Nc F 3 – Fill Out and Use

FORM F-3

NORTH CAROLINA SHERIFFS' EDUCATION AND TRAINING STANDARDS COMMISSION

PERSONAL HISTORY STATEMENT

INSTRUCTIONS: Fill out this form completely and accurately. If you need extra space, add additional pages and identify the information by item number. All questions must be answered.

NOTE: Any statements are subject to validation and any incorrect statements or omissions may disqualify you from certification. Truthful statements to any item requested will not necessarily exclude you from consideration. This form must be notarized upon completion.

POSITION(S) APPLIED FOR :

Agency

Date

PERSONAL

1.Name:

First

Middle

Last

Maiden Name

Other previous last names:

Nicknames or Aliases

Note: If your name was legally changed after the age of 12, please submit documentation showing when that occurred.

2. Social Security

3. Present Mailing Address:

Permanent Mailing Address

Street and Number

Street and Number

City

City

State

Zip Code

State

Zip Code

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Note:	Data solicited in questions 6 and 7 will be utilized for equal employment statistical
	information purposes only

11. Do you object to occasionally being away from home overnight and/or for other periods of time to attend

meetings, acquire training or otherwise perform official duties?					Yes			No
EDUCATIONAL
12. Indicate the type of High School you attended:
Traditional
Home School
GED
Distance Learning
Did not attend high school
Other:
A. High Schools:
NAME:				WHEN ATTENDED:
				GRADUATED:
CITY:
				DEGREE AWARDED:
STATE:
				MAJOR FIELD:
YEARS COMPLETED:
				WHEN ATTENDED:
NAME:
				GRADUATED:
CITY:
				DEGREE AWARDED:
STATE:
				MAJOR FIELD:
YEARS COMPLETED:
B. University or Colleges:
NAME:				WHEN ATTENDED:
				GRADUATED:
CITY:
				DEGREE AWARDED:
STATE:
				MAJOR FIELD:
YEARS COMPLETED:
				WHEN ATTENDED:
NAME:
				GRADUATED:
CITY:
				DEGREE AWARDED:
STATE:
				MAJOR FIELD:
YEARS COMPLETED:

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C. Continuing Education:

NAME:				WHEN ATTENDED:
CITY:				GRADUATED:
STATE:				DEGREE AWARDED:
YEARS COMPLETED:				MAJOR FIELD:
NAME:				WHEN ATTENDED:
CITY:				GRADUATED:
STATE:				DEGREE AWARDED:
YEARS COMPLETED:				MAJOR FIELD:

RESIDENCES

13. List addresses for the past 10 years starting with present address listed first:

FAMILY HISTORY

NOTE: Questions included in the next section are intended to assist in the conducting of a background investigation and are not intended for use by the employing agency as disqualifying factors for employment as a justice officer

15. Name of Spouse / Former Spouse(s)

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(1)

(2)

(3)

(4)

(5)

(6)

17.Are there persons, other than your spouse and listed children, who are presently dependent upon you

for support?		Yes	No	If YES, give details:

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FINANCIAL

20. What sources of income other than salary do you have at present?

21. Have you ever been sued with a civil judgment being rendered against you? Please note this includes

repossessions, evictions, executions, etc.		Yes	No	If YES, explain:

23.What is the total amount of all your debts at present?

24.What is the average monthly total of all your bills, payments, and current living expenses?

25.List credit references, including businesses to which you make monthly payments:

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WORK HISTORY

26. Have you ever been denied employment by a criminal justice agency after a conditional offer of

employment was made?			Yes	No	(If Yes, list agency name and reason.)

27.Have you ever held a position in any capacity which required certification or licensure from any Commission, Board or Agency established to certify or license that position? (Note: List any such

Commission, Board or Agency, whether in or out of North Carolina.)

Yes

No

27a. If yes, was such certification or license ever suspended, revoked, or any sanctions taken against it by

the issuing authority?

Yes

No

27b. If such certification or license was ever suspended, revoked, and any sanctions taken against it by

the issuing authority, please list the agency's name taking action against the certification or license, date of action, reason for the action, and period of time for the suspension, revocation, or sanction.

28. Have you ever been discharged or requested to resign from any position because of criminal misconduct

or rules violations?	Yes	No ( If Yes, list employer, time-frame and reason.)

29.List all jobs, positions or appointments you have held in the last ten years to include inactive, active, reserve, temporary, part-time, paid or not paid employment and internships. Put your present or most recent job first. List a Reason for Leaving for each job. Include military service in proper time sequence and temporary part-time jobs. If you do not have a full ten year job history, be sure to provide an explanation.

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7

If you need more space, attach additional sheets.

Explain periods of unemployment of three months or more, if you do not have a full ten-year job history:

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MILITARY SERVICE

30. Were you ever in the U.S. Military service or any other military organization? (Even if you served for

only one day, list this service.)

Yes

No If YES, complete #31 through #38. If NO, skip to #39.

31.What was your service number?

32.A. What was the highest rank you held?

B.What was the last rank you held?

33.A. What was the date and location of your first enlistment and/or commission?

