Personal Police History Form – Fill Out and Use This PDF

Keeping an up to date record of any police contact connected with your name is a beneficial practice. The Personal Police History Form is a comprehensive account of encounters or behaviors that is reflective of past and present situations. This document allows individuals to have visibility on any contact associated with one's name, as well as easily be accessed for review. It can provide assurance that municipal records are kept accurate, ensuring trust within communities and affiliations. Regardless of location, this form provides an important service by allowing individuals the ability to assess their interactions with police forces across jurisdictions and countries.

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Personal Police History Form PDF Details

It can be daunting to report and share details of your personal police history, especially if you have had prior interactions with the law enforcement community. In many circumstances, it is a legal requirement that you disclose any contact with the police, in whole or part. This blog post will explain why it’s important to fill out a Personal Police History Form as accurately and honestly as possible and what this form entails. Whether you are asked to submit one by a potential employer or educational institution or for another purpose, being accurate on your forms is essential. Beyond just helping protect all parties involved in the process, it may also give rise to more opportunities down the line when seeking admission into academic institutions or applying for various positions of employment. We’ll be exploring some valuable information about these forms today so keep reading!

Question	Answer
Form Name	Personal Police History Form
Form Length	29 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min 15 sec
Other names	phs personal history sample, personal san history template, personal police history get, san diego personal history

Form Preview Example

SAN DIEGO POLICE DEPARTMENT

Personal History Statement

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Application

THIS DOCUMENT IS FOR THE EXCLUSIVE USE OF THE BACKGROUND INVESTIGATIONS UNIT.

Today’s Date	Position Applied for:			Police Recruit		POI	POII	Reserve	CSO


1. Have you ever applied to the San Diego Police Department before?				Yes	No	Date of written test for Police Recruit or Reserve

If yes, did you submit a Personal History Statement?		Yes	No	If yes, see below

2. List the date you last applied to the San Diego Police Department:

Personal

3. Please PRINT clearly or type your full legal name

Last

First

Middle

Age

4. List your current address where you actually reside. (Not a mailing address)

Number & Street	City	State	Zip Code

Rent Own Parents Other

5. How long have you resided there?

Years:

Months:

Name of the County where you reside.

List your residence phone and your

Residence (area code)

Work (area code)

E-Mail

work number (include area codes)

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

Mailing Address

City

State

Zip Code

You must be a citizen of the United States or a permanent resident alien who is eligible for and

Birthdate

has applied for citizenship. Can you provide documentation for one or the other?

Yes

Place of Birth:

In accordance with the Federal Privacy Act of 1974, disclosure of your Social Security Number is

Social Security Number

voluntary. The SSN will be used for identification purposes to ensure proper records are obtained.

10.

For the purposes of identification, please provide the following:

Sex

Height

Weight

Hair

Eyes

11.

List and describe all tattoos: (Indicate where they are located)

12.

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

Last

First

Middle

Year(s) used

PD-923-Bl (Rev. 5-08)

This information is available in alternative formats upon request

Page 1 of 29

Printed on Recycled Paper

Education

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Print your name

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

I possess a high school diploma from a U.S. institution.

I possess a two (2) year college degree from an accredited U.S. college

I possess a four (4) year degree from an accredited U.S. college or university.

I passed the G.E.D. text meeting the required scores.

I 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.

14. Name and address of U.S. high school graduated or last attended

From (Date)

To (Date)

15. Did you graduate?

Yes

16. Have you ever attended college?

Yes

No If yes, list all colleges and universities attended including post graduate work.

Name of college or university

City and State

Major

Date first Attended (mo & yr)

Date last Attended (mo & yr)

Total units	What type
actually	degree
earned	earned

17. Have you ever attended a trade, vocational or business school?

Yes

No If yes, please provide the following information.

Name of school (include city & state)

Type of school or training

Dates attended

Did you finish the course?

18.Have you ever been placed on academic probation or suspended, expelled from any high school, college, university or trade school?

