I I · 2015-11-15 · I . I . 6. List and describe all tal1oos: (indicate where they are located)...

SAN DIEGO POLlCE DEPARTMENT

Personal History Statement - Civilian Personal CONFIDENTIAL IPOWOII applied or

The lollowing information is requesfed of you for verificatjon and contact purpDses (USE BLUE OR BLACK INK OR TYPE) Please print or type your full legal name Laal ~ ~~I IMiddle

Other names (including nicknames) you have used or been known by including maiden name

2 Residence Numbltir Sirae IChy IS18 IZip Coda

3 Please list your residence phone and an ) IEmiddotMallI( I ( ) altemate number for messages RoampldOtlce o Other 0 Work

Please list mailing address if different from residence address Number S61 lICity Sleto ~ Zip Coo

4 BlrthdateI Day Voal

Momh Have you eller applied 10 the San Diego Police Department before DYes 0 No

I 5 Social Security Number

(In accordance wilh the Federal Privacy Act of 1974 disclosure is voluntary The SSN will be used for idenlification purposes to ensure that proper records are obtained ) I I

I 6 List and describe all tal1oos (indicate where they are located)

Education -

7 Please Indicate below all the schools you have attended beginning with high school During the background investigation persons who have known you In a learning environment may be contacled A review of your schoot records may be made in conjunction with those contacts

Name ot School Location of School

(City amp State)

Date6 Attended

From To Major Units

Esrned Degree Earned

-8 Have you ever been suspended or expelled from any high schoo or post-secondary school (Post-secondary schools include

colleges and universities graduale schools business and vocational schools - any formal educalion beyond the high school level) 0 Yes 0 No

11 yes please explain (inctude school date and circumstances)

This Information is available in alternative formats upon request o PMttd 011 lecydefJ ~I

Dmiddot978middot91 (Rev 2middot08) of 19

I

CI

Personal History Statement - Civilian

References Acquaintances Type or prinl your name

9 In the space below please list as references 3-5 Indivlduals who have knowledge of you and your qualifications Exclude relatives former employers and co-workers Example neighbors teachers classmates family friends roommates etc

Address where person can be contacted Name (Include Cltv state and Zip Code) TeJephoneE-Mall

OHomA DWolllt WorlltOtiw

Oc-cupalion EmiddotMan I -lome

- CHoma OWorlt WoIltOIher

Oceuplllion EMall Ho

o Herne o Work WorkiOlho

OltltlupaVon EmiddotMall HQ(Ilamp

OHol04 OWorlt WorklOltle

Oeltl patio EmiddotMali HOrNgt

o Herne OWo WollltiOl~e

Occupallon EMaIi HoIIe

10 Please lls13-5 Individuals such as co-workers and supervisors who have knowledge 01 you and your qualifications ElOclude relatives Past co-worners and 5upeNisors are acceptable

o HOma OWOrlt IWorklOlhe

I

Em)deyor EmiddotMall Hom

OHaJM DWDk War1ltlOlhor

EmplOy E-Mail Home

o Homo OWor1lt worKI01nol

Etoployor EmiddotMall Home

o Horne o Work WoOther

Employe l EmiddotMali Horne

OHo OWo~ WotlVOTnOI

Employe EmiddotMail Home

11 Below please list those individuals with whom you have resided during the last J years (list no information prior to your 15th birthday Exclude family members If more space is needed please continue on page 16

CHoma OWolt1lt WoWOrJgt

~patlon E-Mail Homltgt

DHome DWar1lt WcrklO1he

Oc~lion EmiddotMali Home

I o Homa IJ WO~ WoWOIhat I

Oeevpallon Emiddot18U 1010

OHom CI work Wor1ltlOthe

Oewpalion EMa1 HOIIO

QHome OWorllt worldOln

OCCllp8~on E-Ma1 HOITgtamp

CHoma DWorl WOllclOth

Olaquoupllion EmiddotMAII Hom6

Page ~ of 19

-

ONS

lS o

DNS o LS o

DNS o LS o

ONS Q

LS o

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o lS o

DNS Q

LS

o DNS

o LS

o ONS

o LS

o DNS

o lS o

DNS

o LS

o

o

o

o

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Experience and Employment Type or prinl your name

13 Beginning with your most current employment please list all jobs (includmg part-time temporary and voluntary positions) you have held in the past 7 years (For the purposes 01 this personal history slatement voluntary work should be included as employment) For Identification and verification please indicate the nature of the activity ie full-lime pari-time or voluntary If you have had intervening periods of unemployment please list those periods in sequence in the spaces provided Include mllitaJY service as employment

Dales 01 employment Name and complete address of employer include zip code Name of supervisor DNS LS

From To

MOl Yr MOl Yr fmiddotMail

HR E-Mail I Telephone No Name amp e~mail 01 Co-worker(s)

o Present Name

o FUll-time Title or duties (lor identification purposes) Salary EmiddotMail

o Part-time Vrs NAme

EmiddotM6ilo VoluntafIL Mos -Reason for leaving (be specific)

I I Mo I Yr I Mo I Yr o Not empl~ed From To I

Dates 01 employment Name and complete address of employer include zip code Name 01 supeNisor ONS

I lS From To

MOl Yr MOl Yr~ I EmiddotMoil

HR E-Mail ITelephone No Name amp e-mail 01 co-worker(s)

o Present Nama

o Full-lime ntle or duties (fOf identification purposes) SalaY EmiddotMall

o Part-time v_ Name

(middotMoIIo Voluntary Mo~_

Reason for leaving (be specific)

