anne arundel county police department arundel county police department personal history statement...

Anne Arundel County

Police Department

Personal History Statement

Revised 3/26/18

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Anne Arundel County Police Department

Personal History Statement Table of Contents

Page Number

INSTRUCTIONS TO THE APPLICANT 1-4

PART 1 (PAPERS-DOCUMENTS THAT ARE REQUIRED) 5

PART II (PERSONAL DATA) 6-8

PART III (MILITARY DATA) 9

PART IV (SELECTIVE SERVICE) 9

PART V (FINANCIAL DATA) 10

PART VI (REFERENCES) 10-11

PART VII (ASSOCIATES/FRIENDS) 12-13

PART VIII (RESIDENCE DATA) 13-16

PART IX (EDUCATION) 16-17

PART X (EMPLOYMENT DATA) 18-23

PART XI (DRIVING RECORD) 23-25

PART XII (CONVICTION DATA/ILLEGAL DRUG SALES/USE) 26

PART XIII (MISCELLANEOUS) 27-29

PART XIV (REMARKS SECTION/CONTINUATION SHEETS) 30-36

APPLICANT SIGNATURE PAGE 37

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Instructions to the Applicant

The information that you provide will be the sole property of the Anne Arundel County Police Department.

You are responsible for providing complete, accurate, and truthful responses .

This form must be PRINTED IN BLACK INK by the applicant and each question answered accurately. If a question does not apply to you, write “N/A” (Not Applicable) as your response to that question. Incomplete and /or inaccurate answers will substantially extend the time required to process your application. The personal history statement booklet must be completed per instructions in the booklet. If the personal history statement booklet is incomplete when you return it, you may be eliminated from the process for failing to follow instructions. The information you provide in this personal history statement will be used in the investigation into your background to assist in determining your suitability for the positi on for which you have applied. Please fill out the questionnaire completely and accurately. Keep in mind that: (1) The completion of this form is mandatory to receive consideration for appointment. (2) All statements are subject to verification (3) Deliberate inaccuracies or incomplete statements may bar or remove you from employment (4) All time periods in your background must be accounted for. It is to your advantage to respond openly. Any negative factor contained in the information provided by you will be evaluated in terms of the circumstances and facts surrounding it and its degree of relevance to the job. However, you will be disqualified if you intentionally make a false statement of material fact or intentionally omit a material fact or if you practice or attempt to practice any form of deception or fraud in the statement. If additional space is required for an answer to any question, continuation sheets are provided in the Remarks Section (PART XIV) at the end of this form. Be sure to identify each entry on the continuation sheets with the appropriate section and question number.

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Additional Instructions For The Personal History Statement

A frequent problem encountered by applicants in the completion of this booklet is the failure to follow instructions. You are required to complete this booklet by answering every question. Every question is to be answered with either a yes, yes with an explanation, no, or N/A because it does not apply to you. Additional space for answers is provided in the back of the booklet beginning on page 30. To ensure that your booklet is processed, you must answer all questions. The booklet has several areas where it may ask for names, addresses, and phone numbers. The proper way to include names is to use complete names (first and last). We will accept a title, such as, Mr., Mrs., Ms., Reverend, Captain, Sergeant, etc., and a last name. Unacceptable are first names only, and nick names, as well as a blank space. Addresses are to include, building number, apartment/suite number if applicable, street name, city, state, and complete zip code as well as a phone number if applicable. Please limit the use of post office boxes and rural route numbers for addresses only. If you must use a post office or rural route number, be sure you use the back of the booklet and the extra sheets of paper to provide directions of how to get there. Phone numbers, in state and out of state, are to include area codes. You should make every attempt to provide complete information regarding addresses of employers and residences. Provide the information on every employer since you started working, regardless of the duration of employment. Even if the company is out of business or moved, list it chronologically and provide the required information. This is an integral part of the investigation and if the information is not complete the process may be terminated and your file closed. Family members are a good source of information; what you may have forgotten they can remember. If you have been in the military do your best to remember addresses, and any part-time employment you may have had. A base or military installation for overseas deployment will suffice in most cases. Employment information should include addresses, names of supervisors, telephone numbers, dates worked from and to, and an explanation as to why you left. Limit the use of vague phrases to explain why you left, such as “marital problems”, “family problems”, or “personal reasons” ; explain in detail why you left. Finally, you are responsible for providing copies of the documents that must accompany this booklet. You are to maintain the original documents and you must bring them with you when you are scheduled for your interview with an investigator. You will be required to provide transcripts for high school and college, if applicable. 1) If you have an out-of-state driver’s license, or if you have ever had a license from any

other state: You must contact that State’s Department of Motor Vehicles and obtain a certified copy of your driving record.