Yes No If yes, explain on page 28.

Page 2 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Print your name

19.Beginning with your most current employment please list EVERY job, including military service, you have held in the last twenty

(20) years. All time periods must be accounted for. Jobs include self-employed, part-time jobs, temporary work, voluntary work and internships. You must list all employment regardless of the length of employment. Addresses must be complete, current and accurate. zip codes are required. If you have had intervening periods of unemployment, please list those periods in sequence in the spaces specifically provided. Start with your most current employment.

Dates of employment

From		To
Month/Year		Month/Year
/		/
Full-time		Present
Part-time
Voluntary

How long employed there?

Name of employer and complete address, including zip codes

Job Title

Work Number and Area Code

Supervisor’s Name

Supervisor’s E-Mail

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker	Work or home phone	E-Mail

List another co-worker	Work or home phone	E-Mail

Unemployed

from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

Work or home phone

E-Mail

List another co-worker

Work or home phone

E-Mail

Unemployed

from:

to:

Page 3 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Continued

Print your name

Dates of employment		Name of employer and complete address, including zip codes	Work Number and Area Code
Dates of employment
From	To
Month/Year	Month/Year
/	/		Supervisor’s Name
Full-time	Present
Part-time
Voluntary			Supervisor’s E-Mail
How long employed there?		Job Title

			Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

	Work or home phone	E-Mail

	Work or home phone	E-Mail

Unemployed

from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

Work or home phone

E-Mail

List another co-worker

Work or home phone

E-Mail

Unemployed

from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

Work or home phone

E-Mail

List another co-worker

Work or home phone

E-Mail

	Unemployed from:		to:

Page 4 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Continued

Print your name

Dates of employment		Name of employer and complete address, including zip codes	Work Number and Area Code
From	To
Month/Year	Month/Year
/	/		Supervisor’s Name
Full-time	Present
Part-time
Voluntary			Supervisor’s E-Mail
How long employed there?		Job Title

			Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

Work or home phone	E-Mail
Work or home phone	E-Mail

Unemployed from:			to:


Dates of employment		Name of employer and complete address, including zip codes		Work Number and Area Code
From	To
Month/Year	Month/Year
/	/			Supervisor’s Name
Full-time	Present
Part-time
Voluntary				Supervisor’s E-Mail
How long employed there?		Job Title

				Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

Work or home phone	E-Mail
Work or home phone	E-Mail

Unemployed

from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

Work or home phone

E-Mail

List another co-worker

Work or home phone

E-Mail

Unemployed

from:

to:

Page 5 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Continued

Print your name

Dates of employment		Name of employer and complete address, including zip codes	Work Number and Area Code
From	To
Month/Year	Month/Year
/	/		Supervisor’s Name
Full-time	Present
Part-time
Voluntary			Supervisor’s E-Mail
How long employed there?		Job Title

			Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

	Work or home phone	E-Mail

	Work or home phone	E-Mail

Unemployed

from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

Work or home phone

E-Mail

List another co-worker

Work or home phone

E-Mail

Unemployed

from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

Work or home phone

E-Mail

List another co-worker

Work or home phone

E-Mail

Unemployed from:		to:

Page 6 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Continued

Print your name

Dates of employment		Name of employer and complete address, including zip codes	Work Number and Area Code
From	To
Month/Year	Month/Year
/	/		Supervisor’s Name
Full-time	Present
Part-time
Voluntary			Supervisor’s E-Mail
How long employed there?		Job Title

			Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

	Work or home phone	E-Mail

	Work or home phone	E-Mail

Unemployed from:

to:

Dates of employment

Name of employer and complete address, including zip codes

Work Number and Area Code

From

Month/Year

Supervisor’s Name

Full-time

Present

Part-time

Voluntary

Supervisor’s E-Mail

How long employed there?

