Texas Personal History Statement Form – Fill Out and Use This PDF

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THE UNIVERSITY OF TEXAS SYSTEM POLICE

PERSONAL HISTORY STATEMENT

APPLICANT NAME

POSITION

Date Issued:

Return By:

Received On:

Received By:

9.14.11 MT

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

Instructions to the Applicant

Before you begin to fill out this personal history statement, please ensure that you meet the following requirements. You must meet all five of these requirements to qualify for licensure as a peace officer or jailer in Texas.

I am a citizen of the United States of America.

I have earned a high school diploma or a GED.

I have never been convicted, pleaded guilty to (nolo contendere), nor have I been on court-ordered community service/probation or deferred adjudication for a Class A misdemeanor or a felony.

During the last ten (10) years, I have not been convicted, pleaded guilty to (nolo contendere), been on community service/probation or deferred adjudication for a Class B misdemeanor in this state, other state, or while serving in the military.

I have never had a military court martial that resulted in a dishonorable or bad conduct discharge.

DISQUALIFICATION

There are very few automatic conditions for rejection. Even issues of prior misconduct, employee terminations, and arrests are

usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will

result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent job-relevant

information from their prospective employer.

This personal history statement is a governmental document. Be truthful, as there are criminal consequences for being untruthful on a governmental document.

Once you begin:

∙Type or neatly print, in ink, responses to all items and questions. If a question does not apply to you, write “N/A”

(not applicable) in the space provided for your response. If you cannot obtain or remember certain information, indicate so in your response.

∙If you need more space for any response, use the last page of this form (page 27) and identify the additional information by the question number.

Be as complete, honest and specific as possible in your responses.

Disclosure of Medically-Related Information

In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring process applicants are not expected or required to reveal any medical or other disability-related information about themselves in response to questions on this form, or to any other inquiry made prior to receiving a conditional offer of employment.

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 1: PERSONAL

1. YOUR FULL NAME	1. YOUR FULL NAME	1. YOUR FULL NAME
LAST	FIRST	MIDDLE

2.OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOWN BY

3.ADDRESS WHERE YOU RESIDE

NUMBER / STREET	APT / UNIT
CITY	STATE ZIP

4.MAILING ADDRESS, IF DIFFERENT FROM ABOVE

5.CONTACT NUMBERS

	HOME (	)		WORK (	)	EXT	OTHER (		)	CELL	FAX

6.	EMAIL ADDRESS
	HOME						BUSINESS

7.	BIRTH PLACE		(CITY / COUNTY / STATE / COUNTRY)					8. BIRTHDATE		9. SOCIAL SECURITY #
										–	–

10. DRIVER’S LICENSE
NO.	STATE	EXP

11. PHYSICAL DESCRIPTION
HT.	WT.	HAIR COLOR	EYE COLOR

12. Have you ever attended a basic licensing course?

Yes No

If yes, provide the following information: PID:

ACADEMY NAME

FROM

DID YOU GRADUATE?

Yes

LOCATION

(CITY / STATE)

NAME OF TRAINING OFFICER / ACADEMY

CONTACT NUMBER

COORDINATOR

(

)

ACADEMY NAME

FROM

DID YOU GRADUATE?

Yes

LOCATION

(CITY / STATE)

NAME OF TRAINING OFFICER / ACADEMY

CONTACT NUMBER

COORDINATOR

(

)

13.Have you ever applied to any other law enforcement agency in the last ten years (city, county, state or federal)?...

Yes

∙If yes, list ALL agencies you have applied to, starting with the most recent (give complete and accurate addresses).

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

∙If more space is needed, continue your response on page 27.

A) NAME OF AGENCY	DATE APPLIED

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY					ZIP		CONTACT NUMBER				EXT
				STAT			(	)
POSITION APPLIED FOR								EMAIL

Check each step in the process that you completed, and your status:

STEPS:	Application	Written	Physical agility	Oral		Polygraph/CVSA			Background	Chief’s oral
Conditional job offer
STATUS:	Hired	On List	Withdrawn	Disqualified

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

13. Have you ever applied to any other law enforcement agency… continued

B) NAME OF AGENCY

DATE APPLIED

ADDRESS (NUMBER / STREET)				BACKGROUND INVESTIGATOR’S NAME (IF
			KNOWN)
CITY		ZIP	CONTACT NUMBER		EXT
CITY		ZIP	CONTACT NUMBER		EXT
	STAT		(	)
POSITION APPLIED FOR				EMAIL

Check each step in the process that you completed, and your status:

STEPS:

Application

Written

Physical agility

Oral

Polygraph/CVSA

Background

Chief’s oral

Conditional job offer

STATUS:

Hired

On List

Withdrawn

Disqualified

C) NAME OF AGENCY

DATE APPLIED

ADDRESS

(NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF

KNOWN)

CITY

ZIP

CONTACT NUMBER

EXT

STAT

(

)

POSITION APPLIED FOR

Check each

step in the process that you completed, and your status:

STEPS:

Application

Written

Physical agility

Oral

Polygraph/CVSA

Background

Chief’s oral

Conditional job offer

STATUS:

Hired

On List

Withdrawn

Disqualified

SECTION 2: RELATIVES AND REFERENCES

14.IMMEDIATE FAMILY

∙Provide all applicable information in the spaces below.

∙Mark “N/A” if a category is not applicable or if the individual is deceased.

∙If more space is needed, continue your response on page 27.

N/A A. Father

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

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

()

		WORK PHONE		CELL PHONE			EMAIL
(			)	(	)

N/A
N/A	B. Step-father
NAME				HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP

		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP
		(	)
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 2: RELATIVES AND REFERENCES continued

14.IMMEDIATE FAMILY continued

N/A

C. Mother

NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

(

)

WORK PHONE

CELL PHONE

(

)

(

)

N/A

Step-mother

NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

()

WORK PHONE

()

CELL PHONE

()

N/A E. Spouse / Registered Domestic Partner

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

		HOME PHONE			WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP
		(	)
		WORK PHONE			CELL PHONE			EMAIL
		(	)	(		)
		YEARS OF
		MARRIAGE		Is there, or has there been, a restraining or stay-away order in effect for this individual?						Yes	No


N/A	F. Father-in-law
NAME					HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP

		HOME PHONE			WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP
		(	)
		WORK PHONE			CELL PHONE			EMAIL
		(	)		(	)

N/A	G. Mother-in-law
N/A	G. Mother-in-law
NAME					HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP

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

()

		WORK PHONE		CELL PHONE			EMAIL
(			)	(	)

N/A
N/A	H. Former Spouse(s) / Cohabitant

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

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

()

	WORK PHONE			CELL PHONE			EMAIL
(		)	(		)
	YEAR OF
	DISSOLUTION		Is there, or has there been, a restraining or stay-away order in effect for this individual?						Yes	No


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

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

HOME PHONE			WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE	ZIP
(	)
WORK PHONE			CELL PHONE			EMAIL
(	)		(	)
YEAR OF
DISSOLUTION		Is there, or has there been, a restraining or stay-away order in effect for this individual?						Yes	No

N/A I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc.

1) NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

(

)

ZIP

UNDER

WORK PHONE

CELL PHONE

AGE 18

(

)

(

)

2) NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

(

)

ZIP

UNDER

WORK PHONE

CELL PHONE

AGE 18

(

)

(

)

3) NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

(

)

ZIP

UNDER

WORK PHONE

CELL PHONE

AGE 18

(

)

(

)

4) NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

(

)

ZIP

UNDER

WORK PHONE

CELL PHONE

AGE 18

(

)

(

)

5) NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

(

)

ZIP

UNDER

WORK PHONE

CELL PHONE

AGE 18

(

)

(

)

6) NAME

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

(

)

ZIP

UNDER

WORK PHONE

CELL PHONE

AGE 18

(

)

(

)

N/A

J. Children

List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you.

Provide the name and contact information of the custodial parent or guardian, if other than you.

1) NAME

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

CHILD’S AGE

ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

CONTACT NUMBER

(

)

2) NAME

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

CHILD’S AGE

ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

9.14.11 MT

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

HOME ADDRESS (NUMBER / STREET / APT) ZIP

WORK ADDRESS (NUMBER / STREET / APT) ZIP

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

CONTACT NUMBER

()

3) NAME			CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

M	CHILD’S AGE	ADDRESS (NUMBER / STREET / APT)			CITY	STATE
F				ZIP
			CONTACT NUMBER	EMAIL

()

	4)	NAME		CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

		M	CHILD’S AGE	ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		F					ZIP
				CONTACT NUMBER			EMAIL
				CONTACT NUMBER			EMAIL
				(	)

5)		NAME		CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

		M	CHILD’S AGE	ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		F					ZIP
				CONTACT NUMBER			EMAIL
				CONTACT NUMBER			EMAIL
				(	)

6)		NAME		CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

CHILD’S AGE

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

()

15.REFERENCES

List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.