2) To those applicants who have attended high school and/or college, contact the

school(s) and arrange to obtain your official transcript(s). You may have them sent directly to us by the school, or you may pick them up and bring them to us. Either way, they must be received in a sealed envelope with the school’s official seal.

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3) Do not forget the due date for your Personal History Statement. If you want to be

considered for further processing, your Personal History Statement MUST be returned on or before the due date, and the booklet must be completed as per

instructions. If you fail to complete the booklet per instructions it may not be processed and your file may be closed.

If you have any questions regarding the completion of this booklet, or about the documents you must provide with the booklet, contact the Police Personnel Section between the hours of 08:00am and 04:00pm Monday through Friday at 410-222-3156 or 410-222-8673. There is a voice mail for these numbers if no one is able to take your call. Always leave your name and a telephone number where you can be reached during the above hours, as well as a brief message. Include in your message the position for which you have applied and the name of your investigator if you have been assigned one.

ANNE ARUNDEL COUNTY POLICE DEPARTMENT POLICE PERSONNEL SECTION

8495 Veterans Highway Millersville, Maryland 21108-1485

410-222-3156 Fax-410-222-8678

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ANNE ARUNDEL COUNTY POLICE DEPARTMENT PERSONAL HISTORY STATEMENT

PART I – DOCUMENTS THAT ARE REQUIRED

A thorough background investigation is included in the selection process for the position for which you are applying. The following are documents which are required to complete your background investigation. All documents, which are applicable to you, should be submitted with your Personal History Statement. Clearly legible photocopies are acceptable; however, original copies should be available for verification by the Police Personnel Office.

1. Birth Certificate 2. High School Diploma or G.E.D. and Transcripts 3. College Diploma and Transcripts 4. Marriage Certificate 5. Divorce Decrees, Separation Papers 6. Military Discharge (DD214) 7. Selective Service Acknowledgement 8. Court Ordered Name Changes 9. Certificates or Continued Education or Special Training 10. Awards or Letters of Commendation 11. Naturalization Papers 12. Social Security Card 13. MPTC-Card and Certificate (Current Police/Correctional Officers) 14. Driver’s License - Maryland and Out of State (Certified Copy Required) 15. Financial Aid Transcript (Student Loan) 16. Vehicle Registration and Insurance Cards 17. Child Support Paperwork, Case Number, Contact Person

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ANNE ARUNDEL COUNTY POLICE DEPARTMENT

PERSONAL HISTORY STATEMENT

PART II - PERSONAL DATA

1. Name (LAST, FIRST, MIDDLE)

Last

First

Middle

2. Aliases, Maiden Names/Nicknames (specify which)

3. Date of birth:

4. Place of birth: City, County, State, Country

5. Height Weigh Hair Color Eye Color Scars/Tattoos or Identifying Marks

6. Social Security Number

7. Citizenship

☐ U.S. Citizen

☐ Alien

☐ By Birth

☐ Naturalization

Alien Registration Number

Date, Place and Court

Certificate No.

Petition No.

☐ Derived – Parent’s (s) Cert. No.(s) , specify which or both

Native Country

Date, Place, & Port of Entry into U.S.

Sponsor

8. Address Currently Residing

House Number and Street

Apt #

City: County: State: ZIP Code:

9. Legal Residence

House Number and Street

Apt #

10. Home Telephone (Include area code and hours during which you can be reached)

Area Code ( ) Hours

10a. Mobile Number Area Code ( ) 10b. Email:

11. Work Telephone (Include area code and hours during which you can be reached)

Area Code ( ) Hours

12. Present Marital Status

☐ Married ☐Divorced ☐ Widowed ☐ Separated ☐ Single

13. Full Name of Current Spouse

Last

First

Middle

Maiden

14. Marriage Date (Include present and ALL former marriages)

Date (s) of Marriage Place (s) of Marriage (City and State)

A.