Job Title

Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

Work or home phone	E-Mail
Work or home phone	E-Mail

Unemployed from:			to:


Dates of employment		Name of employer and complete address, including zip codes		Work Number and Area Code
From	To
Month/Year	Month/Year
/	/			Supervisor’s Name
Full-time	Present
Part-time
Voluntary				Supervisor’s E-Mail
How long employed there?		Job Title

				Salary

Describe your duties

Reason for leaving (you must be specific)

List a co-worker

List another co-worker

Work or home phone	E-Mail
Work or home phone	E-Mail

Unemployed from:		to:

Page 7 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Print your name

20.Your current employer will be contacted during the background investigation. Would any problem result if your present employer was contacted in the beginning stages of the background? Yes No If yes, explain.

21.Have you ever held employment under another name? employment.

Yes

No If yes, list the name used, the employer and dates of

Name used	Employer	Dates

Name used	Employer	Dates

Name used	Employer	Dates

Name used	Employer	Dates

22. Have you ever been terminated (fired) from a job or position?

Yes

No If yes, starting with most recent, list the following

information, giving full details. If more space is needed, please explain on page 28.

Date

Details

Employer

Date

Details

Employer

23.Have you ever had any extended work absences for any reason other than medical reasons or earned vacations? (Leave of Absence, Suspensions, Layoffs) If yes, list the dates, name of employer and details.

Yes

Date

Employer

Details

Page 8 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Continued

Print your name

24.Have you ever been investigated by your employer or supervisor for improper conduct, illegal activities, sexual harassment or Equal Employment Violations which resulted in your being found in violation of any policies, regulations, rules, or any State or Federal laws? Yes No If yes, please provide the following information.

Date

Employer

Details and results of Investigation

25. Have you ever been suspended by an employer or received a formal written reprimand?

Yes

No If yes, please explain.

Date

Employer

Circumstances

Details

26. Have you ever held a full-time or part-time position with peace officer powers? (prior police experience includes police officer, police

reserves, military police)		Yes	No If yes, list the dates, employer/agency, rank and duties. Start with the most recent.

Dates	Employer / Agency			Rank

Duties / Assignments

Dates	Employer / Agency			Rank

Duties / Assignments

27.Have you ever attended a police academy or a law enforcement training center? following information

Yes

No If yes, please provide the

Name and address of training site

Date Started

Date Ended

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

Did you complete the training?		Yes	No	If no, please explain below.

Page 9 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Experience and Employment

Continued

Print your name

28. Have you ever been a Police Cadet or Explorer?

Yes

No If yes, please provide the following information.

Agency

Date Started

Date Ended

Prior Applications

29. Have you ever applied to the San Diego Police Department before? (for any position)

Yes

date, the position and results. Check all boxes that apply. Do not include this current application.

No If yes, please provide the

Date applied

Position

Submitted application only

Took written test

Took PAT test

Interviewed

Submitted Personal History Statement

Background Investigation conducted

Took polygraph

Was not selected

Disqualified

Hired or job offer made

Withdrew application

Expired from list

Other:

Date applied

Position

Submitted application only

Took written test

Took PAT test

Interviewed

Submitted Personal History Statement

Background Investigation conducted

Took polygraph

Was not selected

Disqualified

Hired or job offer made

Withdrew application

Expired from list

Other:

Applications With Other Agencies

30. Have you EVER applied for any other law enforcement agency? (City, County, State or Federal Agencies)

Yes

No If yes,

list every agency you have applied with. Start with most recent. Give complete, accurate addresses. All agencies MUST be listed regardless of outcome or current status. Check all boxes that apply for each agency.

Name of agency and complete address including zip code										Date applied

										Position

Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Name of agency and complete address including zip code

Date applied

									Position
Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Phone

Page 10 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Applications With Other Agencies

Continued

Print your name

Name of agency and complete address including zip code

Date applied

Position


Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Phone

Name of agency and complete address including zip code

Date applied

Position


Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Phone

Name of agency and complete address including zip code

Date applied

Position


Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Phone

Name of agency and complete address including zip code

Date applied

Position


Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Phone

Name of agency and complete address including zip code

Date applied

Position


Submitted application only	Took written test		Placed on eligibility list		Interviewed		Failed oral board		Passed interview
Submitted Personal History Statement		Background Investigation conducted				Took polygraph		Background pending
Hired / Job offer made	Was not selected		Disqualified	Unknown status		No response from agency			Withdrew application

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

Phone

Page 11 of 29

Military Service

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Print your name

31.

