PERSONAL HISTORY STATEMENT POLICE PATROL APPLICANTS › vertical › sites... · 4 8. All documents...

CITY OF POTTSBORO, TEXASPOLICE DEPARTMENT

City of Pottsboro Police Department411 Franklin

P.O. Box 1089Pottsboro, Texas 75076

(903) 786-5202

PERSONAL HISTORY STATEMENTPOLICE PATROL APPLICANTS

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PHS.1214/00

TO POLICE PATROL APPLICANTS:

The City of Pottsboro requires that all applicants submit a Personal History Statement to the Chief ofPolice.

Read the instructions for completing the Personal History Statement very carefully and answer allquestions as instructed. This is a detailed document, which requires some research on your part, as wellas furnishing the required documentation. You must respond to all questions, if the question is notapplicable to you, then enter N/A in the space provided.

IMPORTANT! The completed Personal History Statement must be returned to the office of the City ofPottsboro Chief of Police on or before_____________. All documents requested must be enclosed withyour Personal History Statement or it will not be accepted. If we do not receive your Personal HistoryStatement by the above due date, we will assume that you are no longer interested in becoming aPottsboro Police Officer and your name will be removed from the preliminary eligibility list establishedby the written examination.

Please remit your Personal History Statement either by personal delivery or Certified Mail to thefollowing:

City of Pottsboro528 East FM 120P. O. Box 1089

Pottsboro, Texas 75076

Thank you!

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INSTRUCTIONS: Please read these instructions carefully before proceeding.

These instructions are provided as a guide to assist you in properly completing your Personal HistoryStatement. It is essential that the information be accurate in all respects. It will be used as the basis for abackground investigation that will determine your eligibility for employment with the City of Pottsboro.

1. Your Personal History Statement should be printed legibly in ink. Answer all questions to the best ofyour ability.

2. If a question(s) is not applicable to you or if there are more spaces than you need to provide yourinformation, enter N/A in the spaces provided.

3. If there is insufficient space on the form for you to include all information required, attach extrasheets to the Personal History Statement. Be sure to reference the relevant section and questionnumber before continuing your answer.

4. Avoid errors by reading the directions carefully before making any entries on the form. Be sure yourinformation is correct and in proper sequence before you begin.

5. You are responsible for obtaining correct addresses and phone numbers. If you are not sure of anaddress, check it by personal verification. Your local library may have a directory service or copiesof local phone directories.

6. An accurate and complete form will help expedite your investigation. On the other hand, omissionsor falsifications may result in disqualification.

7. I AM FULLY AWARE THAT ANY SUCH OMISSIONS OR FALSIFICATIONS SHALL BEGROUNDS FOR REFUSAL TO HIRE OR IF HIRED, TERMINATION OF EMPLOYMENT.

INSTRUCTIONS

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8. All documents requested must be turned in at the same time the Personal History Statement issubmitted. The following items must be included with your Personal History Statement:

a. A certified copy of your Birth Certificate (This is not a copy of the hospitals complementarybirth certificate).

b. Naturalization papers (if applicable)

c. A certified transcript of ALL of your high school grades and credits, even if you did notgraduate.

d. A certified copy of your G.E.D., if you did not graduate from high school.

e. Certified copies of any completion documents and/or grades from vocational schools.

f. A certified transcript of all college or university hours and/or proof of degree.

g. If you are a former member of the Armed Services, a certified copy of your discharge and/ortransfer papers.

h. If you are married, a certified copy of your marriage certificate. If you are divorced, acertified copy of all divorce decrees applicable to your situation.

YOUR PERSONAL HISTORY STATEMENT AND ALL REQUESTED DOCUMENTS MUSTBE RETURNED TO THE DIRECTOR OF CIVIL SERVICE ON OR BEFORE

____________________

THERE WILL BE NO EXTENSIONS OR EXCEPTIONS MADE

INSTRUCTIONScontinued

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PERSONAL HISTORY STATEMENT

A. APPLICANT INFORMATION - INFORMATION PROVIDED IN THIS SECTION IS FORIDENTIFICATION PURPOSES ONLY.

NAME ______________________________________________________________________(Last) (First) (Middle)

ADDRESS ___________________________________________________________________(Number) (Street)

__________________________________________________________________________________________________________(City) (State) (Zip Code)

TELEPHONE NUMBER (_______) ________________________________________________Area Code