B.

C.

D.

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15. Spouse’s Employment

Company Name

Address

City

State

Office Telephone #

16. Have you ever been:

Widowed Choose an item. Separated Choose an item. Divorced Choose an item.

17. We are going to contact your spouse or former spouse (s). Please state if you have any objections and explain why.

18. List below the name(s) of each of your children, the name and address of each child’s other parent, the name and address of each child’s guardian (if other than either parent) and each child’s birth date, place of birth, and current residence (go to Part XIV if additional space is needed).

Name of Child Date of Birth Place of Birth Current Residence of Child

A.

B.

C.

D.

E.

Name and Address of Other Parent of Each Child Listed Above

A.

B.

C.

D.

E.

Name and Address of Guardian of Each Child Listed Above (If other than either parent)

A.

B.

C.

D.

E.

19. Do you have any dependents other than those listed above: Choose an item. If yes, list the following information:

Name Address Relationship

A.

B.

C.

D.

E.

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20. Are you receiving and/or responsible for paying court ordered child support? Choose an item. If yes, list the following information:

To Whom Paid or From Who Received

Amount Paid Amount Received Frequency Pd/Received

21. Have you EVER been involved as a complainant or defendant in a paternity proceeding? Choose an item. If, yes, enter full details on continuation sheets (Part XIV)

22. Parents – Applicants must provide ALL information requested below concerning their Mother and Father. If your parents are deceased, the information requested in Sections A, B, G, H and I MUST still be provided.

A. Name of Father Last_______________________________________ First _______ Middle__________________ B. Name of Mother Last_______________________________________ First _______ Middle__________________

C. Father’s Address – Street, City, State Zip Code D. Mother’s Address – Street, City, State Zip Code

E. Father’s Telephone Number (___) Email: F. Mother’s Telephone Number (___) Email:

G. Place of Birth City, State Mother: Father:

H. Date of Birth

Father: Month Mother: Month

Day Day

Year Year

I. If Deceased, List Date of Death

Month

Day

Year

23. If you were raised by anyone other than your parents, provide the following information concerning those who raised you (other than institutions or foster homes)

A. Name of Person Who Raised You Last___________________________________ First Middle____________

B. Address – Street, City, State Zip Code

C. Home Telephone Number (___)

D. Relationship

Mo Day Yr Mo Day Yr

From

To

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USE CONTINUATION SHEET IN PART XIV TO PROVIDE ADDITIONAL DATA IF NECESSARY

PART III – MILITARY DATA

24. Branch of Service Last Organization, if known

Primary M.O.S./A.F.S.C.

Dates of Active Duty

Choose an item.

Service Number During This Period

Reserve Service Choose an item.

Branch of Reserve Service

Date Membership

Choose an item.

Service Number During this Period

☐ Army

☐ Air State

Began

Ended

List YOUR Organization and Address on this Line

25. Type of discharge (i.e., Character of Service)

26. Rank at discharge (following most recent period of military service)

27. Highest rank attained

28. Were you recommended for re-enlistment after each period of military duty? Choose an item.

29. Have you ever received a discharge from the Armed Forces which was other than honorable? Choose an item.

30. If you answered “Yes” to Question 33, What type of discharge did you receive? Explain the circumstances in PART - XIV

31. Were you ever subjected to any disciplinary actions (judicial or non-judicial) while in the Armed Forces? Choose an item. If yes, explain the circumstance in PART - XIV

32. Were you ever subjected to any criminal investigation which was being conducted by the military authorities concerning any alleged misconduct on your part? Choose an item. If yes, explain the circumstance in PART - XIV

33. If you still have a National Guard or a Reserve obligation, designate the type of service obligation you currently have and list the date such obligation is scheduled to terminate.