Did you comply with the draft registration law?

Yes

Selective Service Number

32.

Have you ever served in any of the Armed Forces, National Guard or military reserves?

Yes

33.

If yes, what is your current status with the military?

Active

Reserves

Inactive

Discharged

Branch of service

Unit / Occupation

Enlistment Date

Discharge Date

Service Number

Highest Rank Attained

Rank at Discharge

Type of Discharge

Separation code

Re-enlistment Code

If active or current reserve, list your Commanding Officer’s name

34.

Were you ever investigated for any criminal activity while in the military or military reserves?

Yes

No If yes, please explain.

35.

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

National Guard or military reserves?

Yes

If yes, please explain.

Approximate Date

Violation

Penalty

36.

Did you receive an honorable discharge?

Yes

No If you received a discharge other than honorable, please explain.

37. Starting with most recent, list all duty stations (include basic training, tours overseas, etc.) while in the military.

Month and Year

Location

Duties / Purpose (approximate length of your tour)

Page 12 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Legal

38.Have you ever been convicted of a Felony? Yes No

39.Have you ever been convicted of a Misdemeanor? Yes No

40.Have you ever been charged with a Felony, in which the charges were reduced to a Misdemeanor? If yes to any question above, provide the following information. Start with the most recent.

Print your name

Yes No

Date

Explain circumstances

Charges

Police Agency

Penalty

Date	Charges	Police Agency	Penalty

Explain circumstances

Date	Charges	Police Agency	Penalty

Explain circumstances

41. Either as an adult or a juvenile, have you ever been arrested or charged with a criminal act? (not listed above)

Yes

Includes charges that were dismissed, dropped, or reduced. If yes, provide the following information. Start with the most recent.

Date	Charges	Police Agency	Results

Explain circumstances

Date	Charges	Police Agency	Penalty

Explain circumstances

Page 13 of 29

Legal

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Continued

Print your name

42. 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? Yes No

If yes, provide the following information.

Date	Charges or reason for investigation	Penalty

Explain circumstances

Date	Charges or reason for investigation	Penalty

Explain circumstances

43.	Have you ever received a misdemeanor citation in lieu of going to jail?						Yes	No
	If yes, explain on page 28, giving details, dates and name of the law enforcement agency issuing the citation.

44.	Have you ever been placed on court probation?				Yes	No 45.	Are you currently on probation?			Yes	No If yes to
	either question, explain below, giving all details, dates and reason. If you were on probation more than once, please indicate below.

Date:
Details

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


47.	Have you ever had a warrant issued for your arrest or have you ever failed to appear in court on a criminal matter?
	Yes	No If yes, please explain on page 28.

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

Date:
Details

49.	Were you ever required to appear before a juvenile court for an act which would have been a crime if committed by an adult?
	Yes	No If yes, explain giving details, dates and location.

Date:

Details

Page 14 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Legal

Continued

Print your name

50. Have you ever applied for a permit to carry a concealed weapon?

Yes No If yes, provide the following information.

Date applied

Was permit granted?

Yes

Weapon?

Name of agency where applied (City, County & State)

For what purpose?


51. Are you now or have you ever been involved as a plaintiff or defendant in any civil court action?			Yes	No
Ever had a judgment rendered against your?	Yes	No If yes to either question, provide the following information.

Date

Details

Location of Court

Plaintiff

Defendant

Date

Details

Location of Court

Plaintiff

Defendant

52.Are you now or have you ever been a member of any organization, 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 present form of government?