A) NAME

CITY STATE

	HOME PHONE						CITY	STATE
	(	)
	WORK PHONE		CELL PHONE			EMAIL
	(	)	(	)
	HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
	FAMILY FRIEND, CO- WORKER)						THIS PERSON?

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

	HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
	(	)				ZIP
	(	)
	WORK PHONE		CELL PHONE			EMAIL
	(	)	(	)
	HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,
	HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
	FAMILY FRIEND, CO- WORKER)						THIS PERSON?

C) NAME			HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
						ZIP
	HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
	(	)				ZIP
	WORK PHONE		CELL PHONE			EMAIL
	WORK PHONE		CELL PHONE			EMAIL
	(	)	(	)
	HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
	FAMILY FRIEND, CO- WORKER)						THIS PERSON?

D) NAME

HOME ADDRESS (NUMBER / STREET / APT)	CITY	STATE
ZIP

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?

	E) NAME			HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
							ZIP
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?

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

		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?

	G) NAME			HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
							ZIP
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?

	H) NAME			HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
							ZIP
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?

	I) NAME			HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
							ZIP
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?
J) NAME				HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
J) NAME				HOME ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
							ZIP
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		HOME PHONE		WORK ADDRESS		(NUMBER / STREET / APT)		CITY	STATE
		(	)				ZIP
		WORK PHONE		CELL PHONE			EMAIL
		(	)	(	)
		HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,						HOW LONG HAVE YOU KNOWN
		FAMILY FRIEND, CO- WORKER)						THIS PERSON?

SECTION 3: EDUCATION

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

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

16.

Check applicable:

High School Diploma

GED

17. List high schools attended:

NAME

FROM

DID YOU

GRADUATE?

CITY

STATE

Yes

NAME

FROM

DID YOU

GRADUATE?

CITY

STATE

Yes

18. List all colleges or universities attended:

NAME

FROM

TOTAL UNITS

TYPE OF

EARNED

DEGREE

EARNED

CITY

STATE

NAME

FROM

TOTAL UNITS

TYPE OF

EARNED

DEGREE

CITY

STATE

EARNED

NAME

FROM

TOTAL UNITS

TYPE OF

EARNED

DEGREE

CITY

STATE

EARNED

19. List any trade, vocational, or business schools/institutes attended:

NAME

FROM

DID YOU

COMPLETE

TYPE OF SCHOOL OR TRAINING

CITY

STATE

THE COURSE?

Yes

NAME

FROM

DID YOU

COMPLETE

TYPE OF SCHOOL OR TRAINING

CITY

STATE

THE COURSE?

Yes

NAME

FROM

DID YOU

COMPLETE

TYPE OF SCHOOL OR TRAINING

CITY

STATE

THE COURSE?

Yes

9.14.11 MT

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 3: EDUCATION continued

20. Have you ever been placed on academic discipline, suspended, or expelled from any high school, college/university, business or trade school? Yes No

If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.

SECTION 4: RESIDENCE

21.LIST OF RESIDENCES

∙List all residences during the last ten years or since age 15. Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit or apartment number). Do not use P.O. Boxes.

∙If the residence is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LIST military barracks mates unless you shared individual quarters.

∙If more space is needed continue on page 27.

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

	CITY		STATE	ZIP

FROM	TO
	Present

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

Names of those with whom you live:

B) FORMER ADDRESS		(NUMBER / STREET / APT)

	CITY		STATE	ZIP

FROM	TO

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

	ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER				(NUMBER /			CONTACT NUMBER
	STREET / APT)							(	)

	CITY		STATE	ZIP		EMAIL

	Names of those with whom you lived:

	Reason for moving:


C) FORMER ADDRESS		(NUMBER / STREET / APT)					FROM			TO

	CITY		STATE	ZIP		IF RENTING: PROPERTY MANAGER, RENT
						COLLECTOR, OR OWNER
	ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER				(NUMBER /			CONTACT NUMBER
	STREET / APT)							(	)

	CITY		STATE	ZIP		EMAIL

Names of those with whom you lived:

Reason for moving:

9.14.11 MT

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 4: RESIDENCE continued

21.LIST OF RESIDENCES continued

D) FORMER ADDRESS		(NUMBER / STREET / APT)

	CITY		STATE	ZIP

FROM	TO

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER


	ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER				(NUMBER /			CONTACT NUMBER
	STREET / APT)							(	)

	CITY		STATE	ZIP		EMAIL

	Names of those with whom you lived:

	Reason for moving:


E) FORMER ADDRESS		(NUMBER / STREET / APT)					FROM			TO

CITY

STATE ZIP

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

(NUMBER /

CONTACT NUMBER

STREET / APT)

(

)

CITY

STATE

ZIP

Names of those with whom you lived:

Reason for moving:

F) FORMER ADDRESS

(NUMBER / STREET / APT)

FROM

CITY

STATE ZIP

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

	ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER				(NUMBER /			CONTACT NUMBER
	STREET / APT)							(	)

	CITY		STATE	ZIP		EMAIL
	CITY		STATE	ZIP		EMAIL

	Names of those with whom you lived:

	Reason for moving:


G) FORMER ADDRESS		(NUMBER / STREET / APT)					FROM			TO

CITY

STATE ZIP

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER			(NUMBER /		CONTACT NUMBER
STREET / APT)					(	)

CITY	STATE	ZIP		EMAIL

Names of those with whom you lived:

Reason for moving:

9.14.11 MT

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

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 4: RESIDENCE continued

22.Provide contact information for all housemates listed in Question 21 with whom you have resided during the past 10 years, or since the age of 15. DO NOT list anyone for whom you have already provided contact information. If more space is needed, continue your response on page 27.

A) NAME

CONTACT NUMBER

()

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

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)

B) NAME

CONTACT NUMBER

()

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

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)

C) NAME

CONTACT NUMBER

()

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

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)

D) NAME

CONTACT NUMBER

()

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

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)

E) NAME

CONTACT NUMBER

()

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

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)

F) NAME

CONTACT NUMBER

()

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

NATURE OF RELATIONSHIP (FOR EXAMPLE: RELATIVE, LANDLORD, FRIEND, HOUSEMATE ONLY)

23. Have you ever been evicted or asked to leave a residence?................................................................................... ..

Yes

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

24. Have you ever left a residence owing rent?	Yes	No


If you answered yes to Questions 23 and/or 24, explain (include when, where and circumstances):

SECTION 5: EXPERIENCE AND EMPLOYMENT

25.JOB EXPERIENCE

∙List ALL jobs you have had in the last ten years, including part-time, temporary, self-employment and volunteer. (Begin with your most current. If more space is needed continue your response on page 27.)

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

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

A) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS

(NUMBER / STREET OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

(

)

JOB TITLE

DUTIES / ASSIGNMENTS

F-T

P-T

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS

REASON FOR WANTING TO LEAVE

Would there be a problem if

IF YES, EXPLAIN:

we contact your current

employer?

Yes

B) PERIOD OF UNEMPLOYMENT
Check applicable:	Student	Between jobs	Leave of absence	Travel
Other

C) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS (NUMBER / STREET OR BASE)

SUPERVISOR

CITY

JOB TITLE

STATE	ZIP	CONTACT NUMBER		EXT
		(	)
		EMAIL

DUTIES / ASSIGNMENTS

F-T P-T Self-employed

Temp

Volunteer

NAMES OF CO-WORKERS 1)

X 2)

REASON FOR LEAVING

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

D) PERIOD OF UNEMPLOYMENT

FROM

Check applicable:

Student

Between jobs

Leave of absence

Travel

Other

E) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS (NUMBER / STREET OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

(

)

JOB TITLE

DUTIES / ASSIGNMENTS

F-T P-T Self-employed

Temp

Volunteer

NAMES OF CO-WORKERS 1)

X 2)

REASON FOR LEAVING

PERIOD OF UNEMPLOYMENT

FROM

Check applicable:

Student

Between jobs

Leave of absence

Travel

Other

G) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS

(NUMBER / STREET OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

(

)

JOB TITLE

DUTIES / ASSIGNMENTS

F-T

P-T

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS

REASON FOR LEAVING

PERIOD OF UNEMPLOYMENT

FROM

Check applicable:

Student

Between jobs

Leave of absence

Travel

Other

I) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS

(NUMBER / STREET OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

(

)

JOB TITLE

DUTIES / ASSIGNMENTS

F-T

P-T

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS

REASON FOR LEAVING

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

J) PERIOD OF UNEMPLOYMENT					FROM
Check applicable:	Student	Between jobs	Leave of absence	Travel
Other


K) NAME OF EMPLOYER OR MILITARY UNIT					FROM
K) NAME OF EMPLOYER OR MILITARY UNIT					FROM

ADDRESS (NUMBER / STREET OR BASE)			SUPERVISOR

CITY	STATE	ZIP	CONTACT NUMBER		EXT
			(	)
JOB TITLE			EMAIL

DUTIES / ASSIGNMENTS

F-T P-T Self-employed

Temp

Volunteer

NAMES OF CO-WORKERS 1)