PART IV - SELECTIVE SERVICE

34. Selective Service Number:

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PART V – FINANCIAL DATA

35. Do you presently hold a controlling interest in any company? Choose an item. If yes, explain Your interest.

36. Have you ever been found delinquent on income or other tax payments? Choose an item. If yes, explain in PART - XIV

37. Have you ever had a court ordered financial judgment pending in court? Choose an item. If yes, explain in PART - XIV

38. Do you presently have a financial judgment pending in court? Choose an item. If yes, explain in PART - XIV

39. What is your monthly income? 40. Spouse’s monthly income?

41. Do you or your Spouse have any other source(s) of income? Choose an item. If yes, list the source(s) of such income and the monthly amount(s). Convert to monthly amounts ANY income received on other than a monthly basis.

Source of Income Self or Spouse Monthly Income

$

$

$

$

$

42. List Other Assets

List below ALL pertinent information concerning your present assets:

Type of Asset Total Amount

$

$

$

$

$

$

$

Total Assets $

For Additional Space Use Remarks Section (PART – XIV)

PART – VI REFERENCES

43. Provide the data requested below on three (3) references, not related by blood or marriage, not former employers and not mentioned elsewhere in this form, who are responsible adults with reputable standing in their community, and who have known you for at least five (5) years. These references may include, but are not limited to: teachers, counselors, tenants/subtenants, landlords, members of the clergy, or business people.

A.

Name Mr. Mrs. Ms. Miss Residence Address

Last________________________________________ First ______Middle Initial______

Street City State/Zip Code

Home Telephone Number ( ) Email:

Years Known

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Occupation

Place of Employment

Address of Employment: Street City State/Zip Code

Business Telephone Number ( )

B.


Last________________________________________ First _______ Middle Initial______



Years Known

Occupation

Place of Employment



C.


Last_________________________________________ First _________ Middle Initial_____



Years Known

Occupation Place of Employment



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PART – VII ASSOCIATES/FRIENDS

44. Provide the data requested below on three (3) persons with whom you have associated (i.e., persons whom you have seen frequently) during the past three (3) years. Exclude relatives, former employees and persons mentioned elsewhere in this form.

A.


Last_________________________________________ First ______ Middle Initial________



Years Known

Occupation

Place of Employment



B.





Years Known

Occupation

Place of Employment



C.





Years Known

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Occupation Place of Employment



PART VIII – RESIDENCE DATA

45. Provide the information requested below on ALL of your residences since birth, beginning with your present residence. In each case, list the name and present correct street address of one neighbor (not necessarily a personal acquaintance), and the name and address of the realty company or property owner to whom YOU pay/paid rent if applicable, or the name and address of the mortgage holder. Include your mailing and/or street address during ALL periods of military service.

A. Start with Your Present Residence

Dates of Residence Location of Residence

From

To

Street Address Apt. No. City St/Zip Code

Month Day Year Present

Neighbor’s Name Mr. Mrs. Ms. Miss Neighbor’s CURRENT Address

Last First Initial


Neighbor’s Telephone ( ) Email:

Realty Company or Property Owner’s Name

Realty/Owner’s Telephone ( ) Email:

Realty Company or Property’s Owner’s Address


B. For PRESENT Residence Only:

Do you: ☐ Rent or ☐ Own this Property?

Do you reside with: ☐ Self ☐ Spouse & Children, if any or ☐ Other (If Other, list with whom you Reside)

C. Next, list your residence prior to the one above and so on

Location of Residence


Month

Day

Year

Neighbor’s Name

Neighbor’s CURRENT Telephone ( ) Email:

Neighbor’s CURRENT Address


Realty Company or Property’s Owner’s Name

Realty/Owner’s Telephone No. ( ) Email:



D.



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Month

Day

Year

Neighbor’s Name






E.



Month

Day

Year Neighbor’s Name





F.



Month

Day






G.



Month

Day






H.



Month

Day






I.


15



Month

Day






J.



Month

Day






K.



Month

Day






L.



Month

Day






M.



Month

Day






N.

16




Month

Day






O.



Month

Day






PART IX – EDUCATION

46. Provide the information requested below on ALL schools you have attended since the ninth (9 th) grade, beginning with the most recent. Be sure to include colleges, universities, business, trade schools, and if relevant to the position for which you are applying, military schools.