LIST PHONE WHERE YOU CAN RECEIVE DAILY MESSAGES ______________________

DATE OF BIRTH ________________________ AGE ________Month Day Year

NICKNAME(S), MAIDEN NAME, OR OTHER NAMES YOU HAVE USED:_____________________________________________________________________________

NAME YOU PREFER: ____________________________

SOCIAL SECURITY NUMBER __________________________________________________

PLACE OF BIRTH _____________________________________________________________(City) (County) (State)

ARE YOU A U.S. CITIZEN _________ YES __________ NO

DRIVER'S LICENSE # ________________________________ STATE __________________

HEIGHT _______________ WEIGHT ____________

COLOR OF EYES __________________ COLOR OF HAIR _______________________

IDENTIFYING MARKS:

SCARS: _______________________________________________________________________

TATOOS: _____________________________________________________________________

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B. RESIDENCES - LIST ALL ADDRESSES WHERE YOU HAVE LIVED DURING THE PAST10 YEARS. BEGINNING WITH PRESENT ADDRESS. LIST DATE BY MONTH/YEAR.

FROM TO ADDRESS

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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C. MARITAL & FAMILY HISTORY

ARE YOU: ______SINGLE ______ENGAGED______MARRIED ______WIDOWED______SEPARATED ______DIVORCED

IF ENGAGED:NAME OF FIANCE'_____________________________________ DATE OF BIRTH ________

ADDRESS ____________________________________________________________________

PHONE __________________________ WORK PHONE _________________________

PRESENT MARRIAGE:DATE OF MARRIAGE __________________ CITY & STATE _________________________

SPOUSE'S NAME (WIFE'S MAIDEN NAME) _______________________________________

DATE OF BIRTH __________________ PHONE _______________________________

WORK PHONE ____________________

IF EVER SEPARATED, DIVORCED OR WIDOWED:DATE OF MARRIAGE _________________ CITY & STATE _________________________

DATE OF DIVORCE/SEPARATION ___________ CITY & STATE __________________


PRESENT ADDRESS & PHONE __________________________________________________

______________________________________________________________________________

IF EVER SEPARATED, DIVORCED OR WIDOWED:

DATE OF MARRIAGE __________________ CITY & STATE _________________________

DATE OF DIVORCE/SEPARATION ___________ CITY & STATE __________________


PRESENT ADDRESS & PHONE __________________________________________________

______________________________________________________________________________

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NATURAL, STEPCHILDREN, ADOPTED & FOSTER CHILDREN

NAME RELATIONDATE OF

BIRTH ADDRESSSUPPORTEDBY WHOM

LIST ALL OTHER DEPENDENTS

NAME ADDRESS RELATION

LIST OTHER RELATIVES IN THE FOLLOWING ORDER:FATHER, MOTHER (INCLUDE MAIDEN NAME), LIST STEP, PAST OR PRESENT FATHER ORMOTHER, BROTHERS, SISTERS (STEP, HALF, ADOPTED, PAST OR PRESENT). IF DECEASED,SO INDICATE WITH NAME AND DATE OF DEATH.

NAME ADDRESS PHONE RELATIONDATE OF

BIRTH

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D. EDUCATIONAL HISTORY

HIGH SCHOOLATTENDED CITY & STATE FROM TO

GRADUATEDYES NO

COLLEGE OR UNIVERSITY ATTENDED _________________________________________

CITY & STATE ___________________________ DATES ATTENDED ______________

HRS. COMPLETED _________________ MAJOR/MINOR ________________________

DATE & TYPE OF DEGREE RECEIVED __________________________________________


CITY & STATE __________________________ DATES ATTENDED ______________

HRS. COMPLETED ________________ MAJOR/MINOR ________________________

DATE & TYPE OF DEGREE RECEIVED ___________________________________________


HRS. COMPLETED _____________ MAJOR/MINOR _______________________________

DATE & TYPE OF DEGREE RECEIVED ___________________________________________

LIST OTHER SCHOOLS ATTENDED (TRADE, VOCATIONAL, BUSINESS, ETC.) GIVE NAMEAND ADDRESS OF SCHOOL, DATES ATTENDED, COURSE STUDY, CERTIFICATE.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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E. SPECIAL QUALIFICATIONS & SKILLS

LIST ANY SPECIAL LICENSES YOU HOLD (SUCH AS PILOT, RADIO OPERATOR, SCUBA,ETC.), SHOWING LICENSING AUTHORITY, ORIGINAL DATE OF ISSUE, AND DATE OFEXPIRATION.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

LIST ANY SPECIALIZED MACHINERY OR EQUIPMENT THAT YOU CAN OPERATE.