X 2)

REASON FOR LEAVING

L) PERIOD OF UNEMPLOYMENT Check applicable: Student Other

Between jobs

Leave of absence

Travel

FROM

M) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS (NUMBER / STREET OR BASE)

SUPERVISOR

CITY

STATE

ZIP

CONTACT NUMBER

EXT

(

)

JOB TITLE

DUTIES / ASSIGNMENTS

F-T

P-T

Temp

Self-employed

Volunteer

NAMES OF CO-WORKERS

REASON FOR LEAVING

N) PERIOD OF UNEMPLOYMENT Check applicable: Student Other

Between jobs

Leave of absence

Travel

FROM

O) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS (NUMBER / STREET OR BASE)				SUPERVISOR

CITY		STATE	ZIP	CONTACT NUMBER				EXT
				(	)
JOB TITLE				EMAIL

DUTIES / ASSIGNMENTS							F-T	P-T	Temp
							F-T	P-T	Temp
							Self-employed
									Volunteer

NAMES OF CO-WORKERS	X					REASON FOR LEAVING
1)	2)

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

P) PERIOD OF UNEMPLOYMENT Check applicable: Student Other

Between jobs

Leave of absence

Travel

FROM

Q) NAME OF EMPLOYER OR MILITARY UNIT

FROM

ADDRESS (NUMBER / STREET OR BASE)			SUPERVISOR

CITY	STATE	ZIP	CONTACT NUMBER		EXT
			(	)
JOB TITLE			EMAIL

DUTIES / ASSIGNMENTS

F-T P-T Self-employed

Temp

Volunteer

NAMES OF CO-WORKERS 1)

X 2)

REASON FOR LEAVING

26.Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling, reprimands, suspensions, reductions in pay, reassignments or demotions) ..................................................................................

Yes

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

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

29.Have you ever quit without giving two weeks notice? ................................................................................................

Yes

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

31.Have you ever been accused of discrimination (such as sexual harassment, racial bias, sexual orientation harassment, etc.)
by a co-worker, superior, subordinate or customer?	Yes	No

32.Were you ever the subject of a written complaint at work?	Yes	No

33.Have you ever been counseled at work due to lateness or absences?	Yes	No

34.Did you ever receive an unsatisfactory performance review?	Yes	No

35.Have you ever sold, released, or given away legally confidential information?	Yes	No

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

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

Yes

37. If you answered yes to any of Questions 26–36, explain (include when, where and circumstances; indicate corresponding number):

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

38.Has your work performance ever been affected by your use of alcohol or drugs? ....................................................

Yes

WHEN?

NAME OF EMPLOYER

39.In the past ten years, have you been warned by an employer about your drinking or drug habits and their impact on
your performance?	Yes

WHEN?

NAME OF EMPLOYER

SECTION 6: MILITARY EXPERIENCE

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

If yes, have you registered? ......................................................................................................................................

If no, explain:..............................................................................................

Yes Yes

No No

41. BRANCH OF SERVICE

43.DATES OF

SERVICE To

42. TYPE OF		Entry Level	Honorable	General	OTH (Other than Honorable)
DISCHARGE:	Re-entry Code (1–4) if applicable – refer to your DD-214:
	Re-entry Code (1–4) if applicable – refer to your DD-214:

43.Are you currently participating in one of the following?					If checked, date obligation
Military Reserve		National Guard			ends:

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

office hours, company punishment)?	Yes	No

45.Were you ever denied a security clearance, or had a clearance revoked, suspended or downgraded, either military or
any other federal, state, or municipal clearance?	Yes	No


If you answered yes to Questions 44 and/or 45, explain (include dates and circumstances):

SECTION 7: FINANCIAL

46.INCOME AND EXPENSES

For each of the following questions fill in the amounts to the nearest dollar.

A) From your employer(s), what is your take-home monthly income?

per month

B) Do you have income other than from your salary or wages?	......................................................................................
If yes, fill in amount:	$
Explain:

Yes

per month

C) How much do you spend each month?

per month

Estimate your monthly living expenses; include housing, utilities, credit cards or other loan payments, food, gas and car maintenance, entertainment, etc., as well as any other obligation(s) you may have.

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

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

Yes

48. Have any of your bills ever been turned over to a collection agency? .........................................................................

Yes

49 Have you ever had purchased goods repossessed? ....................................................................................................

Yes

50. Have your wages ever been garnished?......................................................................................................................

