Nc F 3 form is a document that is used in the State of North Carolina to report changes in your family's situation or household. This form can be used to report changes such as a birth, death, marriage, or change of address. You can use this form to update your name, Social Security number, and much more.
You may find details about the type of form you intend to submit in the table. It will tell you how much time you'll need to complete nc f 3, what fields you will have to fill in, and so forth.
Question | Answer |
---|---|
Form Name | Nc F 3 |
Form Length | 17 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 4 min 15 sec |
Other names | f3 form, personal history statement form, are nc form fishing license, ncdoj forms form |
Form
Revised August 2014
Sheriffs’ Education and Training Standards Commission
North Carolina Department of Justice
SHERIFFS’ STANDARDS DIVISION
Telephone: (919)
Fax : (919)
Personal History Statement
Note: This form is not designed for use as an initial application for employment and must not be used for that purpose. Rather, the applicant should complete this form prior to beginning his/her background investigation. This form should only be completed by applicants for the position of a justice officer. It is the determination of the Commission that these questions are necessary in order to fully and adequately evaluate applicants for justice officer certification. These questions are designed to ascertain whether the applicant meets the minimum standards for certification and serves no other purpose.
*The Social Security Number is used to make a positive identification of the applicant and/or law enforcement personnel. DISCLOSURE IS VOLUNTARY. However, failure to provide this information may result in a delay in the processing of application materials and may result in inaccurate records being assigned to you.
FORM
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 |
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Deputy
Detention Officer
Telecommunicator
Have you previously submitted an application for employment with this agency?
If YES, approximate date:
Yes
No
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 |
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3. Present Mailing Address: |
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Permanent Mailing Address |
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Street and Number |
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Telephone Numbers:
Home:
Pager:
Cell/Mobile
4a. Date of Birth:
5. Citizenship: |
U.S. Born |
Work:
4b. Place of Birth:
(City/State/Country)
U.S. Naturalized |
Other, specify: |
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Note: |
Data solicited in questions 6 and 7 will be utilized for equal employment statistical |
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information purposes only |
6. Ethnicity:
African American
Asian American
Hispanic
Caucasian
Other:
7. Gender:
Male
Female
8.Do you object to wearing a uniform?
9.Do you object to working nights?
10. Do you object to working rotating shifts?
Yes
Yes
Yes
No
No
No
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 |
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EDUCATIONAL |
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12. Indicate the type of High School you attended: |
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Traditional |
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Home School |
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GED |
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Distance Learning |
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Did not attend high school |
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Other: |
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A. High Schools: |
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NAME: |
WHEN ATTENDED: |
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GRADUATED: |
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DEGREE AWARDED: |
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MAJOR FIELD: |
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WHEN ATTENDED: |
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YEARS COMPLETED: |
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B. University or Colleges: |
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NAME: |
WHEN ATTENDED: |
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GRADUATED: |
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MAJOR FIELD: |
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WHEN ATTENDED: |
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MAJOR FIELD: |
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C. Continuing Education:
NAME: |
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RESIDENCES
13. List addresses for the past 10 years starting with present address listed first:
From: |
To: |
(MM/YY) |
(MM/YY) |
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Address, City, State
County
Landlord
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
14.Marital Status: Never Married
Married
Divorced
Engaged
Separated
Widowed
15. Name of Spouse / Former Spouse(s)
3
16.A. Do you have any children born to you, adopted by you, or stepchildren? B. If Yes, list all of your children below:
Yes
No
Name
Birthdate
Relationship
With whom
resides
Phone Number
(1)
(2)
(3)
(4)
(5)
(6)
C. Are you now supporting all these children?
Yes
No If NO, give details:
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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18.Are you related by blood or marriage to any person (s) now employed by this agency? If YES, give name(s) and details:
Yes
No
19.Is any member of your immediate family now in prison/jail or on probation or parole? Yes If YES, give name(s) and details:
No
4
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: |
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22. Have you ever declared bankruptcy?
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:
Firm / Business
Street Address
City / State
Amount Owing
5
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.) |
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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, |
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29.List all jobs, positions or appointments you have held in the last ten years to include inactive, active, reserve, temporary,
Employer:
Job Title:
Date Employed (MM/YY):
Date Separated (MM/YY):
Full Time: |
YRS |
MOS |
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Part Time: |
YRS |
MOS |
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If
Reason for Leaving:
Address:
Supervisor's Name:
Starting Salary:
Per:
List Major Duties in Order of Importance:
Phone Number:
Ending or Current Salary:
Per:
6
Employer:
Job Title:
Date Employed (MM/YY):
Date Separated (MM/YY):
Full Time: |
YRS |
MOS |
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Part Time: |
YRS |
MOS |
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If
Reason for Leaving:
Address:
Supervisor's Name:
Starting Salary:
Per:
List Major Duties in Order of Importance:
Phone Number:
Ending or Current Salary:
Per:
Employer:
Job Title:
Date Employed (MM/YY):
Date Separated (MM/YY):
Full Time: |
YRS |
MOS |
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Part Time: |
YRS |
MOS |
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If
Reason for Leaving:
Address:
Supervisor's Name:
Starting Salary:
Per:
List Major Duties in Order of Importance:
Phone Number:
Ending or Current Salary:
Per:
Employer:
Job Title:
Date Employed (MM/YY):
Date Separated (MM/YY):
Full Time: |
YRS |
MOS |
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Part Time: |
YRS |
MOS |
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If
Reason for Leaving:
Address:
Supervisor's Name:
Starting Salary:
Per:
List Major Duties in Order of Importance:
Phone Number:
Ending or Current Salary:
Per:
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Employer:
Job Title:
Date Employed (MM/YY):
Date Separated (MM/YY):
Full Time: |
YRS |
MOS |
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Part Time: |
YRS |
MOS |
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If
Reason for Leaving:
Address:
Supervisor's Name:
Starting Salary:
Per:
List Major Duties in Order of Importance:
Phone Number:
Ending or Current Salary:
Per:
Employer:
Job Title:
Date Employed (MM/YY):
Date Separated (MM/YY):
Full Time: |
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MOS |
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Part Time: |
YRS |
MOS |
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If
Reason for Leaving:
Address:
Supervisor's Name:
Starting Salary:
Per:
List Major Duties in Order of Importance:
Phone Number:
Ending or Current Salary:
Per:
If you need more space, attach additional sheets.