____________________________________________________________________________

____________________________________________________________________________

IF YOU ARE FLUENT INA FOREIGN LANGUAGE, INDICATE IN EACH AREA YOUR DEGREEOF FLUENCY (EXCELLENT, GOOD, FAIR)

LANGUAGE READING SPEAKING UNDERSTANDING WRITING

LIST ANY OTHER SPECIAL SKILLS OR QUALIFICATIONS YOU MAY POSSESS.

______________________________________________________________________________

______________________________________________________________________________

_________________________________________________________________________

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F. WORK HISTORY - BEGINNING WITH YOUR PRESENT JOB OR PERIOD OFUNEMPLOYMENT. LIST ALL EMPLOYMENT SINCE THE AGE OF 16, INCLUDING PART-TIME, TEMPORARY OR SEASONAL EMPLOYMENT. INCLUDE ALL PERIODS OFUNEMPLOYMENT.

-----------------------------------------------------------------------------------------------------------------

EMPLOYER __________________________________ PHONE NUMBER _____________

ADDRESS _________________________ CITY/STATE __________________ ZIP______

CHECK JOB DESCRIPTION ____ FULL TIME ____PART TIME ____ TEMPORARY

STARTING DATE __________________ POSITION __________________________

ENDING DATE ____________________ POSITION___________________________

DUTIES/RESPONSIBILITIES: _________________________________________________

___________________________________________________________________________

SUPERVISORS NAME/TITLE _________________________________________________

ARE YOU ELIGIBLE FOR REHIRE? _______ IF NOT, WHY? ______________________

REASON FOR LEAVING OR WANTING TO LEAVE _____________________________

___________________________________________________________________________

MAY WE CONTACT YOUR PRESENT EMPLOYER WITHOUT JEOPARDIZING YOUR JOB?________________

DOES YOUR PRESENT EMPLOYER KNOW YOU ARE APPLYING FOR THIS JOB?_____________________

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EMPLOYER __________________________________ PHONE NUMBER _____________

ADDRESS _________________________ CITY/STATE __________________ ZIP______

CHECK JOB DESCRIPTION ____ FULL TIME ____PART TIME ____ TEMPORARY

STARTING DATE __________________ POSITION __________________________

ENDING DATE ____________________ POSITION___________________________

DUTIES/RESPONSIBILITIES: _________________________________________________

___________________________________________________________________________

SUPERVISORS NAME/TITLE _________________________________________________

ARE YOU ELIGIBLE FOR REHIRE? _______ IF NOT, WHY? ______________________

REASON FOR LEAVING OR WANTING TO LEAVE _____________________________

___________________________________________________________________________

MAY WE CONTACT YOUR PRESENT EMPLOYER WITHOUT JEOPARDIZING YOUR JOB?________________

DOES YOUR PRESENT EMPLOYER KNOW YOU ARE APPLYING FOR THIS JOB?_____________________

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EMPLOYER _________________________________ PHONE NUMBER _____________

ADDRESS _____________________________CITY/STATE ________________ZIP______

CHECK JOB DESCRIPTION _____ FULL TIME _____ PART TIME _____TEMPORARY

STARTING DATE ______________ POSITION __________________________________

ENDING DATE ________________ POSITION __________________________________

DUTIES/RESPONSIBILITIES ___________________________________________________

_____________________________________________________________________________

SUPERVISORS NAME/TITLE ___________________________________________________

ARE YOU ELIGIBLE FOR REHIRE? ____ IF NOT, WHY? _________________________

REASON FOR LEAVING OR WANTING TO LEAVE ________________________________

______________________________________________________________________________

MAY WE CONTACT YOUR PRESENT EMPLOYER WITHOUT JEOPARDIZING YOURJOB?_________

DOES YOUR PRESENT EMPLOYER KNOW YOU ARE APPLYING FOR THIS JOB?_____

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G. MILITARY RECORD

HAVE YOU SERVED IN THE U.S. ARMED FORCES? ____ YES ____ NO

DATE OF SERVICE: FROM ____________ TO ___________________________________

BRANCH OF SERVICE _____________UNIT DESIGNATION _________________________

MILITARY SERVICE NUMBER __________________________________________________

HIGHEST RANK _______________________________________________________________

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TYPE OF DISCHARGE __________________________________________________________