Yes

53.Are you now or have you ever been a member of any organization, 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? Yes No

54.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?	Yes	No
If yes to any of the above three questions, please explain.

Details

55. Have you ever participated in an unlawful demonstration? Yes No If yes, please explain.

Details

56. Are you now or have you ever been associated with any organization, movement or group who engages in civil disobedience?

Yes No If yes, please explain.

Details

Page 15 of 29

Legal

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Continued

Print your name

57.Have you ever used, attempted to use, thought you were using, smoked, inhaled or experimented in any fashion with Marijuana? Yes No If yes, provide the following information. Be as specific as possible.

Date first used

Date last used

Estimated use during last two (2) years

What was your approximate age when you first used?

What was your approximate age when you last used?

Estimated use during your lifetime

58.Have you ever used, thought you were using, tasted, sniffed, smoked, ingested, inhaled, injected, swallowed, smelled, attempted to use or experimented with any form of illegal drug, narcotic or substance such as, but not limited to, “crack cocaine”, speed, PCP, cocaine, meth, heroin, mescaline, LSD, mushrooms, Hashish, Opiates, barbiturates, amphetamines, hallucinogenic, steroids,

	designer drugs, peyote, morphine or any other illegal substance other than those drugs prescribed by your physician?
	Yes	No If yes, list all drugs and or narcotics used. Be as specific as possible.

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

Name of substance or drug			Date first used	Date last used		Estimated use during last two (2) years

What was your approximate age when you first used this substance?			What was your approximate age when you last used?			Estimated use during your lifetime

59.	Have you ever sold or supplied any form of illegal drug, narcotic or substance including marijuana?					.................................	Yes	No
60.	Have you ever manufactured any form of drug, narcotic or substance?						Yes	No
61.	Have you ever cultivated, grown or attempted to grow marijuana?						Yes	No
62.	Have you ever injected any form of illegal drug, narcotic or substance, including steroids?						Yes	No
63.	Have you ever remained at a private gathering or party where illegal drugs or narcotics were being used?						....................... Yes	No
64.	Have you ever allowed someone to use illegal drugs/narcotics including marijuana at your residence or
	in your vehicle?						Yes	No

65.	When was the last time you were at a private gathering where illegal drugs were being used?				Month:		Year:
	Type of location:

Page 16 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Traffic History / Motor Vehicle Operation

Print your name

Operation of a motor vehicle is an integral part of the position of police officer. An investigation of your driving history will be made.

66.California driver’s license number

Class or type

Expiration date

67. Name under which license was granted

Other names used (married names)

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

State	State

Name under license issued	Name under license issued

Number	Number

State	State
Name under license issued	Name under license issued
Number	Number

69.Have you ever been refused a driver’s license by any state? Yes No If yes, please explain. (Give State, dates and reasons.)

70.Have you ever applied for or obtained a driver’s license or state identification card under a fictitious name or date of birth?

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

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

If yes, please explain. (Give State, dates and reasons.)

Yes

72.Have you ever failed to appear in court on a traffic citation or parking citation? information.

Yes

No If yes, provide the following

Approx. Date

Traffic Violation

City / County / State

Reason you failed to appear

73.Have you ever had a warrant issued for you regarding a traffic citation or parking citation? following information.

Yes

No If yes, provide the

Approx. Date

Traffic Violation

City / County / State

Penalty

Page 17 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Traffic History / Motor Vehicle Operation

Continued

Print your name

74.Have you ever received a traffic citation? recent citation.

Yes

No If yes, list all traffic citations for the last ten (10) years. Start with the most

Month / Year

Traffic Violation

City & State

What action resulted? Dismissed, Fine, Traffic School

75. List all vehicles that you own and/or that are registered to you. (Include vehicles you use frequently)

Year

Make / Model

Color

License Number & State

Is the vehicle currently registered?

76. As a driver, have you ever been involved in a motor vehicle accident?

Yes

No If yes, provide the following information.

