Was not selected 9 Hired or job offer made 9 Withdrew application or declined				9 Expired from the list	9 Other

Date applied

Position

9	Submitted application only 9 Took written test			9	Failed written test	9 Oral interview taken	9 Failed oral interview	9 Took PAT
9	Failed PAT	9	Submitted Personal History Form	9	Background investigation conducted 9 Background pending 9 Took polygraph
9	Disqualified	9	Was not selected 9 Hired or job offer made 9 Withdrew application or declined				9 Expired from the list	9 Other

Applications with other agencies

Have you ever applied for any other law enforcement agency (city, county, state ,or federal agencies)? 9 Yes 9 No

If yes, list EVERY agency you have applied with. Start with the most recent. Give complete, accurate addresses. All agencies

MUST be listed regardless of the outcome or current status. Check all boxes that apply for each agency.

Name of agency

Date applied

Complete address including zip code

Position

9 Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

9 Failed oral interview

9 Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency 9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Applications with other agencies (continued)

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Applications with other agencies (continued)

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Name of agency

Date applied

Complete address including zip code

Position

Submitted interest card only

9 Submitted application only

9 Took written test

9 Failed written test

9 Oral interviewed taken

Failed oral interview

Placed on eligibility list

9 Submitted Personal History Statement

9 Background investigation conducted

Background pending

Took polygraph

Disqualified

Was not selected

9 Hired / job offer made

Unknown status

No response from agency

9 Withdrew application or declined

9 Other

What was your background investigator’s name and phone number?

Military Service

Did you comply with the draft registration law?			9	Yes	9 No		Selective Service number

Have you ever served in any of the Armed Forces, National Guard, or military reserves?
9 Yes	9 No			9 Active		9 Reserves 9 Inactive		9 Discharged
If yes, what is your current status with the military?				9 Active		9 Reserves 9 Inactive		9 Discharged

Branch of service		Unit / Occupation					Enlistment date	Discharge date

Service number		Highest rank attained					Rank at discharge	Type of discharge

Separation code		Reenlistment code					If active or current reserve, list your commanding officer s name

Were you ever investigated for any criminal activity while in the military or military reserves? 9 Yes	9 No
If yes, please explain.

Have you ever been reduced in pay grade or been the subject of any judicial or nonjudicial disciplinary action while in the military,

National Guard, or military reserves? 9	Yes	9	No
If yes, please explain.
Approximate date	Violation			Penalty





Did you receive an honorable discharge?	9	Yes	9 No

If you received a discharge other than honorable, please explain.

Starting with	most recent, list all duty stations (include basic training,		tours overseas, etc.) while in the military.
From	To
(Month/Year)	(Month/Year)	Location	Duties / purpose

Education

The Commission on Peace Officer Standards and Training requires a peace officer to possess a US high school diploma or its equivalent. Please indicate your current status with this requirement. Check all boxes that apply.

9I possess a high school diploma from a US institution.

9I possess a two-year college degree from an accredited college.

9I possess a four-year degree from an accredited college or university.

9I passed the GED test meeting the required scores.

9I passed the California High School Proficiency Examination.

During the background investigation, persons who have known you in a learning environment will be contacted. A review of your school records may be made in conjunction with those contacts.

Name and address of US high schools attended and/or graduated from

From (month/year)

To (month/year)

Did you graduate

9 Yes 9 No

Have you ever attended college? 9 Yes 9 No

If yes, list all colleges and universities attended including post graduate.

Name of college or university

City and state

Major

From To

(month/year) (month/year)

Total units earned

Type degree earned

Have you ever attended a trade, vocational, or business school?	9 Yes 9 No
If yes, please provide the following information.			Did you finish the
			Did you finish the
Name of school (include city and state)	Type of school or training	Dates attended	course?

			9 Yes	9	No

			9 Yes	9	No

			9 Yes	9	No

Have you ever been placed on academic probation, suspended, or expelled from any high school, university, or trade school? 9 Yes 9 No If yes, please explain in detail.

Motor vehicle operation & insurance

Have you ever received a traffic citation? 9 Yes 9 No

If yes, list all traffic citations for the last four years. Start with most recent.