Yes

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

Yes

52. Have you ever failed to file income tax or cheated/lied on an income tax form?..........................................................

Yes

53. Have you ever had an employment bond refused?......................................................................................................

Yes

54. Have you ever avoided paying any lawful debt by moving away? ...............................................................................

Yes

55.	Have you ever defaulted on (failed to pay) a loan, including a student loan?	Yes	No

56.	Have you ever borrowed money to pay for a gambling debt?	Yes	No
If yes, do you currently have any outstanding debts as a result of gambling?		Yes	No

57.	Have you ever spent money for illegal purposes (e.g., illegal drugs, prostitution, purchase of fraudulent documents, etc.)?		Yes
	No
58.	Have you ever failed to make or been late on a court-ordered payment (e.g., child support, alimony, restitution, etc.)?		Yes
	No

59. Have you written three or more bad checks in a one-year period? ..............................................................................

Yes

60. Are you in arrears on court ordered child support? .....................................................................................................

Yes

If you answered yes to any of Questions 47–60, explain (include when, where, and why; indicate corresponding number):

SECTION 8: LEGAL

Disclosure of Arrests and Convictions

As an applicant for a peace officer position, you are required to disclose any of the following which occurred on or after your 15th birthday, even if the records/Final Adjudication were sealed, dismissed or pardoned:

∙ALL detentions or arrests, whether they resulted in a conviction or not

∙ALL convictions

∙ALL diversion programs that were not successfully completed

If more space is needed, continue on page 27.

61.Either as an adult or a juvenile, have you EVER been detained for investigation, held on suspicion,
questioned, fingerprinted, arrested, indicted, criminally charged, or convicted of any misdemeanor or
felony offense in this state or in any other legal jurisdiction (including offenses punishable under
the Uniform Code of Military Justice)?	Yes	No
If yes, explain each incident.

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

A) APPROXIMATE DATE

ARRESTING OR DETAINING AGENCY

CHARGE

DISPOSITION OR PENALTY

B) APPROXIMATE DATE

ARRESTING OR DETAINING AGENCY

CHARGE

DISPOSITION OR PENALTY

C) APPROXIMATE DATE

ARRESTING OR DETAINING AGENCY

CHARGE

DISPOSITION OR PENALTY

D) APPROXIMATE DATE

ARRESTING OR DETAINING AGENCY

CHARGE

DISPOSITION OR PENALTY

62.Have you ever been placed on court probation as an adult?	Yes	No

63.Were you ever required to appear before a juvenile court for an act which would have been a crime if
committed as an adult?	Yes	No

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

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

66.Have you or your spouse/partner ever been referred to Child Protective Services? ..................................................

Yes

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 8: LEGAL continued

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

68.Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf was
required to make payment to the other party?	Yes	No

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

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

If you answered yes to any of Questions 62–70, explain (include court case or document, dates, and circumstances; indicate corresponding number):

71.UNDETECTED ACTS – PART 1

Within the past seven years OR at any time after you were first employed in law enforcement, have you ever committed any of the following misdemeanors?

A) Annoying / obscene phone calls	Yes	No

B) Assault (use of force or violence upon another)	Yes	No

C) Assault (use of force or violence upon a family member)	Yes	No

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

E) Carrying a concealed weapon without a permit	Yes	No

F) Contributing to the delinquency of a minor	Yes	No

G) Defrauding an innkeeper (not paying for food or room at a hotel/motel)	Yes	No

H). Driving under the influence of alcohol and/or drugs	Yes	No

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

J) Hit & run collision (no injuries)	Yes	No

K) Hunting/fishing without a license	Yes	No

L) Illegal gambling	Yes	No

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

N). Indecent exposure (including flashing or mooning)	Yes	No

O) Joyriding (using a car or other vehicle without owner’s permission)

Yes

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 8: LEGAL continued

71. UNDETECTED ACTS – PART 1 continued

P). Theft (value up to $500, including shoplifting/switching price tags) ............................................................................

Yes

Q) Possession of alcohol as a minor	Yes	No

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

S) Possession of stolen property (including vehicles)	Yes	No

T). Prostitution or soliciting a prostitute	Yes	No

U) Resisting arrest (including running from the police)	Yes	No

V) Trespassing	Yes	No

W) Vandalism (including “tagging,” malicious mischief and/or property damage)	Yes	No

X). Intentionally writing a bad check	Yes	No

Y) Filing a false police report	Yes	No

Z) Any other act amounting to a misdemeanor within the past seven years	Yes	No

If you answered yes to any item(s) in Question 71, fully explain circumstances, including date(s), names of individuals involved, and resolution. Indicate the corresponding letter (71-A, etc.) for each explanation.