WERE YOU EVER DISCIPLINED WHILE IN THE MILITARY SERVICE (INCLUDE COURTMARTIAL, CAPTAIN'S MASS, COMPANY PUNISHMENT, OFFICE HOURS, ETC.)?_____ YES _____ NO

CHARGE _____________________________________________________________________

MILITARY AGENCY ___________________________________________________________

DATE ____________________

COMPLETE EXPLANATION OF DISPOSITION ____________________________________

______________________________________________________________________________

______________________________________________________________________________

CHARGE _____________________________________________________________________

MILITARY AGENCY ___________________________________________________________

DATE ____________________

COMPLETE EXPLANATION OF DISPOSTION _____________________________________

______________________________________________________________________________

______________________________________________________________________________

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H. ARRESTS, DETENTION AND LITIGATION

HAVE YOU EVER BEEN ARRESTED, DETAINED BY THE POLICE OR SUMMONED INTOCOURT? ______ YES ______ NO

IF YES, COMPLETE THE FOLLOWING:

OFFENSE CHARGED ___________________________________________________________

DATE _________________

POLICE AGENCY ______________________________________________________________

CITY/STATE __________________________________________________________________

DISPOSITION OF CASE _________________________________________________________

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OFFENSE CHARGED ___________________________________________________________

DATE _________________

POLICE AGENCY ______________________________________________________________

CITY/STATE __________________________________________________________________

DISPOSITION OF CASE ________________________________________________________

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OFFENSE CHARGED __________________________________________________________

DATE _________________

POLICE AGENCY _____________________________________________________________

CITY/STATE __________________________________________________________________

DISPOSITION OF CASE _________________________________________________________

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I. TRAFFIC RECORD

HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED OR REVOKED?

______ YES ______ NO

IF YES, GIVE DATE, LOCATION AND REASONS:

______________________________________________________________________________

______________________________________________________________________________

WITH WHAT INSURANCE AGENCY DO YOU CARRY AUTO INSURANCE?

NAME _______________________ ADDRESS ____________________________________

PHONE _______________________ POLICY # ____________________________________

LIST TO THE BEST OF YOUR RECOLLECTION, ALL TRAFFIC CITATIONS YOU HAVERECEIVED, EXCLUDING PARKING TICKETS.

MONTH &YEAR CHARGE CITY & STATE DISPOSITION

DESCRIBE IN A BRIEF NARRATIVE ANY TRAFFIC ACCIDENTS IN WHICH YOU HAVE BEENINVOLVED IN THE LAST TEN YEARS, GIVING DATE, CITY, STATE AND STREET ADDRESS.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

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J. FINANCIAL HISTORY

SOURCES OF INCOME

WHAT IS YOUR PRESENT SALARY OR WAGES? _______________________________

DO YOU HAVE INCOME FROM ANY OTHER SOURCE OTHER THAN YOUR PRINCIPALOCCUPATION?

IF YES, HOW MUCH? ____________

HOW OFTEN? ___________________

THE SOURCE: ______________________________________________________________

DO YOU OWN ANY REAL ESTATE? ______ YES ______ NO

VALUE ____________ LOCATION _______________________________________

DO YOU OWN ANY BONDS, GOVERNMENT OR OTHER?

______ YES ______ NO VALUE __________________

DO YOU OWN ANY CORPORATE STOCK?

______ YES ______ NO VALUE __________________

DO YOU HAVE A BANK ACCOUNT? ____ YES ____ NO

CHECKING:

ACCOUNT NUMBER _________________ AVERAGE BALANCE ________________

NAME AND ADDRESS OF BANK _____________________________________________

___________________________________________________________________________

SAVINGS:

ACCOUNT NUMBER _________________ AVERAGE BALANCE ________________

NAME AND ADDRESS OF BANK _____________________________________________

___________________________________________________________________________

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K. FINANCIAL OBLIGATIONS

GIVE NAMES AND ADDRESSES OF THE INDIVIDUALS, COMPANIES, OR OTHERS TO WHOMYOU ARE INDEBTED, AND THE EXTENT OF YOUR DEBT. INCLUDE RENT, MORTGAGES,VEHICLE PAYMENTS, CHARGE ACCOUNTS, CREDIT CARDS, LOANS, CHILD SUPPORTPAYMENTS, AND ANY OTHER DEBTS AND PAYMENTS. INCLUDE ACCOUNT NUMBERSWHERE APPLICABLE.