I I Mo I Yr I To I Mo I Yr

o Not employed From Dates 01 employment Name and complete address of employer include zip code Name 01 supervisor

ONS LS From To

MOl YI Mal Yr EmiddotMoll

HR E-Mail ITelephole No Name amp e-mail of co-worker(s)

o Present Name

o FUll-time Title or duties (for identification purposes) Salary EmiddotMall

o Partmiddottime VIS_ Nome

EmiddotMallo VotuntaJL MOA_



o Not employed From

Dates 01 emplovment Name and comple1e address of emptoyer include zip code Name of supervisor DNS LS

From To

MOlYr MOYr EmiddotMall

HR E-Mail ITelephone No Name amp e-mail of co-worker(s)

o Present Name

o Full-time TItle or duties (for identification purposes) Satary EmiddotMgtlll

o Part-time Yrs lIIama

IO-Mono VoluntallL 110$

Reason lor leaving (be specific)


o Not emploved From

Page4 01 19


Relatives Print your name

12 During the course 01 the background investigation your family and other relatives will be asked to comment upon your suitability lor Ihe position Supply the appropriate information in the spaces provided below If a category is 1101 applicable print NA in the box provided for the name

-shyNm~ 01 you Aldenco Addrepound (Include ZIF Code) TelephoN (Inludo Aree COda)

Spovsamp Hcvne

IAgamp EmiddotMall D Oeltu~IIOh We

Fel~amp Home

IA9~ EmiddotM~I 0 Occup arion Worle

MDther Home

IAge e-Mail 0 OC(1IIgt610n Worgtlt

Sloplal~e I-tomamp

IAge E-Mad 0 Occupation Wok

SIOPIIO OrtlB

IAge E-Mail 0 OoGupaliofl WOrk

F8~r middotfr middotf8W 110

lAgshy EmiddotMall 0 Oocupalion WO~

Mothemiddothmiddotlaw Home

IA 9

0 EmiddotMail 0 ()capaliOt) Work

BrolM Ho

IAge I EmiddotMail 0 Occupampllo~ Wor)(

8rolhit HO(1e

198 EmiddotMa1 0 OeeuptaliDn Work

8ottgter Home

IAge emiddotMall 0 Oogtltupatlon Wo

Slsl~ Home

IAge EmiddotMall 0 OCCup8~ion Wotlt

SLs1 Home

IAge E-Mail 0 OcGuga1iol Wok

Slo Home

lAg Emiddotts1t 0 OocupQUon Wok

Siste Homa

lAgS E-Mail 0 Occupallon Work

Sepbolhel Homo

lAg E IA a1 0 OoGupalian Wok

Slaplsle Hoe

IAge EmiddotMali 0 OccupMon Wo

Page 3 0119


Experience and Employment Continued

Type or print your name

Dates of emplovment Name and complete address of emplover include zip code Name 01 su~ervisor I ONS LS

From To teMuMOl Yr Mal Yr I HR E-Mail ITelephone No Name amp e-mail 01 co-workerIs

o Present Naroe

o Full-time nus or duties (for identilicalion purposes) Salary EmiddotMaIl

o Part-time VIS Nrn

EmiddotMaII o Voluntary Uos -Reason for leaving (be specific) I

I

I I Mo I Yr I To I Mo I Yr o Not employed From

Dates 01 employment Name and complete address of em~loyer Include zip code Name of supervisor DNS I lS

From To

IMOl Yr MOl Yr f middotMall

HR E-Mail I Telephone No Name amp e-mail of co-workels)

o Present Name

o Full-lime TItle or duties (for identiticahon purposes) Salary EmiddotM II

o Part-lime Ys Name

EmiddotMeil OVoluntarv Mos


I I Mo I Yr I To J Mo I Yr

o Not employed From Dates of employment Name and complete address of employer include zip code Name of supervisor

DNS lS From To

MOl Yr MOlYr EmiddotMoll

HR E-Mail JTelephone No Name amp e-mail of co-worker(s)

o Present Ne

o Full-lime Title or duties (for identification purposes) Salary E bll

I

o Pan-time VIS Name

I E-Mailo Voluntary 110-


I I Mo I Yr i To I Mo I Yr

o Not employed From

Dates of employment Name and complete address of employer include zip code Name of supervisor DNS LS

From To MOYr MOl Yr

Emiddot tillil

HR E-Mail ITelephone No Name amp a-mail 01 co-worker~

o Present L Nama

o Full-time nile or dulies (tor identification purposes) Salary E-MII

o ParHime VS Neme

f-wllo Voluntary Mos

Reason tor leaving (be specflc)

I I Mo I Yr I To I Mo I Yr o N01 employed From

Page 5 of 19


Experience and Employment ContInued


Dates of employment Name and complete address of employer include zip code Name of supervisor DNS

I

LS From To

MOYr Mal Yr EmiddotMeil I

HR E-Mail I Telephone No Name amp e-maIl of cQ-worker(s)

o Present Name

o FUll-time ntle or duties (for identification purposes)

Salary EMall

o Part-lime y Nama

I EmiddotMaY OVoluntaJV MO$


I I Mo I Yr I I Mo

I Yr o Not employed From To

Dates of employment Name and complete address of employer Include zip code Name of supervisor ONS LS

From To

Mal Yr MOl Yr Emiddotllojl

HR E-Mail I Telephone No Name amp e-mail of co-worker(s)

o Present Nama

o Full-lime Title or duties (tor identification purposes) Salary rmiddotMgt11

o Part-time Yr NI$

Emiddot)taUo Voluntary Moo



o Not emploved From

Dales of employment Name and complete address of employer include zip code Name of supervisor ONS LS