72. UNDETECTED ACTS – PART 2

At any time in your life have you ever committed any of the following?

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

B) Assault with a deadly weapon	Yes	No

C) Theft of a vehicle and/or vehicle parts	Yes	No

D) Burglary (entering a structure or vehicle to commit theft or other crime).....................................................................

Yes

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

E) Child molestation (performing unlawful acts with a child) ............................................................................................

Yes

F) Accessing, producing, or possessing child pornography	Yes	No

G). Injury to a child/elderly/or disabled	Yes	No

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

I) Felony drunk driving (involving injuries)	Yes	No

J) Forcible rape or other act of unlawful intercourse	Yes	No

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

L) Hit & run (with injuries)	Yes	No

M). Hate crime	Yes	No

N) Insurance fraud	Yes	No

O). Theft (value of over $500, or any firearm)	Yes	No

P) Murder, homicide, or attempted murder	Yes	No

Q). Perjury (lying under oath)	Yes	No

R) Possession of an explosive/destructive device	Yes	No

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

T) Stalking	Yes	No

U) Blackmail or extortion	Yes	No

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

Yes

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

If you answered yes to any item(s) in Question 72, fully explain circumstances, including date(s), names of individuals involved, and resolution. Indicate the corresponding letter (72-A, etc.) for each explanation.

SECTION 8: LEGAL continued

Questions 73 and 74 ask about your current and past recreational drug use. This covers the use of any drug, including the unauthorized use of prescription drugs or over-the-counter drugs. Your answers should include, but not be limited to, your use of any of the following drugs:

–	Amphetamines / Methamphetamine	–	Glue	–	Mescaline
	(Uppers, Speed, Crank, etc)	–	Hallucinogens	–	Morphine
–
	Barbiturates (Downers)		(Peyote, LSD, Mushrooms)	– PCP / Angel Dust
–		–
	Cocaine / Crack Cocaine		Hashish / Hashish Oil	–	Quaaludes
–		–
	Designer Drugs		Heroin / Opium	–	Steroids
	(Ecstasy, Synthetic Heroin, etc.)	–
			Marijuana	–	Tetrahydrocannabinal (THC)
– GHB (Date Rape Drug)

73. Within the past three years, have you used any non-prescribed drug(s) as indicated above? ......................

If yes, give details, including drug(s) used and circumstances:

Yes

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

74.Prior to the past three years (check all that apply):

I have never used any drug recreationally.

I have tried or used one or more drugs, but only under limited circumstances (for example, experimentation, at parties, concerts, special events, etc.).

If checked, give details including drug(s) used, most recent date used, and circumstances.

75. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including marijuana?

Sold	Purchased	Cultivated
Manufactured	Furnished	Carried or held for another

If you checked any items above, give details including drug(s) involved, over what time period(s), and circumstances.

SECTION 9: MOTOR VEHICLE OPERATION

76. CURRENT DRIVER’S LICENSE NUMBER

STATE OF ISSUE

EXPIRATION DATE

NAME UNDER WHICH LICENSE WAS GRANTED

77. LIST OTHER STATES WHERE YOU HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE:

		Name under which license was granted and license number, if
State of issue	Type of license	Name under which license was granted and license number, if

..............................................................................78. Have you ever been refused a driver’s license by any state?	Yes	No
If yes, explain (include when, where, and circumstances):

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

...............................................................................79. Has your driver’s license ever been suspended or revoked?	Yes	No
If yes, explain (include when, where, and circumstances):

80. List your current liability insurance on your vehicle(s):

TYPE OF COVERAGE

VEHICLE MAKE

YEAR

VEHICLE LICENSE

Insured

Bonded

Cash Deposit

INSURANCE COMPANY

POLICY NUMBER

EXPIRES

ADDRESS

(NUMBER / STREET

CITY

STATE

ZIP

CONTACT NUMBER

(

)

B) TYPE OF COVERAGE

VEHICLE MAKE

YEAR

VEHICLE LICENSE

Insured

Bonded

Cash Deposit

INSURANCE COMPANY

POLICY NUMBER

EXPIRES

ADDRESS

(NUMBER / STREET

CITY

STATE

ZIP

CONTACT NUMBER

(

)

TYPE OF COVERAGE

VEHICLE MAKE

YEAR

VEHICLE LICENSE

Insured

Bonded

Cash Deposit

INSURANCE COMPANY

POLICY NUMBER

EXPIRES

ADDRESS

(NUMBER / STREET

CITY

STATE

ZIP

CONTACT NUMBER

(

)