B.List all tours of duty where a DD214 was issued.

34. List all stations of assignment including active, reserve and/or National Guard (Attach additional pages if needed.)

37.Were you ever court martialed, tried on charges, or the subject of a summary court, deck court, non-judicial punishment, captains mast, company punishment, article 15, written reprimand, and/or any other disciplinary action while a

member of the military, Nation Guard or reserve unit?

Yes

No

If YES, explain what occurred and what type of punishment you received:

38.If you are presently a member of the National Guard or any military reserve, give the unit, location, and describe your obligation, and provide your expected date of separation:

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USE OF ALCOHOL

NOTE: In question #39 the word "drink" means one time or more, including experimentation.

PRIOR CRIMINAL CONDUCT

NOTE: Answer all of the following questions completely and accurately. Any falsification or misstatement of facts may be sufficient to disqualify you from certification. The word "used" in the following questions includes even one time use or experimentation. Applicants for the position of Justice Officer must disclose all prior criminal conduct.

40. Have you ever used any illegal drugs including but not limited to marijuana, synthetic or designer drugs, steroids, opiates, pills, heroin, cocaine, crack, LSD, etc., to include even one time use or experimentation? Yes No (If YES, specify the circumstances, drugs used, and when the usage last occurred.)

41. Have you ever used prescription drugs other than under the supervision or as prescribed by a physician to include even one time use or experimentation? Yes No (If YES, specify what drug(s), how and from whom you received the drug(s), and when the usage last occurred)

42. Have you ever purchased, possessed, manufactured, grown, delivered or sold any amount of illegal drugs or controlled substances for which you did not have a valid prescription. Yes No (If YES, please identify the drug(s) and provide details concerning the purchase, possession, manufacture, growth, delivery or sale.)

43. Have you ever had a Domestic Violence Protective Order or Civil No Contact Order issued against you? (Include both

ex-parte domestic violence protective orders and those entered subsequent a hearing.) Yes No

(If YES, complete the following and provide documentation of the initial allegations and the judge's findings at the hearing where both parties were present.)

Date of Issuance

County of Issuance:

Name of Plaintiff:

Date of Expiration:

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NOTE: In response to the following question, include all offenses other than minor traffic offenses. The following

are NOT minor traffic offenses and must be listed below: DWI, DUI (alcohol and drugs), Failure to Stop in the Event of an Accident (hit and run) and Driving While License Permanently Revoked or Permanently Suspended (DWLR). Attached to this form is an additional list of North Carolina traffic offenses which should also be listed. Juvenile charges or arrests should also be listed.

If any doubt exists in your mind as to whether or not you were arrested or charged with a criminal offense at some point in your life or whether an offense remains on your record, you should answer "YES." You must include any and all convictions regardless of whether or not the convictions were expunged pursuant to NCGS 15A-145.4 and 15A-145.5.

44.Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense?

(As used in this question, the term "charged" includes being issued a citation or criminal summons.)

A.OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

B.OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

C.OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

D.OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

E.OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

F.OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

(ADD EXTRA SHEETS, IF NECESSARY.)

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45.Under federal law you may be disqualified to receive or possess a firearm if you meet any of the following conditions:

(A)currently under indictment for information in any court for a crime punishable by imprisonment for a term exceeding one year.

(B)have been convicted in any court of a crime punishable by imprisonment for a term exceeding one year. A person would not be ineligible under this criteria if the person has been pardoned for the crime or conviction, the crime or conviction has been expunged or set aside or the person has had their civil rights restored, and under the law where the conviction occurred, the person is not prohibited from receiving or possessing any firearm.

(C)are a fugitive from justice.

(D)are an unlawful user of, or addicted to marijuana, or any depressant, stimulant, or narcotic drug, or any other controlled substance.

(E)have ever been adjudicated mentally defective or have been involuntarily committed to a mental institution.

(F)have been discharged from the armed forces under dishonorable conditions.

(G)are illegally in the United States.

(H)have renounced your citizenship, having previously been a citizen of the United States.

NOTE: A "crime punishable by imprisonment for a term exceeding one year," as discussed in (A) and (B) above is defined in federal law so as to exclude most misdemeanors in North Carolina.

If any of the above (A though H) apply, please note below and submit an explanation on a separate sheet of paper which accompanies this form. Your signature on the attestation found on page 15 of this document indicates you have read this section and understand each of the disqualifiers.

46. Have you been convicted of a misdemeanor under federal or state law which has, as an element, the use or

attempted use of physical force, or the threatened use of a deadly weapon?		Yes	No (If YES, explain)

If so, did you commit the act(s) against a current or former spouse, parent, or guardian, or against a person with whom you share a child in common, or against a person with whom you were or are cohabiting with, or a person

similarly situated to a spouse, parent, or guardian or the victim (Domestic Violence Offense)?

Yes

No

OFFENSE CHARGED:

LAW ENFORCEMENT AGENCY:

DATE:

DISPOSITION:

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47.Have you ever been charged with or convicted of a felony? You must include any and all felony convictions regardless of whether or not the convictions were expunged pursuant to NCGS 15A-145.4 and 15A-145.5

49.Have you ever paid a court-imposed fine?