NAME OF CREDITOR ACCOUNT NUMBER BALANCE PAYMENTPASTDUE

TOTALS: ___________________________ _________________

Amount Owed Payments

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L. MEMBERSHIP IN ORGANIZATIONS (PAST AND/OR PRESENT)

NAME & ADDRESSTYPE (SOCIAL, FRATERNAL,

PROFESSIONAL, ETC) FROM TO

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M. PERSONAL DECLARATIONS

1. DESCRIBE IN YOUR OWN WORDS THE FREQUENCY AND EXTENT OF YOUR USE OFINTOXICATING LIQUORS.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

2. HAVE YOU EVER TRIED MARIJUANA? ____ YES ____ NOIF YES, HOW MANY TIMES? _________

3. HAVE YOU EVER TRIED ANY DRUG (BESIDES MARIJUANA) NOTPRESCRIBED BY YOUR PHYSICIAN? ____ YES ____NO

IF YES, WHAT DRUGS & HOW MANY TIMES?____________________________________________________________________________

____________________________________________________________________________

4. DO YOU HAVE ANY RELIGIOUS OR OTHER BELIEFS, WHICH WOULD PREVENT YOUFROM FULLY PERFORMING THE DUTIES OF A POLICE OFFICER, INCLUDINGWORKING ON WEEKENDS, EVENING OR NIGHT SHIFT? ____ YES ____ NO

IF YES, EXPLAIN: __________________________

5. HAVE YOU EVER MADE APPLICATION FOR EMPLOYMENT WITH THIS OR ANYOTHER LAW ENFORCEMENT OR RELATED AGENCY?____ YES ____ NO

IF YES, START WITH YOUR MOST RECENT APPLICATION:

---------------------------------------------------------------------------------------------------------------------

DATE APPLIED __________________________ DEPARTMENT _________________________________

CITY/STATE _____________________________

JOB APPLIED FOR ________________________________

ARE YOU PRESENTLY BEING CONSIDERED FOR EMPLOYMENT? ____ YES ____ NO

IF ANSWER IS YES ABOVE, LIST ALL STAGES YOU HAVE COMPLETED IN THE HIRING PROCESS:

_______________________________________________________________________________________________

IF NOT HIRED, LIST REASON ____________________________________________________________________


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CITY/STATE _____________________________

JOB APPLIED FOR ________________________________



_______________________________________________________________________________________________


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CITY/STATE _____________________________

JOB APPLIED FOR ________________________________



_______________________________________________________________________________________________


_______________________________________________________________________________________________

_______________________________________________________________________________________________

LAW ENFORCEMENT APPLICATIONS:---------------------------------------------------------------------------------------------------------------------------------------

DATE APPLIED __________________ DEPARTMENT ____________________________________

CITY/STATE ________________________________

JOB APPLIED FOR ___________________________



__________________________________________________________________________________________

IF NOT HIRED, LIST REASON _______________________________________________________________

----------------------------------------------------------------------------------------------------------------------------------------


CITY/STATE ________________________________

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JOB APPLIED FOR ___________________________



__________________________________________________________________________________________


----------------------------------------------------------------------------------------------------------------------------------------


CITY/STATE ________________________________

JOB APPLIED FOR ___________________________



__________________________________________________________________________________________

IF NOT HIRED, LIST REASON ______________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________LAW ENFORCEMENT APPLICATIONS:---------------------------------------------------------------------------------------------------------------------------------------


CITY/STATE ________________________________

JOB APPLIED FOR ___________________________



__________________________________________________________________________________________


----------------------------------------------------------------------------------------------------------------------------------------


CITY/STATE ________________________________

JOB APPLIED FOR ___________________________



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__________________________________________________________________________________________


----------------------------------------------------------------------------------------------------------------------------------------


CITY/STATE ________________________________

JOB APPLIED FOR ___________________________



__________________________________________________________________________________________

IF NOT HIRED, LIST REASON ______________________________________________________________

6. ARE THERE ANY INCIDENTS IN YOUR LIFE OR DETAILS NOT MENTIONED HEREINWHICH MAY INFLUENCE THIS DEPARTMENTS EVALUATION OF YOURSUITABILITY FOR EMPLOYMENT AS A POLICE OFFICER?