Date		City and State	Were you at fault?		Yes	No
			Was there a police report taken?		Yes	No
			Did the accident cause injury to another person?		Yes	No
Police agency that took the report			Were you cited or arrested?		Yes	No
			Were you cited or arrested?		Yes	No
			Was the accident a Hit & Run?		Yes	No

Date		City and State	Were you at fault?		Yes	No
			Was there a police report taken?		Yes	No
			Did the accident cause injury to another person?		Yes	No
Police agency that took the report			Did the accident cause injury to another person?		Yes	No
Police agency that took the report			Were you cited or arrested?		Yes	No
			Were you cited or arrested?		Yes	No
			Was the accident a Hit & Run?		Yes	No

Date		City and State	Were you at fault?		Yes	No
			Was there a police report taken?		Yes	No
			Did the accident cause injury to another person?		Yes	No
Police agency that took the report			Did the accident cause injury to another person?		Yes	No
Police agency that took the report			Were you cited or arrested?		Yes	No
			Were you cited or arrested?		Yes	No
			Was the accident a Hit & Run?		Yes	No

77.	As a driver, have you ever been involved in an accident where you left the scene without identifying yourself?			Yes	No
	(Hit & Run) If yes, please explain.

Page 18 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Traffic History / Motor Vehicle Operation

Continued

Print your name

78.California Law requires that drivers and owners of vehicles be covered by automobile liability insurance. Please list your insurance company.

Company

Telephone Number

Policy Number

Expiration Date

79. Have you ever been refused auto insurance for any reason?

Yes

No If yes, please explain on page 28.

Marital Status

Single

Married

Widowed

Separated

Annulled

Divorced

Full Name of Spouse	Maiden Name

Date of Marriage	Place of Marriage (City, County & State)

Other Names Spouse has used

Date of Birth

Age

Spouse’s Employer		Occupation or Position

Current Address of Spouse if not living with you	Home Phone (area code)		Work Phone (area code)

E-Mail

How Long Employed

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

Full Name of Spouse	Maiden Name

Date of Marriage	Place of Marriage (City, County & State)

Other Names Spouse has used

Date of Birth

Age

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)	E-Mail

Date filed for Divorce	City, County, State of Divorce					Is Divorce Final?

Full Name of Spouse	Maiden Name		Other Names Spouse has used			Date of Birth		Age

Date of Marriage	Place of Marriage (City, County & State)

Former Spouse’s Employer		Occupation or Position

Current Address of Former Spouse or last known address		Home Phone (area code)	Work Phone (area code)

Date filed for Divorce	City, County, State of Divorce

How Long Employed

E-Mail

Is Divorce Final?

80. A.	Have you ever been required to pay child support?	Yes	No
B.	Have you ever been delinquent in child support payments?		Yes	No

C.What is the amount of child support paid monthly? $ If yes to question 80B, please explain:

Page 19 of 29

Financial

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Print your name

81.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 financial obligations.

	Current Monthly Income		Current Monthly Expenditures

Monthly Salary		$	Real Estate (mortgage) Payments			$
		$				$
Spouse’s Salary			Rent

Other Income			Credit Cards (charge accounts)

Other Income			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 & Bonds			Other liabilities

Life Insurance	(Cash value of Whole Life policy)		Other Liabilities

Autos			Other Liabilities

Other Assets			Other Liabilities

	TOTAL ASSETS	$		TOTAL LIABILITIES		$
82. Please list all banks or savings institutions where you have current accounts.

Bank		Address		Checking	Savings
				Checking	Savings
				How long there?	Yrs:	Mos:

Bank		Address		Checking	Savings
				Checking	Savings
				How long there?	Yrs:	Mos:

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

Name of Creditor, Bank, Firm or Lender

Reason for Debt

Monthly Payment

	Current Balance	List the number of times you have
	Current Balance	been late 30 days or more
		been late 30 days or more

Page 20 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Financial Continued

84. Have you ever filed for or declared bankruptcy?

Yes

Print your name

No If yes, please explain below.