From To

MOlYr Me LYr cmiddotMI~

HR E-Mail Telephone No Name amp e-mail 01 co-worker(s)

o Present 11$111amp

o Full-time Title or duties (for idenllficalion purposes) Salary Emiddot~ail

o Part-time Yts ~lun6

-f-Ma~

DVolunta~ Mos

Reason for leaving (be specllic)

I

I Mo I Yr I To I Mo I Yr o Not employed From I

Dates of employment Name and complete address of emplover Include zip code Name of supervisor

I

DNS lS I

From To

Mal Yr MOl Yr I EmiddotMaoi

I HR E-Mail I Telephone No Name amp e-mail of co-worker(s)

o Present Name

Title or duties (for identification purposes) Salary EmiddotM~ o Full-lime

D Part-time y hlAmo

~ o Voluntary Mobull


I I Mo I Yr I I Mo I Yr

o Not emploved From To Page S or 19


Experience and Employment Continued Type or print your name

14 Have you ever held employment under another name DYes 0 No If yes please explain (include when where circumstances) (include maiden name)

Nam U~ed EmplOyer

N me Used Employer

15 Have you ever been tired or asked to resign from any place of employment 0 Yes 0 No If yes please give delails (include when where ci rcumstances) If more room is needed explain on page 16

Dale Employer

o lC IEmpoy6f

16 Have you ever be en suspended by an employer DYes D No If yes please give details (include when where circumstances) It more room is needed explain on page 17

D te IEmployer

_

17 Have you ever been investigated by your employer or supervisor for improper conduct illegal activities sexual harassment or Equal Employment Violations which resulted in your being found in violation of any policies regulations rules or any State or Federal laws D Yes 0 No If ves please oro vide the fofowing information

Dale IEmpoyer

Details ond rosuits 01 Investigation

_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _

18 Have you ever received a formal written reprimand from an employer DYes DNo Date IEmployer ICIr(UmSI3nces

If yes please explain

Page 7 of 19


Military Service Type or print your name

19 Did you comply with the draft registration law DYes D No I Selective SeMce Numbtr

20 Have you ever served in any of the Armed Forces National Guard or military reserves DYes DNa

21 It tes what is your current status with the military o Active 0 Reserves 0 Inactive 0 Discharged Sf nd1 0 SoMce Unit I Oc~pntjon E~tment Dr6 Dchag Date

Se rvtoe NI~r Highest flank At1ampinl)(1 Rnk at OiS(harge Type or Dtsdarge

Sep8f hon Code Re-enllstrnent Coda If actlv or ourrent ressrvbull n2t V(WI Commanding Officers name

22 Were you ever investigated for any criminal activity while in the military or military reserves DYes 0 No If yes please explain rshy

23 Have you ever been reduced in pay grade or been the subject of any judicial or non-judicial disciplinary action While in the military National Guard or military reserves 0 Yes 0 No If yes plaase explain

ApprOltltTale Dare ViOl31JOtl Penamprt

-

24 Did you receive an han-arable discharge DYes 0 No If you received a discharge other than honorable please explain

25 Starting wrth most recent list all duty stations (include basic training tours overseas etc ) while in the military

Month and YelU locatIon [)u1i1l6 I Purposo (approximate leng1h 01 y our tour)

(

Page 8 of 19


Type or print your nameIRgmiddotM 26 Have you ever been convicted of a Felony DYes DNo 27 Have you ever been convicted of a Misdemeanor DYes DNa 2B Have you ever been charged with a Felony in which Ihe charges were reduced 10 a Misdemeanor DYes 0 No

If yes to any question above provide the following informacion Start with (he most recent

Dale Charg6 Pel Agenov - Penally -

ElCplOln cieumsl6ne~

Dale ChetQu Police AgallCV Peoolry

EJtptam ccumuaneamp$

Dale ClIO$ Pellee geey r-OMlty

-shyEJrpllin clrcum fI fl ces

29 Either as an adult or a Juvenile have you ever been arresled or charged with a criminal act (not listed above) DYes D No Includes chalges that were dismissed dropped or reduced If yes provide the following information Start with the most recent

DalC Charges r-olleo AJ6ney RasUIlamp

I

Expl el OJtII518~

Dala Charges Polletgt Agency RawllS

Expln dmn

Page 9 019



34M Continued

30 Either as an adult or ajuvenile have you ever been detained for a criminal investigation or named as a suspect in a police report or held on suspicion or questioned or fingerprinted by any law enforcement agency or military authority DYes ONo If yes provide the folowing information

Oalamp CMrgM or rSBOn lor inve~~98IltOO PoilU Ajency I---

Explaln clrCLJI1SiLaIC8S

I

Date C harges 01 reason tor irwetlgalion Pollee Agency

upsln crreurMIncamps

31 Have you ever received a misdemeanor citation in lieu of going to iai) DYes DNo If yes eXplain on page 28 giving details dates and name of the law enforcement agency issuing the citation

32 Have you ever been placed on court probalion DYes 0 No Are you currenlly on probation 0 Yes 0 No If yes to either question explain below giving all derails dales and reason If you were on probation more than once please Indicate befow

Dall IDetails

33 Have you ever violated probation DYes DNa I ves please explain

34 Have you ever had a warrant issued for your arrest or have you ever failed to appear in court on a criminal matter DYes DNo If yes please explain on page 16

35 Have YOU ever been reported to a law enforcement agency as a missinQ person or runaway DYes DNo If ves elease exelain Onto I QoteU

36 Were you ever required to appear before a luvenile court for an act which would have been a crime if committed by an adult DYes ONo If yes explain giving details dates and location