Yes	No If YES, give details:

51.Do you or have you ever possess(ed) a driver’s license issued in any state other than North Carolina?

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CAREER OBJECTIVES

54.Briefly explain your reasons for applying for this position:

55.List special skills, training, field of work for which you are licensed, registered, or certified, and hobbies which may be useful in the performance of the duties of the position for which you have applied:

56.What are your feelings about the use of deadly force if it became necessary in the performance of official duties?

(Not applicable for telecommunicators)

REFERENCES

57.Give the names of five responsible persons, other than relatives or past employers, who could provide information about your character, ability, experience, personality, and other qualities.

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STATE OF NORTH CAROLINA

COUNTY OF

I hereby certify that each and every statement made on this form is true and complete and understand that any misstatements or omission of information may subject me to disqualification or dismissal. I also acknowledge that I have a continuing duty to update all information contained in this document. I will report to the employing agency and forward to the Sheriffs' Education and Training Standards Commission any additional information which occurs after the signing of this document.

THIS THE

DAY OF

, 20

(SIGNATURE IN FULL)

SUBSCRIBED AND SWORN TO BEFORE ME,

THIS THE

DAY OF

, 20

(SIGNATURE IN FULL)

Notary Public (Official Seal)

MY COMMISSION EXPIRES:

, 20

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EXCERPT FROM CLASS B MISDEMEANOR MANUAL OF TRAFFIC OFFENSES WHICH ARE NOT MINOR

	20-28	Driving while license permanently revoked (20-28(b)[(b) Repealed]	10/1/94 -11/12/96	1
	20-28(d)(3)	Driving while license permanently revoked (3rd offense)	5/31/02-Present	1
	20-30(5)	Fictitious name or address in any application for a driver’s license or learner’s permit	5/31/02-Present	2
		(20-35)
	20-37.7(e)	Special identification card (fraud or misrepresentation in application of or use thereof)	01/01/06-Present	2
	20-37.8	Fraudulent use of a fictitious name for a special identification card (20-37.8(b))	10/1/94-12/1/99	2
		[NOTE: violations of 20-37.8(b) became felonious eff. 12/1/99]
	20-37.8	Fraudulent use of a fictitious name for a special identification card (20-37.8(c))	5/31/02-Present	2
	20-63(g)	Registration of plates furnished by the Division, etc. (alteration, disguise, or	01/01/06-Present	2
		concealment of numbers)
	20-71.4	Failure to disclose damage to a vehicle	01/01/06-Present	2
	20-102.1	False report of theft or conversion of a motor vehicle	10/1/94-Present	2
	20-111(5)	Fictitious name or address in application for registration	10/1/94-Present	1
	20-130.1	Use of red or blue lights on vehicles prohibited (20-130.1(e))	10/1/94-Present	1
	20-136.2	Air bag installation	01/01/06-Present	1
	20-137.2	Operation of vehicles resembling law-enforcement vehicles (20-137.2(b))	10/1/94-Present	1
	20-138.1	Driving while impaired (punishment level 1; 20-179(g) or 2 (20-179(h))	10/1/94-5/31/02	M
	20-138.1(d)	Driving while impaired (punishment level 1; 20-179(g) or 2 (20-179(h))	5/31/02-Present	M
	20-138.2	Impaired driving in commercial vehicle (20-138.2(e))	10/1/94-Present	M
	20-141(j)	At least 15 mph over; trying to elude arrest	10/1/94-12/1/97	1
		[NOTE: Repealed paragraph (j) eff. 12/1/97; recodified under 20-141.5(a)]
	20-141.3(a) & (c)	Unlawful racing on streets and highways	11/12/96-Present	1
	20-141.5(a)	Speeding to elude arrest	11/17/99-Present	1
	20-157(h)	Duty to Move Over	01/01/06-Present	1
	20-166(b)	Duty to stop in event of accident or collision	10/1/94-Present	1
	20-166(c)	Duty to stop in event of accident or collision	10/1/94-Present	1
	20-166(c1)	Duty to stop in event of accident or collision	10/1/94-Present	1
	20-183.8(b1)	Inspection violation by Inspector	3/1/11-Present	3
	20-279.31(b)(1)	Other violation; penalties (gives information required in a report of a reportable	01/01/06-Present	1
		accident, knowing/having reason to believe information is false)
	20-279.31(b)(2)	Other violations; penalties (forges or without authority signs any evidence of proof of	01/01/06-Present	1
		financial responsibility)
		Other violations; penalties (forges/offers for filing any evidence of proof of financial
	20-279.31(b)(3)	responsibility, knowing/having reason to believe that evidence is forged/signed without	01/01/06-Present	1
		authority)
	20-313.1	Making false certification or giving false information	01/01/06-Present	1
	20-371	Regulation of professional house moving [increased punishment from Class 3 to Class	3/1/11-Present	1
		1 misdemeanor]

*Note that violations of 20-138.1 Driving While Impaired (punishment levels 3, 4 & 5) are considered Class A

Misdemeanor and should also be listed in response to number 44.

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