Date

Reasons

85.

Have you ever been delinquent on income or other tax payments?

Yes

No If yes, was it more that once?

Yes

Date

Reasons

86.

Have you ever had your wages attached or garnisheed?

Yes

Date

Reasons

87.

Have you ever had any of your bills, accounts or loans turned over to a collection agency?

Yes

No If yes, list all accounts.

Date

Account / current status

Date

Account / current status

Date

Account / current status

Date

Account / current status

88. Have you ever had any purchased goods, vehicles, property or any items repossessed? (This includes voluntary repossession)

Yes

Date

Reasons

89.

Have you ever been refused credit?

Yes

No If yes, please explain below.

Date

Reasons

90.	Are you currently an owner, partner or investor in any business enterprise that requires the attainment of a Federal, State, County
	or City permit or license to operate?	Yes	No

Name and Type of Business and Address

91.	If employed by this agency, do you anticipate any other income other than your city salary or spouse’s salary?

Page 21 of 29

Residence

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Print your name

92.List all of your residences during the last twenty (20) years. List no information prior to your 15th birthday. Begin with your most current residence.

Current Address		City & State		Since (month & year)

Names of other occupants?	If renting, give complete address & phone of person who collects the rent

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Address		City & State	From (month & year)		To (month & year)

Names of other occupants?	If rented, give name and complete address & phone of person who collected the rent

Reason for moving

Page 22 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Relatives, References, Acquaintances

Print your name

93.During the course of 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 below. If a category is not applicable, print “N/A” in the box provided for the name.

	Name of your:			Residence Address (include Zip Code)	Telephone (include Area Code)

Spouse					Home

Occupation		Age	E-Mail		Work

Father					Home

Occupation		Age	E-Mail		Work

Mother					Home

Occupation		Age	E-Mail		Work

Stepfather					Home

Occupation		Age	E-Mail		Work

Stepmother					Home

Occupation		Age	E-Mail		Work

Father-in-law					Home

Occupation		Age	E-Mail		Work

Mother-in-law					Home

Occupation		Age	E-Mail		Work

Brother					Home

Occupation		Age	E-Mail		Work

Brother					Home

Occupation		Age	E-Mail		Work

Brother					Home

Occupation		Age	E-Mail		Work

Sister					Home

Occupation		Age	E-Mail		Work

Sister					Home

Occupation		Age	E-Mail		Work

Sister					Home

Occupation		Age	E-Mail		Work

Sister					Home

Occupation		Age	E-Mail		Work

Stepbrother					Home

Occupation		Age	E-Mail		Work

Stepsister					Home

Occupation		Age	E-Mail		Work

Page 23 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

Relatives, References, Acquaintances

Continued

Print your name

During the course of 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 below. If a category is not applicable, print

“N/A” in the box provided for the name.

	Name of your:			Residence Address (include Zip Code)	Telephone (include Area Code)
Uncle					Home

Occupation		Age	E-Mail		Work

Aunt					Home

Occupation		Age	E-Mail		Work

Former Spouse					Home

Occupation		Age	E-Mail		Work

Former Spouse					Home

Occupation		Age	E-Mail		Work

94.Please list those individuals with whom you have resided during the last ten (10) years, i.e, roommates, friends, etc. Exclude your spouse, children, or parents. Start with most recent. Provide us with their most current address. If current address is unknown, indicate unknown. Do not include Military personnel if lived on a military base.

	Name and Occupation			Address (include Zip Code)		Telephone (include Area Code)
Name					Home

Occupation		Age	E-Mail		Work

Name					Home

Occupation		Age	E-Mail		Work

Name					Home

Occupation		Age	E-Mail		Work

Name					Home

Occupation		Age	E-Mail		Work

Name					Home

Occupation		Age	E-Mail		Work

Children

95. Please list all your children, including step-children and adopted children.

Full Name

Age

Date of Birth

Current Address

Page 24 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

References, Co-Workers

Print your name

During the course of the background investigation, your references and co-workers will be asked to comment upon your suitability for the position of peace officer. Supply the appropriate information in the spaces provided below. If a category is not applicable, print “N/A” in the box provided for the name.