What action resulted? (Fined, traffic school attended, dismissed)

Month/year

Traffic violation

City and state

List all	vehicles that you own and/or operate that are registered		to you.	Is the vehicle			Is the vehicle currently
				Is the vehicle			Is the vehicle currently
Year	Make/Model	Color	License number and state	currently registered?			insured?

				9 Yes	9	No	9 Yes	9	No

				9 Yes	9	No	9 Yes	9	No

				9 Yes	9	No	9 Yes	9	No

				9 Yes	9	No	9 Yes	9	No

				9 Yes	9	No	9 Yes	9	No

California law requires that drivers and owners of vehicles be covered by automobile liability insurance. Please list your insurance company or companies.

Company

Telephone number (area code)

Policy number

Expiration date

Have you ever been refused auto insurance for any reason? 9 Yes 9 No

If yes, please explain.

As a driver, have you ever been involved in an accident where you left the scene without identifying yourself (hit and run)? 9 Yes 9 No

If yes, please explain.

Motor vehicle operation & insurance (continued)

As a driver, have you ever been involved in a motor vehicle accident? 9 Yes 9 No

If yes, please provide	the following information for the past four years		9 Yes	9
If yes, please provide	the following information for the past four years
Date	City and state	Were you at fault?			No
		Were you at fault?			No
		Was there a police report taken?	9 Yes	9	No
Police agency that took the report		Was there a police report taken?	9 Yes	9	No
Police agency that took the report			9 Yes	9 No
		Did the accident cause injury to another person?	9 Yes	9 No
		Were you cited or arrested?	9 Yes	9 No
		Was the accident a hit and run?	9 Yes	9 No

Date	City and state

Police agency that took the report

Were you at fault?	9 Yes	9
Was there a police report taken?	9 Yes	9
Did the accident cause injury to another person?	9 Yes	9
Were you cited or arrested?	9 Yes	9
Was the accident a hit and run?	9 Yes	9

Date	City and state

Police agency that took the report

Were you at fault?	9 Yes	9
Was there a police report taken?	9 Yes	9
Did the accident cause injury to another person?	9 Yes	9
Were you cited or arrested?	9 Yes	9
Was the accident a hit and run?	9 Yes	9

List other states where you are, or have been, licensed to operate a motor vehicle.

State

Name under which license was issued

License number

Have you ever been refused a driver’s license by any state, including California? 9 Yes 9 No If yes, please explain. Give state, dates, and reasons.

Have you ever applied for, or obtained, a driver’s license or state identification card under a fictitious name? 9 Yes 9 No If yes, please explain. Give state, dates, and reasons.

Has your driver’s license ever been suspended, revoked, or placed on negligent operator’s probation by any state, including California?

9 Yes 9 No If yes, please explain. (Give state, dates, and reasons.).

Motor vehicle operation & insurance (continued)

Have you ever failed to appear in court on a traffic citation or parking citation?			9 Yes 9 No
If yes, provide	the following information.
Approximate date
	Traffic violation	City / county / state	Reason you failed to appear

Have you ever had a warrant issued for you regarding a traffic citation or parking citation? 9 Yes 9 No
If yes, provide	the following information.
Approximate date
		Traffic violation	City / county / state		Penalty






				Legal


Date		Charges		Police agency	Penalty


Explain circumstances





Date		Charges		Police agency	Penalty


Explain circumstances




Date		Charges		Police agency	Penalty


Explain circumstances

Legal (continued)

Either as an adult or a juvenile, have you ever been arrested or charged with a criminal act (not listed prior sections)

9Yes 9 No Include charges that were dismissed, dropped, or reduced. If yes, provide the following information. Start with most recent.

Date

Charges

Police agency

Results

Explain circumstances

Date	Charges	Police agency	Results

Explain circumstances

Either as an adult or a juvenile, have you ever been detained for a criminal investigation, or named as a suspect in a police report, or held on suspicion, or questioned, or fingerprinted by any law enforcement agency or military authority, even as a victim or witness?