Oale IDelalls

Page 1001 19



SM Continued

37 Have you ever applied lor a permit to carry a concealed weapoli DamplO IlPpll6d IWas pol 9ed

DVamp$ CJ No IWeapon

DYes ONo If yes provide he foJowino information

Nama or gancy wee ~ppli(ld (City County amp S318)

For whal purpose

38 Are you now or have you ever been involved as a plaintiff or defendant in any civil court action DYes ONo Ever had a judgement rendered against you DYes 0 No If yes 0 e)thar question provide the following Information

Del4 IIACellOn 01 Courl

I0 PInhll 0 Oalndnt

I

OoLel1lt

Dale IloeB Uon or Court I0 PIanlr 0 CelOM Dealllt

39 Are you now or have you ever been a member 01 any organization association movement group or combination of persons which advocated or advocates the overthrow of our constilutional form 01 govemment by any means other than Ihe democratic procedures provided by our present form of govemment DYes DNo

40 Are you now or have you ever been a member 01 any organization association movement group or combination 01 persons which advocated or advocates acts of force or violence 10 deny other persons their rights under the Constitution of the Uhiled States by uncons1i1utional means DYes ONo

41 Are you now associating with or have you ever aSsociated wilh any individuats including relatives who you know or have reason t--shybelieve are or have been members 01 any of the type of organizations idenlilied above DYes DNo If yes to any 01 the above fhree questions please explain

-

42 Have you ever participated in an unlawful demonstration DYes ONo If ves plats9 explain

43 Are you now or have you ever been associated with any organization movement or group who engages in civil disobedience DYes ONo I yes please explain

Page 11 at 19



Traffic History I Motor Vehicle Operation

OPERATION OF A MOTOR VEHICLE MAY BE AN INTEGRAL PART OF THE POSITION AN INVESTIGATION OF YOUR DRIVING HSTORY WILL BE MADE

44 California drivers license number -I EIplrraquoliM dale

45 Name under which license was granted

46 List other states where YOU are or have been licensed to operale a motor vehicle Slale I SIBle ISIB Sln~

N Brne under hce 1ll6 iss LJG d NIlIlII urgtao IIeampnse iuud N~mll dlar ~CIUS6 i9Sued Nam oj Me ~eonso tBsued

Number ~urnb6 Numbor umbr

50 Have you ever failed to appear in cour on a traffic citation or parking citation DYes ONo If yes provide the following information

Appro 0amp1amp Traffc Violatlon City I Cltgtunty I Stale Roason you tBiled 10 appear

51 Have you ever had a warrant Issued (or you regarding a traffic citation or parkIng citation DYes 0 No I yes provide the folowlng information

ApprOl( Dale Tafflc VIolation City f County f SI Pl8lty

-

47 Have you ever beerl refused a drivers license by any stale 0 Yes D No If yes piease explain (Give State dales and reasons)

48 Have you ever applied for or obtained a drrvers license or slate identification card under a fictitious name or date of birth DYes D No If yes please explain (Give State daras and reasons)

49 Has your drivers license ever been suspended revoked or placed on negllgen operators probation by any state DYes D No If yes please explain (Give State dates and reasons)

Page 12019


i ype Dr print your name

Traffic History I Motor Vehicle Operation Continued

52 Have you ever rece ived a traffic citation DYes 0 No If yes list all traffic citations for the last 7 years Start with most recent citation

Month IVear Tralll~ Violallon City a Siale WMI ocltOn resultod DJSmrSS4d Fne Tra1Jc School

53 List all vehicles that YOU own andor that are reQiste red to yOU (Include vehic les you use freauently Vear Make I MMel Color License Numbor amp Siale Is thO chIao clmeruty ramppfsen~d

DYes DNo

D v es D No

DVes D NO

DVes DNa

~ As adrive~ h~evouev~been invo~ed inamo~r v~e~h~ic~l~e~a~c~c~id~e~n~t~~~~~Y~e~s_O N~O~f~fL~e~S~I~D rO v~~~e~~~ w ~ rma t~~n~~~~~ ~~~ ~e fu~J~~~~i~n~qin~fu~~~~ ~~oal~ 1City and Stale W re you at lautt 0 Veg 0 No

Wes tM16 It pcltoe report taken OVes D No ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ D~~eoc~mcausi~u~~ano~r ~~n D~s DNo

O~~~o~~u~~~~~~mher~~on7 _ _ ~~ ~No

Pohee agency Ih I took the roport Wero you Oiled 01 61 $ltd 0 Yes 0 No Wos U accrdont fI hll amp run 0 VOfgt 0 No

DAle City nM Slate W~gt(fJ you ~ flault 0 los 0 No

Was ther poIico rcort laken 0 Yes 0 No I

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Police agency tha t took the report Were you cIted or 3JrMled 0 Yes 0 No

Wu lho aocldant a hit amp Tun 0 Yes ~ No

Date City end Stale Were YOLI at fault 0 Yes D Il1o Was there Q pOlice report I ken O Ve-l 0 NoI

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~O~t~~~Mt~u~~u~~a~~~~~n _ ~ _~~i D No

Police agor1iy 11181 took the ropon Were you cited or arrested 0 lcs 0 No

Was IN accident a hit amp run 0 Ves 0 No

55 As a driver have you ever been involved in an accident where you left the scene without identifying yourself 0 Yes 0 No (Hit amp Run) If ves please explain