96.Please list as references five (5) individuals you have known for at least two (2) years who have knowledge of you and your qualifications. Examples can be personal friends, fiancé, boyfriend, girlfriend, friends of the family, roommates, teachers, neighbors, classmates, co-workers, past supervisors, and military superiors or military acquaintances. DO NOT include relatives or family members.

Name / Occupation / Relationship		Address (include Zip Code)
		Address (include Zip Code)
Name	Home	Work
Name

Occupation

Telephone (Include Area Code)

Home

Work

Relationship	Age	How long known	E-Mail

Name	Home	Work		Home
Name				Home

Occupation				Work
Occupation				Work

Relationship	Age	How long known	E-Mail

Name	Home	Work		Home
Name				Home

Occupation				Work
Occupation				Work

Relationship	Age	How long known	E-Mail

Name	Home	Work		Home
Name				Home

Occupation				Work
Occupation				Work

Relationship	Age	How long known	E-Mail

Name	Home	Work		Home
Name				Home

Occupation				Work
Occupation				Work

Relationship	Age	How long known	E-Mail

97. List five (5) current or past co-workers and/or supervisors not listed above. Addresses may be their residence or their place of employment.

	Name and Employer		Address (Include Zip Code)	Telephone (Include Area code)

Name		Home	Work	Home
Name				Home

Employer		E-Mail		Work
Employer		E-Mail		Work

		Home	Work
Name				Home

Employer		E-Mail		Work

		Home	Work
Name				Home

Employer		E-Mail		Work
Employer		E-Mail		Work

		Home	Work
Name				Home

Employer		E-Mail		Work
Employer		E-Mail		Work

		Home	Work
Name				Home

Employer		E-Mail		Work
Employer		E-Mail		Work

Page 25 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

References, Co-Workers

Continued

Print your name

98.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. Addresses may be their residence or their place of employment. Addresses must be complete with zip codes. Telephone numbers must have area codes. If already listed on previous pages, do not list again.

	Name and Employer	Address (Include Zip Code)	Telephone (Include Area code)

Name	Home	Work	Home
Name			Home


Occupation	E-Mail		Work

	Home	Work
Name			Home


Occupation	E-Mail		Work

	Home	Work
Name			Home


Occupation	E-Mail		Work

	Home	Work
Name			Home


Occupation	E-Mail		Work

	Home	Work
Name			Home


Occupation	E-Mail		Work

	Home	Work
Name			Home

Occupation

E-Mail

Work

99. List any additional experience or qualifications you have which may be beneficial (if more space is needed, continue on page 28).

Page 26 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

General Information

Print you name

100.In your own PRINTING, please print an autobiography and state your reasons for wanting to be a police officer in the City of San Diego. Do not go beyond this page.

Page 27 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

General Information

Print your name

Use this page as an addendum or supplemental to any question you responded to.

If responding to a question, please indicate the question number.

Continue on next page (page 29)

Page 28 of 29

IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. ALL PHONE

NUMBERS AND ADDRESSES MUST BE COMPLETE AND ACCURATE. IF

THE QUESTION IS NOT APPLICABLE, PLEASE SPECIFY WITH N/A

Personal History Statement

General Information

Print your name

Use this space for any additional information

I understand that any conditional job offer or appointment tendered 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 San Diego Police Department Background Investigations Unit any changes in my personal history covered in this Personal History Statement within five (5) 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 Statement, I reviewed it carefully for completeness and accuracy.

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

__________________________________________________________________		_______________________
	FULL SIGNATURE	DATE

OFFICE USE ONLY

PHS reviewed with applicant by Background Investigator _____________________________________________

Date__________________________

Page 29 of 29

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