D) TYPE OF COVERAGE

VEHICLE MAKE

YEAR

VEHICLE LICENSE

Insured

Bonded

Cash Deposit

INSURANCE COMPANY

POLICY NUMBER

EXPIRES

ADDRESS (NUMBER / STREET CITY

STATE ZIP

CONTACT NUMBER

()

SECTION 9: MOTOR VEHICLE OPERATION continued

81.List all traffic citations, excluding parking citations, you have received within the past seven years:

A)NATURE OF VIOLATION

LOCATION (STREET) CITY STATE

DATE VIOLATION OCCURRED

Month Year

ACTION TAKEN

Not Guilty

Fined

Traffic School

Dismissed

B)NATURE OF VIOLATION

LOCATION (STREET) CITY STATE

DATE VIOLATION OCCURRED

Month Year

ACTION TAKEN

Not Guilty

Fined

Traffic School

Dismissed

C)NATURE OF VIOLATION

DATE VIOLATION

OCCURRED

Month Year

LOCATION (STREET) CITY

STATE

ACTION TAKEN
Not Guilty	Fined	Traffic School	Dismissed

D)Has a traffic citation ever resulted in a warrant or caused your driver’s license to be withheld due to the following? (Check all that apply.)

Failed to appear

Failed to complete traffic school

Failed to pay the required fine

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

If checked, explain circumstances:

82. Have you been involved as the driver in a motor vehicle accident within the past seven years?	Yes
If yes, give details.

A)		DATE		LOCATION	(NUMBER / STREET / APT)	CITY		STATE	ZIP

		POLICE REPORT		LAW ENFORCEMENT AGENCY			INJURY		NON-
		YES	NO				INJURY


B)		DATE		LOCATION	(NUMBER / STREET / APT)	CITY		STATE	ZIP

		POLICE REPORT		LAW ENFORCEMENT AGENCY			INJURY		NON-
		YES	NO				INJURY


C)		DATE		LOCATION	(NUMBER / STREET / APT)	CITY		STATE	ZIP

		POLICE REPORT		LAW ENFORCEMENT AGENCY			INJURY		NON-
		YES	NO				INJURY


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

		IF YES, GIVE REASON:

DATE

Month Year

LOCATION (NUMBER / STREET / APT)

CITY STATE

84. Have you ever been refused automobile liability insurance or a bond, or had them cancelled?

Yes

IF YES, GIVE REASON:

INSURANCE COMPANY

DATE

Month Year

LOCATION (NUMBER / STREET / APT)

CITY STATE

SECTION 9: MOTOR VEHICLE OPERATION continued

Use this space for additional information you would like to include regarding your driving record.

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 10: OTHER TOPICS

85. Have you ever been refused a permit to carry a concealed weapon?

Yes

86.Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other group that advocates, promotes or engages in violence in general or violence against individuals because of their race, religion,

political affiliation, ethnic origin, nationality, gender, sexual preference, or disability?

Yes

87.Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise, street gang, or any other group that advocates, promotes or engages in violence in general or violence against

individuals because of their race, religion, political affiliation, ethnic origin, nationality, gender, sexual preference,
or disability?	Yes	No
88. Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or other
violent act?	Yes	No

89. Have you ever hit or physically overpowered a spouse or romantic partner?	Yes	No

If you answered yes to any of Questions 85–89, give details including dates and circumstances; indicate corresponding number.

SECTION 11: SOCIAL MEDIA SITES

90. Have you ever had a social media site (i.e. Facebook, My Space, etc.)?.............................................................

Yes

91. List all social media sites and/or blogs or web sites created by you. Provide website (URL) and your username.

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PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

SECTION 12: CERTIFICATION

92.I hereby certify that I have personally completed and initialed each page of this form and any supplemental page(s) attached, and that all statements made are true and complete to the best of my knowledge and belief. I understand that any misstatement of material fact may subject me to disqualification; or, if I have been appointed, may disqualify me from continued employment.

SIGNATURE IN FULL

ADDITIONAL SPACE

DATE

∙Duplicate this page as needed to include additional information that does not fit elsewhere on this form (e.g., additional family members, schools, residences, employers, explanations to questions, etc.

∙Identify the corresponding question and specific item being referenced.

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Question	Answer
Form Name	Texas Personal History Statement Form
Form Length	28 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min
Other names	texas dp 1, texas personal history statement police, tcole personal history statement, texas personal history

ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

CONTACT NUMBER

STREET / APT)