9 Yes	9 No	If yes, provide the following information.
Date		Charges or reason for investigation

Police agency

Explain circumstances

Date

Charges or reason for investigation

Police agency

Explain circumstances

Have you ever received a misdemeanor citation in lieu of going to jail? 9 Yes 9 No

If yes, explain below giving details, dates, and name of the law enforcement agency issuing the citation.

Legal (continued)

Have you ever been placed on court probation?	9 Yes	9	No
Are you currently on probation?	9 Yes	9	No

If yes to either question, explain below giving details, dates, and reason. If you were on probation more than once, please
indicate.
Date		Details





Have you ever violated probation?			9 Yes 9 No
If yes, please explain below.




Have you ever had a warrant issued for your arrest or have you ever failed to appear in court on a criminal matter?
9 Yes 9	No If yes, please explain below.




Have you ever been reported to a law enforcement agency as a missing person or runaway? 9 Yes 9 No
If yes, please explain		below.
Date		Details

Were you ever required to appear before a juvenile court for an act which would have been a crime if committed by an adult?

9 Yes	9	No
If yes, please explain			below.
Date			Details




Have you ever applied for a permit to carry a concealed weapon?
9 Yes	9	No If yes, please explain below.		9 Yes 9
Date applied			Was permit granted?	9 Yes 9	Weapon?
Date applied					Weapon?
			No

Name of the agency where applied (city, county, and state).

For what purpose?

Legal (continued)

Are you now or have you ever been involved as a plaintiff or defendant in any civil court action? 9 Yes 9 No Ever had a judgment rendered against you? 9 Yes 9 No

If yes to either questions, provide the following information.		9 Plaintiff	9 Defendant
Date	Location of court


Details



Date	Location of court	9 Plaintiff	9 Defendant
		9 Plaintiff	9 Defendant

Details

Are you now, or have you ever been, a member of any organized association, movement, group, or combination of persons which advocated or advocates the overthrow of our constitutional form of government by any means other than the democratic procedures provided by our form of government?

9 Yes 9 No

Are you now, or have you ever been, a member of any organized association, movement, group, or combination of persons which advocated or advocates acts of force or violence to deny other persons their rights under the Constitution of the United States by

unconstitutional means?	9 Yes
9 No

Are you now associating with, or have you ever associated with, any individuals, including relatives, who you know or have reason to believe are, or have been, members of any of the type of organizations identified above?

9 Yes 9 No

If yes to any of the above three questions, please explain below.

Have you ever participated in an unlawful demonstration? 9 Yes 9 No

If yes, please explain below.

Have you ever engaged in civil disobedience?

9 Yes 9 No If yes, please explain below.

Finances

The management of personal finances is relevant to an individual’s qualifications for the position of peace officer. Please provide the following information. The amount of indebtedness in itself will not be used in evaluating your qualifications, but rather the behavior exhibited in meeting your overall financial obligations.

Current monthly income		Current monthly expenditures
Monthly salary	$	Home payment (mortgage or rent)	$

Spouse’s salary		Car payment

Other income		Auto insurance

		Credit cards (charge accounts)

		Utilities and other monthly payments

Total monthly income	$	Total monthly expenditures	$


Current assets		Current liabilities
Savings	$	Real estate indebtedness	$

Checking		Long-term loans

Real estate		Credit cards (total amount of charge accounts)

Stocks and bonds		Other liabilities

Auto (s)		Other liabilities

Other assets		Other liabilities

		Other liabilities

Total assets

Total liabilities

Please list all banks or savings institutions where you have current accounts.

Bank	Address	9	Checking	9	Savings How long there?
		9	Checking	9	Savings How long there?

Bank	Address	9	Checking	9	Savings	How long there?
		9	Checking	9	Savings	How long there?

Bank	Address	9	Checking	9	Savings	How long there?
		9	Checking	9	Savings	How long there?

Please list information on all of your current (open) charge accounts, loans, financial contracts and long-term liabilities.

				List the number of times
		Monthly	Current	you have been late thirty
Name of creditor, bank, firm or lender	Reason for debt	payment	balance	days or more.