A. Name of School B. Address of School


C. Dates Attended D. Highest Grade Completed E. Did you Graduate?

From To Choose an item.

Month Year Month Year













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47. Did you graduate from High School? ☐ Yes ☐ No

48. Did you pass a G.E.D. (General Education Development) Test? ☐ Yes ☐ No ☐ I have NOT taken the test

GED# Date Received

49. Did you obtain your G.E.D. Certificate from the Armed Forces? ☐ Yes ☐ No ☐ Not Applicable

50. If you have a G.E.D. Certificate, has it been presented to a Board of Education? ☐ Yes ☐ No ☐ Not Applicable

51. If YOU have answered “Yes” to Question 50, did that Board present you with a High School Diploma? ☐ Yes ☐ No ☐ If Yes, complete the following:

Name of Board of Education Board’s Complete Mailing Address

Date Diploma Issued

52. If you have taken the G.E.D., but you answered “No” to Question 50 and 51, explain:

53. If you attended college, list your area(s) of concentration:

54. What, if any, degree(s) have been conferred upon you beyond the high school level?

55. If you attended college, but did NOT graduate, please provide a brief explanation. Also, give the number of semester (or quarter) hours satisfactorily completed.

56. Have you ever been dismissed or expelled from ANY school or college for any academic or disciplinary reason?

☐ Yes ☐ No ☐ If Yes, give full details below:

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PART X – EMPLOYMENT DATA

57. List below your completed Work History, starting with your present position. Be sure to list ALL periods of active military duty (including active duty for training for more than fifteen days) and ALL periods of unemployment (identifying it as such). Also include ALL part-time, temporary, and/or voluntary employment and identify it as such.

A. Start with PRESENT Employment

Dates of Employment Name of Employer/Firm/Agency US, State or Local Govt. Agency


Month

Day

Year

Present

Work Telephone Number ( )

Place An ‘X ’ in One Box Address of Employer/Firm/Agency

☐ Full-Time ☐ Part-Time

☐ Temporary ☐ Voluntary

☐ Intermittent ☐ Unemployed


Name of Supervisor Title of Supervisor Supervisor’s Phone No. Your Salary

Supervisor’s Email: $

Your Title/Position

Describe your duties (briefly) and reason(s) for leaving

B. Would any problem result if your present employer was contacted during the course of this background investigation? ☐ Yes ☐ No If yes, please explain

C.



Month

Day

Year

Present



☐ Full Time ☐ Part-Time






Your Title/Position


D.



Month

Day

Year

Present







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Your Title/Position


E.



Month

Day

Year

Present


Place An ’ X ’ in One Box Address of Employer/Firm/Agency







Your Title/Position


F.



Month

Day

Year

Present









Your Title/Position


G.



Month

Day

Year

Present

Work Telephone Number ( ) -


20








Your Title/Position


H.



Month

Day

Year

Present









Your Title/Position


I.



Month

Day

Year

Present









Your Title/Position


J.


21



Month

Day

Year

Present









Your Title/Position


K.



Month

Day

Year

Present









Your Title/Position


L.



Month

Day

Year

Present


Place An ’ X ’ in One Box Address of Employer/Firm/Agency







Your Title/Position


22


M.



Month

Day

Year

Present









Your Title/Position


N.



Month

Day

Year

Present









Your Title/Position


O.



Month

Day

Year

Present









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Your Title/Position


58. Have you ever received any disciplinary actions for any reason documented or otherwise? ☐ Yes ☐ No If yes, explain including when, name of employer, and why.

59. Have you: A. Even been discharged from employment ( fired) for ANY reason? ☐ Yes ☐ No

B. Ever resigned (quit) after being informed that your employer intended to discharge (fire) you for ANY reason?

☐ Yes ☐ No

C. Ever resigned (quit) after being informed that your employer intended to take ANY form of disciplinary action against you? ☐ Yes ☐ No

If you answered “Yes” to ANY of the above three questions, give full details in the space provided below, including the name and address of the employer, approximate date(s), and the circumstances in each case. If additional space is needed, use Remarks Section (PART – XIV).