____ YES ____ NO

IF SO, EXPLAIN:___________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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N. REFERENCES

NAME _______________________________________________ PHONE ____________________________

ADDRESS __________________________________________________________________________________

OCCUPATION ___________________________________ BUSINESS PHONE __________________________

BUSINESS ADDRESS _____________________________________________ YEARS KNOWN______

NAME _________________________________________________PHONE _____________________________

ADDRESS ___________________________________________________________________________________

OCCUPATION __________________________________ BUSINESS PHONE ___________________________

BUSINESS ADDRESS _____________________________________________ YEARS KNOWN ______

NAME ________________________________________________ PHONE ______________________________

ADDRESS ____________________________________________________________________________________

OCCUPATION _________________________________ BUSINESS PHONE _____________________________

BUSINESS ADDRESS______________________________________________ YEARS KNOWN_______

NAME _______________________________________________ PHONE ______________________________

ADDRESS ____________________________________________________________________________________

OCCUPATION ________________________________ BUSINESS PHONE _____________________________

BUSINESS ADDRESS _____________________________________________ YEARS KNOWN _______

NAME ______________________________________________ PHONE _______________________________

ADDRESS _____________________________________________________________________________________

OCCUPATION ______________________________ BUSINESS PHONE ______________________________

BUSINESS ADDRESS ____________________________________________ YEARS KNOWN ________

NAME _____________________________________________ PHONE ________________________________

ADDRESS ______________________________________________________________________________________

OCCUPATION _________________________________ BUSINESS PHONE ______________________________

BUSINESS ADDRESS _____________________________________________ YEARS KNOWN_________

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__________________________________________________________________

SECURELY ATTACH A POLAROID SIZE PHOTOGRAH OF YOURSELF

BETWEEN THESE LINES

WHICH WAS TAKEN WITHIN THE LAST 6 MONTHS

NO SUNGLASSES

NO CAPS, HATS, ETC.

NO UNIFORMS OF ANY TYPE

___________________________________________________________

INCLUDE ORIGINALS OR CERTIFIED COPIES OF THESE DOCUMENTS, IF APPLICABLE, WHENSUBMITTING THIS DOCUMENT.

XEROX COPIES AND SIGNED BY A NOTARY IS NOT ACCEPTABLE.

PLEASE CHECK THE APPROPRIATE BOX IF YOU HAVE TO SEND FOR ORIGINALS OR CERTIFIEDCOPIES.

REQUESTED DOCUMENT YES NO

BIRTH CERTIFICATE

HIGH SCHOOL TRANSCRIPT

GED CERTIFICATE

COLLEGE TRANSCRIPT

MARRIAGE CERTIFICATE

DISSOLUTION OF MARRIAGE PAPERS

MILITARY DISCHARGE PAPERS

NATURALIZATION PAPERS

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I, HEREBY CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME INCONNECTION WITH MY APPLICATION, WHETHER ON THIS DOCUMENT OR NOT, ISTRUE AND COMPLETE, AND I UNDERSTAND THAT ANY MISSTATEMENT,FALSIFICATION, OR OMISSION OF INFORMATION SHALL BE GROUNDS FORREFUSAL TO HIRE OR, IF HIRED, TERMINATION.

_____________________________________Signature

SUBSCRIBED AND SWORN TO BEFORE ME ON THE _____ DAY OF ________, 20__

____________________________________________Notary Public

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AFFIDAVIT

TO: TCLEOSE

FROM: City of Pottsboro, Texas

APPLICANT SOCIAL SECURITY #(Last) (First) (MI)

CRIMINAL HISTORY: (IF NONE, STATE NONE)

OFFENSE DATE DISPOSITION*

*ATTACH CERTIFIED COPIES OF DOCUMENT FROM THE APPROPRIATE COURT.

OTHER THAN THE ABOVE, I SWEAR OR AFFIRM THAT I HAVE NEVER BEEN ARRESTED, CHARGED,CONVICTED OR PLACED ON PROBATION FOR ANY CRIMINAL OFFENSE (INCLUDING DOMESTICVIOLENCE).