Finances

Have you ever filed for or been granted bankruptcy? 9 Yes 9		No
If yes, please explain	reasons below.
Date	Reasons



Have you ever been delinquent on income tax payments? 9 Yes		9	No
If yes, was it more than once? 9 Yes 9 No
Date	Reasons (give the year (s) involved and the current status)



Have you ever had your wages attached or garnished? 9 Yes		9	No
If yes, please explain	reasons below.
Date	Reasons

Have you ever had any of your bills, accounts, or loans turned over to a collection agency? 9 Yes 9 No

If yes, list all accounts.
Date	Account / current status

Date	Account / current status

Date	Account / current status

Date	Account / current status

Date	Account / current status

Date	Account / current status

Have you ever had any purchased goods, vehicle, property, or any items repossessed? (This includes voluntary repossessions.)

9	Yes	9 No
If yes, please explain.
Date			Reasons



Have you been refused credit in the last year? 9 Yes				9 No
If yes, please explain.
Date			Reasons



Are you currently an owner, partner, or investor in any business enterprise that requires a federal, state, county, or city
permit/license to operate?				9 Yes
9	No

If yes, please provide the following information.

Name and type of business & address

If employed by LAPD, do you anticipate any other income other than your city salary or spouse’s salary? 9 Yes 9 No If yes, from where?

References

Please list as references seven individuals you have know for at least two years who have knowledge of you and your qualifications. Examples are personal friends, friends of the family, teachers, neighbors, classmates, or military acquaintances. DO NOT include relatives, family members, or individuals who belong to the law enforcement profession.

Name / occupation / relationship		Address (including zip code)		Telephone (including area code)

Name				Home

Occupation				Work

Relationship	Age		How long have you known?

Name

Occupation

Relationship

Home

Work

Age	How long have you known?

Name

Occupation

Relationship

Home

Work

Age	How long have you known?

Name

Occupation

Relationship

Home

Work

Age	How long have you known?

Name

Occupation

Relationship

Home

Work

Age	How long have you known?

Name

Occupation

Relationship

Home

Work

Age	How long have you known?

Name

Occupation

Relationship

Home

Work

Age	How long have you known?

Optional: Please list any individuals who are members of law enforcement agencies that you are acquainted with and who have knowledge of you and your qualifications. Address may be their residence or place of employment. Addresses must be complete with zip codes. Telephone numbers must include area codes.

Name / occupation / agency	Address (including zip code)	Telephone (including area code)


Name		Home

Agency		Work


Name		Home

Agency		Work


Name		Home

Agency		Work


Name		Home

Agency		Work

Key Addresses

The following information has been asked of you earlier in this application. Please provide it again, as requested.

List all addresses of your residences during the last ten years or since age fifteen. Begin with your most current residence.

Address	City	State	From	To













List addresses for all your employers. Begin with your most current employment. List every job, including military service.


Address	City	State	From	To

List all law enforcement agencies that have conducted a background check on you.

Agency

Address

ZONE 1

ZONE 2

ZONE 3

ZONE 4

ZONE 5

S/T

N/T

ATLAS

General information

Use this page as an addendum or supplement to any question you responded to. If responding to a question, please indicate the question number.

General information (continued)

Use this space for any additional information.

I understand that any conditional job or appointment tendered to me will be contingent upon the results of a thorough background investigation.

I further understand that during the application process and/or background investigation, I am required to report to the Los Angeles Police Department, Personnel Division, Administrative Investigation Section (backgrounds) any changes in my personal history covered in this Personal History Form within five business days. I am aware that failure to report any changes in my personal history may cause my name to be removed from further consideration.

Prior to submitting my Personal History Form, I reviewed it carefully for completeness and accuracy.

I hereby certify that all statements made in this Personal History Form are true and complete. I understand that any discrepancies, misstatements, omissions, and/or falsifications will be cause for disqualification, for my name to be removed from the eligibility list, or for immediate termination if an appointment has been made.

Applicant’s signature:		Date:

Reviewing investigator’s name and serial number:		Date:

Question	Answer
Form Name	Lapd Personal History Form
Form Length	40 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	10 min
Other names	lapd personal history statement, lapd phs, lapd history form, lapd forms pdf

Lapd Personal History Form – Fill Out and Use This PDF

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