PART XI – DRIVING RECORD

60. Indicate below ALL traffic violations or citations (excluding parking tickets) that you have received. Include in your response, but do NOT limit it to, such violations as speeding, reckless driving, changing lanes without caution, defective equipment, stop sign violations, and red light violations. For each incident, give the following data:

Date Violation/Charge Location/City/State Police Agency

Final Disposition Amount of Fine Points

61. Provide the information requested below on ALL driver’s licenses which are now or have been issued to you from ANY state (even though these licenses may now be expired or have been replaced by another issuing agency or state).

Issuing State License Number Expiration Date Type of License

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62. Is your driver’s license now or has it ever been: A. Denied or refused? ☐ Yes ☐ No

B. Suspended? ☐ Yes ☐ No

C. Revoked? ☐ Yes ☐ No

D. Subjected to ANY other similar penalty or action? ☐ Yes ☐ No

If you answered “Yes” to ANY of the above, explain in detail below:

63. Are your vehicle license plates now or have they ever been:

A. Denied or refused? ☐ Yes ☐ No

B. Suspended? ☐ Yes ☐ No

C. Revoked? ☐ Yes ☐ No

D. Subjected to ANY other similar penalty or action? ☐ Yes ☐ No

If you answered “Yes” to any of the above, explain in detail below:

64. Do you currently have a valid driver’s permit? ☐ Yes ☐ No

65. Were you ever involved in an accident? ☐ Yes ☐ No

If yes, give complete details in item number 68 below, or in the Remarks Section (PART XIV) for each accident. Include (as a minimum) date, place, fault, charges, injuries, and name of the police department that made the report.

66. Enter the following information concerning ANY motor vehicle(s) owned or operated by you:

Vehicle No. 1 Vehicle No. 2

Make Make

Model Model

Year Year

License Plate Number License Plate Number

State Registered State Registered

Name and Address of Owner(s)

Name and Address of Owner(s)

67. Please check the types of insurance coverage which you carry on your primary automobile. Please include the name of your insurance company, and the policy number. Insurance Company: _________________________ Police Number: _____________________

Liability ☐ Collision ☐ Property Damage ☐ Medical ☐ Comprehensive (Fire, Theft, Etc.) ☐

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68. If there is anything you wish to state about your driving record, please use this space below. Include any insurance cancellations since you began driving, and the reason for the cancellations.

PART XII – CONVICTION DATA/ILLEGAL DRUG SALES AND USES

69. Have you ever been:

A. Charged with a criminal offense? ☐ Yes ☐ No

B. Convicted of ANY offense against the law? ☐ Yes ☐ No

C. Subjected to forfeiture of collateral in connection with an arrest? ☐ Yes ☐ No

D. Placed on probation? ☐ Yes ☐ No

E. Have you ever had to appear before a juvenile court? ☐ Yes ☐ No

F. Have you ever been served with a summons to appear in court as a witness in a criminal proceeding? ☐ Yes ☐ No

G. Have you ever received probation before judgment or any disposition other than “not guilty” in a criminal proceeding?

☐ Yes ☐ No

70. Are you now:

A. Charged with an offense by ANY law enforcement authority? ☐ Yes ☐ No

B. Presently on bail or out on personal recognizance or other conditional release? ☐ Yes ☐ No

C. On probation of any type? ☐ Yes ☐ No

71. Are you now or have you ever been involved as a plaintiff or defendant in ANY civil court action? ☐ Yes ☐ No

72. If you answered “Yes” to ANY part of questions 69, 70, or 71, give complete details in the section below. Include (as a minimum): (1) the date of the offense, (2) charge(s), (3) city and state, (4) name of law enforcement agency involved, and (5) final disposition. For additional space, use the Remarks Section (PART XIV).