Page 13 of 19



Prior Applications

56 Have you ever applied 10 the S8n Diego Police Department before (for any position) 0 Yes 0 No If yes please provide the date the position and results Check all boxes that apply Do not include this current application

~~~~~~~ __ ____ _ _= __ r~~I~~~__ __ _ ___ __o SubmiOed Appliealion only 01 wflne esl D Too~ PAT 11 0 InieIVi8wed 0 Sunmmad PeoNgt Hbullbullory Sulemen( 0 E1aClltgrouM Iigahon condUCIeo

_ o Took PoIY9r1Dh 0 Wtu nol 5010e l6d 0 D($qua~ned 0 Hired 01 lOti 01161 maoe 0 WilNlrampw ppUca lion Cl amppred Iom II~I

000

~~~~~~~~_______J~~i~~~______ o Subminampd Appllcelion Iy 0 TOOk WYllie 1amp51 0 Too~ PAT bullbull1 DlnI6Njed 0 Sublnod POMI Hillary SIemol 0 Sackgou InvoslIg11on corgtductod

o Took Polygraph 0 Wu not 0101amp( 0 DI~~lirampd 0 HIeltj 0 lo b ofo de 0 Wilildrew apphoaUon D E-gtpirigtltlom HI

DOIIgto r

Applications With Other Agencies

57 Have you ever applied or any other law enforcement agency (City County State or Federal Agencies) DYes DNo If yes list every agency you have applied with Start wtth most recent Give complete accurate addresses All agencies MUST be listed re9ardless 01 outcome or current status Check aI boxes that apply for each agency

am 01 89McY 8lt6 oompl~16 acJds irlOIudlllllp GOltIa 0 aplgtlI11O

I

_ _ ___1~~~__ o Submil10d Appllcallon only OToole WfRen eol 0 Plaeed on ~~glblilly lisr DlnloNlowod 0 Failod ora) board 0 Passed IRISNI

o SubmH6d Po1 Hisiory Slalomsni o Elael(gC d IM lg Ion ondveIQd OToOk Po~saph o B8ckgro~nD Panding

o Hed J Job aH6 ae OWe nol 68 ec1ampd o Oiltquh~hd o UnlUOWIgt Ius o No ampSPonso IDm eganey o Wl)ldew ~pplloiilIoo Voiha Vol your b6ckgron~ mvampst9ampIOr~ nsMo enrS PhQne 1Umbor

I no

Olle applied

o ~~middot~~~d~~~I~j~~middot~~~ middot middoti5T~~ middot~~middot Dp~~~~~~~~i~j~~lis D~~~ ci i~~ ~~~Dp~~ ~~i~- _ o Subrnlllod Pe~nII-4I~ry S(alernenl 0 9altkQlOund IIVlloallDn eonduetod 0 Took oogaph 0 SackgfOund Pendo

o Hiled J Job o~e made Dwru nol Iewd 0 OisQuallred D U~nDW ul~ o No $S_ Irorn IgtgcY 0 Wi1hdt6w aplgtlicallon

WMI Wl5 y ~k9u(d frwig8Io(s name ano pnou number Itoo~

56 Have you ever held a tull-time or parHime position with peace officer powers (Prior police experience includes police officer police reserves military police) DYes 0 No If yes lisl the dates employefagency rank and duties Start with the most recent

OalO IEmploya J Ago Y IRan~ Oul()$ I ~ignmamp(

Page 140119


Type 01 print your name

Marital Status

59 o Single 0 Married D Widowed D Separated D Annulled 0 Divorced

F II II Nam0 of $00~e MIlI1 erne IO1hnr Names SPOUSO ~ used I0810 or Birth IAge

OB~ 01 Marriage P13C6 01 rlarri~ge (City County amp SlJllel IIEmiddotrlall

Spouscs Employe Oceuoalio[ or Pos(LJon How long Employed

ClJrrO(1 dross 01 Spouse nol HvI(Ig Wlh you Homo Phone (8oa code) WO~ Phone (ae eIIOe)

60 If divorced widowed or had an annullmenl provide the following information Full N fYo 01 FoIMo SIgtO~ MIllden I 011amp1 Nil SPOUpoundB ~d OA 01 Birth IA~

Oelo 01 Marriage PI~e at Marriage IClry County a Slale) Emiddot~JI

~o SpOil Employe Occupallol or P~lio How Lall Em ployad

CIJRlnl Addrl-I of Former SPOUS4 01 jas1 know addCSt Ho Phone ( e~ code) Work Pnone (oea cod)

Oal Filed 10 OWO( ICIV CouY Sale 01 0 ~ Ovoru Final

Full Name 01 Forme Spous I Maiden Name IOl~e Nme SPOUS6 has ueoo

DVos DNO

Oale 01 eh IAge

()ale ot Mamnge Pia 01 Monlago (C Counly amp Slale) EmiddotQI

FOrm()r Spauos E mplOYb Oce~pllon (gt( PoalM HDW Lo9 Employa

Cun(ml AdlttrojS 0 Forms Spouse 0 lut kno~n eddress Home Pnon ( OOdltraquo WOr( PhOM (6e 0000)

Date Flied 10Owo ICity County SIampI~ 01 OIvOIltl I~ Olvaeogt ~Innl

DVlIS DNo

61 List any addItional experience or qualifications you have which may be beneficial

I--

Page 150119

I


Type or pllnt your name

Financial

62 The management 01 personal linances is relevant to an individuals qualifications for a position wnhln the Police Depanmenl Please provide the following inlormation The amount at indebtedness in itself will not be used in evaluating your qualifications but rather the behavior exhibited in meeting your financial obligations