Explain periods of unemployment of three months or more, if you do not have a full
8
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.
Branch
Date Entered
Date Released
34. List all stations of assignment including active, reserve and/or National Guard (Attach additional pages if needed.)
Branch
Unit (Company or Ship)
Location
From (MM/YY) TO (MM/YY)
35.What was the date and location of your last discharge from active duty?
36.Have you ever received any of the following types of discharge:
Uncharacterized (includes entry level separations)
Honorable
General (under honorable conditions)
Under other than honorable conditions (includes undesirable)
Bad Conduct discharge
Dishonorable discharge
Dismissal
Yes
Yes
Yes
Yes
Yes
Yes Yes
No
No
No
No
No
No No
37.Were you ever court martialed, tried on charges, or the subject of a summary court, deck court,
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:
9
USE OF ALCOHOL
NOTE: In question #39 the word "drink" means one time or more, including experimentation.
39. Do you drink alcoholic beverages?
Yes
No
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
(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 |
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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
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.)
Yes
No (If YES, complete the following and provide documentation of each offense listed.)
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) |
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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:
12
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
Yes
No If YES, give details:
48.Have you ever been placed on
Yes
No If YES, give details:
49.Have you ever paid a
Yes |
No If YES, give details: |
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50.Do you or have you ever possess(ed) a driver’s license from the State of North Carolina?
License Number |
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Year Issued |
Yes
No
51.Do you or have you ever possess(ed) a driver’s license issued in any state other than North Carolina?
Yes
State
No If YES, give the State and number:
License Number
52.A. Was your license ever suspended or revoked?
Yes |
No If YES, give details: |
B. IF Yes, was your license ever restored?
Yes
No |
If YES, state when and give details: |
53.Have your driving privileges ever been restricted?
Yes |
No If YES, give details: |
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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.
1)
2)
3)
4)
5)
Name
Address
City
State
Telephone
14
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 |
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(SIGNATURE IN FULL)
SUBSCRIBED AND SWORN TO BEFORE ME,
THIS THE |
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DAY OF |
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(SIGNATURE IN FULL)
Notary Public (Official Seal)
MY COMMISSION EXPIRES: |
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EXCERPT FROM CLASS B MISDEMEANOR MANUAL OF TRAFFIC OFFENSES WHICH ARE NOT MINOR
Driving while license permanently revoked |
10/1/94 |
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Driving while license permanently revoked (3rd offense) |
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Fictitious name or address in any application for a driver’s license or learner’s permit |
2 |
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Special identification card (fraud or misrepresentation in application of or use thereof) |
2 |
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Fraudulent use of a fictitious name for a special identification card |
2 |
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[NOTE: violations of |
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Fraudulent use of a fictitious name for a special identification card |
2 |
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Registration of plates furnished by the Division, etc. (alteration, disguise, or |
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concealment of numbers) |
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Failure to disclose damage to a vehicle |
2 |
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False report of theft or conversion of a motor vehicle |
2 |
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Fictitious name or address in application for registration |
1 |
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Use of red or blue lights on vehicles prohibited |
1 |
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Air bag installation |
1 |
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Operation of vehicles resembling |
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Driving while impaired (punishment level 1; |
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Driving while impaired (punishment level 1; |
M |
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Impaired driving in commercial vehicle |
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At least 15 mph over; trying to elude arrest |
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[NOTE: Repealed paragraph (j) eff. 12/1/97; recodified under |
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Unlawful racing on streets and highways |
1 |
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Speeding to elude arrest |
1 |
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Duty to Move Over |
1 |
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Duty to stop in event of accident or collision |
1 |
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Duty to stop in event of accident or collision |
1 |
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Duty to stop in event of accident or collision |
1 |
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Inspection violation by Inspector |
3 |
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Other violation; penalties (gives information required in a report of a reportable |
1 |
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accident, knowing/having reason to believe information is false) |
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Other violations; penalties (forges or without authority signs any evidence of proof of |
1 |
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financial responsibility) |
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Other violations; penalties (forges/offers for filing any evidence of proof of financial |
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responsibility, knowing/having reason to believe that evidence is forged/signed without |
1 |
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authority) |
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Making false certification or giving false information |
1 |
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Regulation of professional house moving [increased punishment from Class 3 to Class |
1 |
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1 misdemeanor] |
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*Note that violations of
Misdemeanor and should also be listed in response to number 44.
16