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PART XII –ILLEGAL DRUG SALES AND USES

In the space below complete with respect to ANY use you have had of the following illegal drugs, illegal use of legal drugs (not prescribed by a physician for you)

Drug Date First Used Date Last Used Number of Times

Marijuana

Hashish

PCP

Angel Dust

THC

LSD

Peyote

Mescaline

Mushrooms

Psilocybin

Heroin

Cocaine

Quaaludes

Uppers

Downers

Tranquilizers

Amphetamines

Biphetamines

Ecstasy (XTC)

Preludin

Talwin & PBZ

Speed

Inhalants

Methamphetamine

Opium

Steroids

Others

Have you ever sold ANY illegal drugs or legally prescribed drugs (other than in the course of legal employment), regardless of

whether or not you received any profit? ☐ Yes ☐ No

If you have sold ANY drugs as described above, what was the total estimated value? _____________________

Have you ever used illegal drugs (including legal drugs for which you do not have a prescription) at work? ☐ Yes ☐ No

If yes, indicate the number of times and date last used. ______________________________

Do you now take or have you ever taken ANY medication other than under a doctor’s prescription (with the exception of over -the-counter drugs)? ☐ Yes ☐ No

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PART XIII – MISCELLANEOUS

73. Do you belong to any organization and/or adhere to any belief which would in any way:

A. Limit or prohibit your use of weapons or firearms? ☐ Yes ☐ No

B. Restrict or prohibit you from working on particular days or hours? ☐ Yes ☐ No

C. Restrict you from conforming to departmental standards of appearance

and/or grooming which may from time to time be set? ☐ Yes ☐ No

If you answered “Yes” to any of the above, explain in the Remarks Section (PART XIV).

74. Has the consumption of alcohol beverages ever affected your job performance with respect to attendance or carrying out your duties and responsibilities? ☐ Yes ☐ No

If yes, give the number of times __________________

75. Are you now or have you ever been a member of or espoused the basic tenets and beliefs of an organization that to your present knowledge seeks the overthrowing of the Government of the United States by force or violence or other unlawful means? ☐ Yes ☐ No

If you answered “Yes”, give full details in the Remarks Section (PART XIV).

76. Have you ever been issued a permit to license to carry a handgun or other weapon on your person? ☐ Yes ☐ No

If yes, give full details below.

77. List any special skills you possess which you believe may be applicable to the position for which you are applying (skills with machines or equipment, public speaking experience, membership in a professional, scientific, community or other such organization etc.)

78. A. Have you ever applied for a position with ANY federal, state, or local law enforcement agency or any fire department? ☐ Yes ☐ No

B. Have you ever applied for ANY position with the federal, state, or local government for which a background

investigation was initiated? ☐ Yes ☐ No

C. If you have ever been denied employment by an organization covered in questions “A” or “B”, provide complete details in the space provided below with regard to ALL positions. Be sure to include the name and address of each organization applied to, the position(s) applied for, the date(s) of your application(s), and the reason(s) you were not employed in each instance (including a thorough explanation of why you were denied employment, if such was the case.) If additional space is needed, use Remarks Sections (PART – XIV).

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79. Family: List the order given, showing relationship, brothers, and sisters, even if deceased. (Include any others you have resided with or with whom a close relationship existed or exists.)

A: Relationship Name and Date of Birth Present Address: City/State/Zip

B: Others

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80. List any family members and acquaintances who are currently employed by this Department or who have been employed by this Department in the past:

81. Foreign Language: Enter foreign language and indicate your knowledge of each by placing an “X” in the proper column.

Language Reading Speaking Understanding Writing

Excell Good Fair Excell Good Fair Excell Good Fair Excell Good Fair

82. Foreign Travel: Exclude trips of less than 30 days to Canada or Mexico and foreign travel as a direct result of U.S. Military duties

Dates Country Visited Purpose of Travel

From To

83. Are there incidents in your life not mentioned herein which may reflect upon your suitability to perform the duties which you may be called upon to take or which might require further explanation?

☐ Yes ☐ No

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PART XIV – REMARKS SECTION/CONTINUATION SHEETS

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SIGNATURE PAGE

If information should surface during any stage of this investigation which would disqualify you from further consideration, the investigation may be terminated immediately and you will be notified accordingly.

On this __________________ day of _______________________ 20___,

I have completed the foregoing Personal History Statement and understand the contents.

The information given is correct to the best of my knowledge and belief and does not

knowingly contain any material misrepresentation of fact. I understand that any

material misrepresentation of fact given by me will be cause for rejection before

appointment or dismissal from the department after appointment.

________________________________________________________

(Full Legal Signature)

anne arundel county police department arundel county police department personal history statement...

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