CUUMI Monlnly Income Cur Monlhlv ~penall

Real Esal~ (mongalla) Paymen$$Monohly Sa I ry $

ReolSpoUO Salary

eradll ClaquoIs (elloge aCCGunlS)other Income

UHIIea and ohor Monrhly PaYl1lets Olhe r I0me

TOTAL MONTl1LY INCOME S TOTAL MONn-lLV EXPENOfTURES S

Current Atuttt1 Currerrt Uablllll -

S I

Real ESele IIdODI8dno~Savings S

Lbng Term loaMChampUltirgtg

Codlt Cald (Total ornoun 01 ch~g ocounl~)Real EOI

oke LIalllJtlcSIOGIcs amp 80lt1$

ICa sn velu 1gt1 Ollie Uabll~iesLlle Insurane wlolo 1010 QOIIeyI

OIIr LlablliieAU I

O1ne r LI ampbi tltie s00 Assampts

- r--TOTAL ASSETS TOTAL LI9ILmES

63 Please list all banks or savinqs institutions where you have current accounts B4IIk Adoe I0 Champdlti(g 0 Sangs

HolY long thel Yrs Moo

Sak AdOress I 0 Checking 0 Savings

HIgt kI~g Ihe~ s MoS

64 Please list information on all 01 your current (ooen) charlle accounts loans financial contracts and lonq-Ierm liabilities I

Neme DI Creditor Sank Firm 01 Lender Rauon 101 Debt IIonligtly P6ymel CUllenl 9alaTgtQO LI Ihe Iumb~r 04 limes you have ~e Isle 30 oavs 01111018

I $ s

s $

s $

$ So

S S

S S

I s Is

Page 6 of 19



Financial ContInued

65_ Have you ever Hied for or declared bankruptcy DYes DNo If ves oJease explain reasons below Dale I Reasons

I

66 Have you ever been delinquent on income or other tax payments DYes 0 No If ves was it more than once DYes DNo OaO FOM (gi~e (he vltgtarfs) nyen~IvM uM 1M amenl SlaIUS)

67 Have you ever had your W8QeS attached or Qarnisheed DYes DNo DalC Aeaso()s

-

68 Have you ever had any of your bills accounts or loans turned over 10 a collection aQency DYes DNa If ves list all accounts Os I Accoun I eurro~1 sial

()1~ AeeoUi11 e4JfOnl slalus

D~le Accounll currant itamptu~

Dale ACQI)unll curt6(t ~~ahJ$

69 Have you ever had any purchased goods vehicles property or any items repossessed (This includes voluntary repossession) DYes DNo

Data Reasons

70 Have you ever been refused credit DYes ONe Oa1e ReASons

71 Are you currently an owner partner or investor In any business enterprise that requires the attainment of a Federal State County or City permlt or license to operate DYes DNo

Name and TYPB or eusirampss amp Add

72 If employed by this agency do you anticipate any other income other than your city salary or spouses salary DYes DNo If yes what

Page 17 0119


Type 01 prinl your (sme

Residence

73 List all 01 your residences during the last 20 years Ust no informallon prior to your 15th birthday Begin with your most current residence

Currenl Add6S$ ICity amp Stett ISince (mO~II amp yalll)

WlII whom do you rJVO (n8mb) II renll-g pov ldlt address M4 none 01 1 ~1I~ClI-g lent

I Emiddot Man Pho(oQ

Address I City amp SI~Iamp From (Ill a yea) I T~ 11IOtItI amp ytgter)I I

It rbnlod provide nmamp ano completo eddreu 8lt1 phoM 01 popsop who eoIlecbullbulld ronl WIII wtgtOIT Gd you hve (namu)

RlIIAIorl lOt moving EmiddotMail Phone

I

Addroos ICity amp Sialo IFrom (Inonlh amp your) ITo (month amp yea)

l onlod provldo name and omplDUI Qddro pounds ad phone of persOt wro eoUected rell With wnOm dld you 1116 (namos)

[ middotMall~eosol lor mo ltoQ IP~Re From (month yaar)AddroS ICity amp SLaIO ITo (MOnlh yoe)

Jf ened ~IOVJda nAme 85d compieto edoreSE and phone 0 pellQ(I wka collected 16nlWhh rt()l did you IhIe (nam~l

Rc 380( 10 mOVIng EmiddotMali -IPnolO

Addess ICIV Siale IFrom (monlh amp 1amp8 1) ITo Imont~ year)

IIlcnlod provide name a~d comple te ampddfGss ampd phone 01 p8son a() eolleCleo retll Wllh whom did vou lIVe (nas)

EmiddotMaII~o 101 1TIO~ 119 IPhone

AdOro CII Sial I FngtJ (mMlh a y~ ar) I To (rnonl~ ~ veo)I 1 eMod plOvida nam 8n~ oornplAlo addeS6 anlt igt~ona 01 person w~o eolleclampd raniWHh W~11 did vou I (name~)

E-MailRe it$on 10 moving IPOlO

Addleos ICily amp SUI10 IFom (monlh 1 yoal ITo (mORIII amp year)

It Mlod provida name ~nd ooll1plele ~GdO$ and phOlio 01 igtD~1 Who eollCGlOd lon( Whh whOm did you Iilla (~Dms)

E~IIReason to lNIoIing rPhone

AdoltOss ICity Siale 1From (nttl yeer) ITo (=nlll yeal)

If rented provtde name nd IBle add end phD O( pc=n who colled en(With whom did Iou live (nllJTles

EmiddottAaUReson lor Il0l19 1P~one

AdOr CIIV SIOle I From (monlh year) ITo (monl~ amp ye)I Wfth w~j)m did you rNe (namu) III nled provde nQme and comp lete address tld ohone 01 person w~o CDlleeled rent