SIGNED THIS THE ______________ DAY OF ___________________ , 20__

_______________________________________Printed Name

_______________________________________Signature

SUBSCRIBED AND SWORN TO BEFORE ME ON THE ______ DAY OF _______, 20__

_______________________________________Notary Public

28


AUTHORITY FOR RELEASE OF INFORMATION

NAME _______________________________________________________________________________________________________

SOCIAL SECURITY NUMBER ___________________________________________________________________________________

SEX ____________ RACE ___________________ DATE OF BIRTH _________________________________________________

PLACE OF BIRTH _____________________________________________________________________________________________City & County State Country

I, _______________________________________________, DO HEREBY AUTHORIZE A REVIEW OF AND FULL DISCLOSURE OFALL RECORDS, OR ANY PART THEREOF, CONCERNING MYSELF, BY AND TO ANY DULY AUTHORIZED AGENT OF THE CITYOF POTTSBORO, OFFICE OF PROFESSIONAL STANDARDS, WHETHER THE SAID RECORDS ARE OF PUBLIC, PRIVATE ORCONFIDENTIAL NATURE.

THE INTENT OF THIS AUTHORIZATION IS TO GIVE MY CONSENT FOR FULL AND COMPLETE DISCLOSURE OF THERECORDS OF EDUCATIONAL INSTITUTIONS: FINANCIAL OR CREDIT INSTITUTIONS, INCLUDING RECORDS OFDEPOSITS, WITHDRAWALS AND BALANCES OF CHECKING AND SAVINGS ACCOUNTS, AND LOANS, AND ALSO THERECORDS OF COMMERCIAL OR RETAIL CREDIT AGENCIES (INCLUDING CREDIT REPORTS AND/OR RATINGS):PUBLIC UTILITY COMPANIES; EMPLOYMENT AND PRE-EMPLOYMENT RECORDS; REAL AND PERSONAL PROPERTYTAX STATEMENTS AND RECORDS, AND OTHER FINANCIAL STATEMENTS AND RECORDS WHEREVER FILED;RECORDS OF COMPLAINT, ARREST, TRIAL AND/OR CONVICTIONS FOR ALLEGED OR ACTUAL VIOLATIONS OF LAW,INCLUDING CRIMINAL, CIVIL AND/OR TRAFFIC RECORDS; THE RESULTS OF ANY POLYGRAPH EXAMINATIONS;RECORDS OF COMPLAINT OF A CIVIL NATURE MADE BY OR AGAINST ME, WHERESOEVER LOCATED, AND TOINCLUDE THE RECORDS AND RECOLLECTIONS OF ATTORNEYS AT LAW, OR OF OTHER COUNSEL, WHETHERREPRESENTING ME OR ANOTHER PERSON IN ANY CASE WHICH I PRESENTLY HAVE, OR HAVE HAD AN INTEREST.

I, REITERATE, AND EMPHASIZE THAT THE INTENT OF THIS AUTHORIZATION IS TO PROVIDE FULL AND FREE ACCESS TOTHE BACKGROUND AND HISTORY OF MY PERSONAL LIFE, FOR THE SPECIFIC PURPOSE OF PURSUING A BACKGROUNDAND HISTORY OF MY PERSONAL LIFE, FOR THE SPECIFIC PURPOSE OF PURSUING A BACKGROUND INVESTIGATIONWHICH MAY PROVIDE PERTINENT DATA FOR THE CITY OF POTTSBORO POLICE DEPARTMENT TO CONSIDER INDETERMINING MY SUITABILITY FOR EMPLOYMENT BY THAT DEPARTMENT. IT IS MY SPECIFIC INTENT TO PROVIDEACCESS TO PERSONAL INFORMATION, HOWEVER PERSONAL OR CONFIDENTIAL IT MAY APPEAR TO BE, AND THESOURCES OF INFORMATION SPECIFICALLY IDENTIFIED HEREIN.

I UNDERSTAND THAT ANY INFORMATION OBTAINED BY A PERSONAL HISTORY BACKGROUND INVESTIGATION WHICH ISDEVELOPED DIRECTLY OR INDIRECTLY, IN WHOLE OR IN PART, UPON THIS RELEASE AUTHORIZATION WILL BECONSIDERED IN DETERMINING MY SUITABILITY FOR EMPLOYMENT BY THE CITY OF POTTSBORO POLICE DEPARTMENT.I UNDERSTAND THAT ALL MATERIALS PERTAINING TO THIS BACKGROUND INVESTIGATION BECOME THE PROPERTY OFTHE CITY OF POTTSBORO PUBLIC SAFETY DIVISION, OFFICE OF PROFESSIONAL STANDARDS, AND WILL NOT BERETURNED TO ME.