Rauon rer mollin9 EmiddotMall IPnone

Page 180119

I


General Information Type or print your name

USE THIS PAGE FOR ANY ADDITIONAL INFORMATION

II you are responding 10 a question please write the number of the question

-

-

f-

I UNDERSTAND THAT ANY APPOINTMENT TENDERED ME WILL BE CONTINGENT UPON THE RESULTS OF A THOROUGH BACKGROUND INVESTIGATION J HEREBY CERTIFY THAT ALL STATEMENTS MADE IN THIS PERSONAL HISTORY STATEMENT ARE TRUE AND COMPLETE AND I UNDERSTAND THAT ANY DISCREPANCIES MISSTATEMENTS OMISSIONS ANDOR FALSIFICATIONS WILL CAUSE MY NAME TO BE REMOVED FROM THE EUGIBLE LIST OR BE CAUSE FOR IMMEDIATE DISMISSAL IF AN APPOINTMENT WAS MADE

I HAVE READ THE ABOVE STATEMENT AND PRIOR TO SUBMITTING MY PERSONAL HISTORY STATEMENT I HAVE REVIEWED IT CAREFULL Y FOR ACCURACY

Fl)U SIGNATURE DATE

lpoundAV~ BLANl(

DATE OF PACKET REVIEW WITH APPLICANT

CATE 61

Page 190f19

CI


References Acquaintances Type or prinl your name

9 In the space below please list as references 3-5 Indivlduals who have knowledge of you and your qualifications Exclude relatives former employers and co-workers Example neighbors teachers classmates family friends roommates etc

Address where person can be contacted Name (Include Cltv state and Zip Code) TeJephoneE-Mall

OHomA DWolllt WorlltOtiw

Oc-cupalion EmiddotMan I -lome

- CHoma OWorlt WoIltOIher

Oceuplllion EMall Ho

o Herne o Work WorkiOlho

OltltlupaVon EmiddotMall HQ(Ilamp

OHol04 OWorlt WorklOltle

Oeltl patio EmiddotMali HOrNgt

o Herne OWo WollltiOl~e

Occupallon EMaIi HoIIe

10 Please lls13-5 Individuals such as co-workers and supervisors who have knowledge 01 you and your qualifications ElOclude relatives Past co-worners and 5upeNisors are acceptable

o HOma OWOrlt IWorklOlhe

I

Em)deyor EmiddotMall Hom

OHaJM DWDk War1ltlOlhor

EmplOy E-Mail Home

o Homo OWor1lt worKI01nol

Etoployor EmiddotMall Home

o Horne o Work WoOther

Employe l EmiddotMali Horne

OHo OWo~ WotlVOTnOI

Employe EmiddotMail Home

11 Below please list those individuals with whom you have resided during the last J years (list no information prior to your 15th birthday Exclude family members If more space is needed please continue on page 16

CHoma OWolt1lt WoWOrJgt

~patlon E-Mail Homltgt

DHome DWar1lt WcrklO1he

Oc~lion EmiddotMali Home

I o Homa IJ WO~ WoWOIhat I

Oeevpallon Emiddot18U 1010

OHom CI work Wor1ltlOthe

Oewpalion EMa1 HOIIO

QHome OWorllt worldOln

OCCllp8~on E-Ma1 HOITgtamp

CHoma DWorl WOllclOth

Olaquoupllion EmiddotMAII Hom6

Page ~ of 19

-

ONS

lS o

DNS o LS o

DNS o LS o

ONS Q

LS o

01$

o lS o

DNS Q

LS

o DNS

o LS

o ONS

o LS

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DNS

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o

o

o

o

o

o

o





From To



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o Present Nama


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ONS LS From To



o Present Name






o Not employed From


From To



o Present Name






o Not emploved From

Page4 01 19





Spovsamp Hcvne


Fel~amp Home


MDther Home


Sloplal~e I-tomamp


SIOPIIO OrtlB





IA 9


BrolM Ho


8rolhit HO(1e


8ottgter Home


Slsl~ Home


SLs1 Home


Slo Home


Siste Homa


Sepbolhel Homo


Slaplsle Hoe


Page 3 0119






o Present Naroe


o Part-time VIS Nrn


I



From To



o Present Name


o Part-lime Ys Name





DNS lS From To



o Present Ne


I

o Pan-time VIS Name




o Not employed From


From To MOYr MOl Yr

Emiddot tillil


o Present L Nama


o ParHime VS Neme




Page 5 of 19





I

LS From To



o Present Name


Salary EMall

o Part-lime y Nama



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DVolunta~ Mos


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Nam U~ed EmplOyer

N me Used Employer


Dale Employer

o lC IEmpoy6f


D te IEmployer

_


Dale IEmpoyer


_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _



Page 7 of 19











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Page 8 of 19












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Dall IDetails





Oale IDelalls

Page 1001 19



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For whal purpose



I0 PInhll 0 Oalndnt

I

OoLel1lt





-



Page 11 at 19














-




Page 12019







DYes DNo

D v es D No

DVes D NO

DVes DNa



O~~~o~~u~~~~~~mher~~on7 _ _ ~~ ~No







~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~O~t~~~Mt~u~~u~~a~~~~~n _ ~ _~~i D No




Page 13 of 19



Prior Applications




000



DOIIgto r




I




I no

Olle applied






Page 140119



Marital Status












DVos DNO

Oale 01 eh IAge





DVlIS DNo


I--

Page 150119

I



Financial




ReolSpoUO Salary





S I






OIIr LlablliieAU I









I $ s

s $

s $

$ So

S S

S S

I s Is

Page 6 of 19



Financial ContInued


I



-






Data Reasons





Page 17 0119



Residence








I



















Page 180119

I





-

-

f-



Fl)U SIGNATURE DATE

lpoundAV~ BLANl(


CATE 61

Page 190f19





From To



o Present Name






I lS From To



o Present Nama


o Part-time v_ Name





ONS LS From To



o Present Name






o Not employed From


From To



o Present Name






o Not emploved From

Page4 01 19





Spovsamp Hcvne


Fel~amp Home


MDther Home


Sloplal~e I-tomamp


SIOPIIO OrtlB





IA 9


BrolM Ho


8rolhit HO(1e


8ottgter Home


Slsl~ Home


SLs1 Home


Slo Home


Siste Homa


Sepbolhel Homo


Slaplsle Hoe


0119






o Present Naroe


o Part-time VIS Nrn


I



From To



o Present Name


o Part-lime Ys Name





DNS lS From To



o Present Ne


I

o Pan-time VIS Name




o Not employed From


From To MOYr MOl Yr

Emiddot tillil


o Present L Nama


o ParHime VS Neme




Page 5 of 19





I

LS From To



o Present Name


Salary EMall

o Part-lime y Nama



I I Mo I Yr I I Mo



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o Part-time Yr NI$




o Not emploved From


From To



o Present 11$111amp



-f-Ma~

DVolunta~ Mos


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N me Used Employer


Dale Employer

o lC IEmpoy6f


D te IEmployer

_


Dale IEmpoyer


_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _



Page 7 of 19











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Page 1001 19



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-



Page 11 at 19














-




Page 12019







DYes DNo

D v es D No

DVes D NO

DVes DNa



O~~~o~~u~~~~~~mher~~on7 _ _ ~~ ~No







~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~O~t~~~Mt~u~~u~~a~~~~~n _ ~ _~~i D No




Page 13 of 19



Prior Applications




000



DOIIgto r




I




I no

Olle applied






Page 140119



Marital Status












DVos DNO

Oale 01 eh IAge





DVlIS DNo


I--

Page 150119

I



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ReolSpoUO Salary





S I






OIIr LlablliieAU I









I $ s

s $

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Page 6 of 19



Financial ContInued


I



-






Data Reasons





Page 17 0119



Residence








I



















Page 180119

I





-

-

f-



Fl)U SIGNATURE DATE

lpoundAV~ BLANl(


CATE 61

Page 190f19





Spovsamp Hcvne


Fel~amp Home


MDther Home


Sloplal~e I-tomamp


SIOPIIO OrtlB





IA 9


BrolM Ho


8rolhit HO(1e


8ottgter Home


Slsl~ Home


SLs1 Home


Slo Home


Siste Homa


Sepbolhel Homo


Slaplsle Hoe


Page 3 0119






o Present Naroe


o Part-time VIS Nrn


I



From To



o Present Name


o Part-lime Ys Name





DNS lS From To



o Present Ne


I

o Pan-time VIS Name




o Not employed From


From To MOYr MOl Yr

Emiddot tillil


o Present L Nama


o ParHime VS Neme




Page 5 of 19





I

LS From To



o Present Name


Salary EMall

o Part-lime y Nama



I I Mo I Yr I I Mo



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o Not emploved From


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DVolunta~ Mos


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Dale Employer

o lC IEmpoy6f


D te IEmployer

_


Dale IEmpoyer


_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _



Page 7 of 19











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Page 1001 19



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DYes DNo

D v es D No

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DVes DNa



O~~~o~~u~~~~~~mher~~on7 _ _ ~~ ~No







~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~O~t~~~Mt~u~~u~~a~~~~~n _ ~ _~~i D No




Page 13 of 19



Prior Applications




000



DOIIgto r




I




I no

Olle applied






Page 140119



Marital Status












DVos DNO

Oale 01 eh IAge





DVlIS DNo


I--

Page 150119

I



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S I






OIIr LlablliieAU I









I $ s

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Page 6 of 19



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I



-






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Page 17 0119



Residence








I



















Page 180119

I





-

-

f-



Fl)U SIGNATURE DATE

lpoundAV~ BLANl(


CATE 61

Page 190f19






o Present Naroe


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DNS lS From To



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of 19





I

LS From To



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Salary EMall

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_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _



Page 7 of 19











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DYes DNo

D v es D No

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Page 13 of 19



Prior Applications




000



DOIIgto r




I




I no

Olle applied






Page 140119



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DVos DNO

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DVlIS DNo


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Page 150119

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OIIr LlablliieAU I









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Page 6 of 19



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I



-






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Page 17 0119



Residence








I



















Page 180119

I





-

-

f-



Fl)U SIGNATURE DATE

lpoundAV~ BLANl(


CATE 61

Page 190f19





I

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_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _



Page 7 of 19











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DYes DNo

D v es D No

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Page 13 of 19



Prior Applications




000



DOIIgto r




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Page 140119



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Page 150119

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Page 17 0119



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Page 180119

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Fl)U SIGNATURE DATE

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Page 190f19




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_ __ _ __ _ _ __ __ ____ ____ _ _ _ 4 _ _ ____ _ __ __ ~___ ------ _ _ gt- __ o _ _ ___ __ _ __ __ __ _ _ _ _ __ oo _ _



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Page 13 of 19



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Page 140119



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Page 150119

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Page 13 of 19



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Page 13 of 19



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Page 150119

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I I · 2015-11-15 · I . I . 6. List and describe all tal1oos: (indicate where they are located)...

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Transcript of I I · 2015-11-15 · I . I . 6. List and describe all tal1oos: (indicate where they are located)...