I AGREE TO INDEMNIFY AND HOLD HARMLESS THE PERSON TO WHOM THIS REQUEST IS PRESENTED AND HIS/HERAGENTS AND EMPLOYEES, FROM AND AGAINST ALL CLAIMS, DAMAGES, LOSSES AND EXPENSES, INCLUDINGREASONABLE ATTORNEY'S FEES, ARISING OUT OF OR BY REASON OF COMPLYING WITH THIS REQUEST. I FURTHERUNDERSTAND THAT IN THE EVENT MY APPLICATION IS DISAPPROVED, THE SOURCES OF CONFIDENTIAL INFORMATIONCANNOT BE REVEALED TO ME.

A PHOTOCOPY OF THIS RELEASE FORM WILL BE VALID AS AN ORIGINAL, EVEN THOUGH THE SAID PHOTOCOPY DOESNOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.

MUST BE SIGNED IN THE PRESENCE OF A NOTARY

Signature _____________________________________________________________ Date _______________________________

Address ____________________________________________________________________________________________________

SUBSCRIBED AND SWORN TO BEFORE ME ON THE ______ DAY OF _____________, 20__

___________________________________________________________Notary Public

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AUTHORITY FOR RELEASE OF MEDICAL INFORMATION

NAME__________________________________________________________________________________________________

SOCIAL SECURITY NUMBER ______________________________________________________________________________

SEX _______ RACE ____________ DATE OF BIRTH ___________________________________

PLACE OF BIRTH ________________________________________________________________________________________City & County State Country

THIS RELEASE WHEN PRESENTED BY A DULY AUTHORIZED REPRESENTATIVE OF THE CITY OF POTTSBORO, OFFICE OFPROFESSIONAL STANDARDS, CONSTITUTES MY CONSENT AND AUTHORITY TO EXAMINE AND OBTAIN COPIES ANDABSTRACTS OF RECORDS AND TO RECEIVE STATEMENTS OF INFORMATION REGARDING MY BACKGROUND.

SPECIFICALLY, I AUTHORIZE THE RELEASE OF THE FOLLOWING DATA OR RECORDS TO THE CITY OF POTTSBORO, OFFICEOF PROFESSIONAL STANDARDS, EMPLOYMENT; EDUCATIONAL; MEDICAL; PSYCHOLOGICAL; SELECTIVE SERVICE, POLICEAND CRIMINAL; MILITARY SERVICE; FINANCIAL AND CREDIT; POLYGRAPH EXAMINATIONS; AND THE UNDELETED COPYOF THE SEPARATION DOCUMENT AND MEDICAL RECORDS TO THE NATIONAL PERSONNEL RECORDS AND MILITARYPERSONNEL RECORDS CENTERS.

THIS AUTHORIZATION IS GIVEN IN CONNECTION WITH A BACKGROUND INVESTIGATION BEING CONDUCTED RELATIVE TOMY APPLICATION FOR, OR CONTINUED EMPLOYMENT WITH, THE CITY OF POTTSBORO. I UNDERSTAND THAT ALLMATERIALS PERTAINING TO THIS BACKGROUND INVESTIGATION BECOME THE PROPERTY OF THE CITY OF SHERAMNPUBLIC SAFETY DIVISION, OFFICE OF PROFESSIONAL STANDARDS, AND WILL NOT BE RETURNED TO ME.

I AGREE TO INDEMNIFY AND HOLD HARMLESS THE PERSON TO WHOM THIS REQUEST IS PRESENTED AND HIS/HER AGENTSAND EMPLOYEES, FROM AND AGAINST ALL CLAIMS, DAMAGES, LOSSES AND EXPENSES, INCLUDING REASONABLEATTORNEY'S FEES ARISING OUT OF OR BY REASON OF COMPLYING WITH THIS REQUEST. I FURTHER UNDERSTAND THATIN THE EVENT MY APPLICATION IS DISAPPROVED, THE SOURCES OF CONFIDENTIAL INFORMATION CANNOT BE REVEALEDTO ME.

A PHOTOCOPY OF THIS RELEASE FORM WILL BE VALID AS AN ORIGINAL HEREOF, EVEN THOUGH THE SAID PHOTOCOPYDOES NOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.

MUST BE SIGNED IN THE PRESENCE OF A NOTARY.

Signature ________________________________________________________ Date __________________________________

Address ________________________________________________________________________________________________________

Subscribed and sworn to before me on the _______day of ______________, 20__

_______________________________________________Notary Public

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