Personal History Statement (Phs)
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24Akron Police Division
Personal History Statement (PHS)
Appl
icati
Today’s Date:
Position Applied for:
Police Officer
Reserve
Year of most recent exam for Police Officer:
1.
Have you ever applied to the Akron Police Division before?
Yes
No
If Yes, did you submit a questionnaire?
Yes
No
If Yes, see below
2.
List the date you last applied to the Akron Police Division:
Personal
The following information is requested of you for verification and contact purposes:
3.
Please print or type your full legal name
Last
First
Middle
Maiden Name
Age
Other names
Name
Years Used
Name
Years Used
(including
Maiden or
Name
Years Used
Name
Years Used
nicknames) you
have used:
4.
Residence
Own
Rent
Live with relative/or others
Number
Street
City
State
Zip Code
5. Please list your residence phone and an alternate number for
(
)
(
)
messages
Residence
Cell
Other
Please list your mailing address if it is different from your residence address
Number
Street
City
State
Zip Code
6.
Birth Date
7. You must be a citizen of the United States or a permanent resident alien who is eligible for and has
applied for citizenship. Can you provide documentation to confirm this?
Month
Day
Year
Yes
No
Place of Birth:
8.
Social Security Number
(In accordance with the Federal Privacy Act of 1974, disclosure is voluntary. The SSN will be used for
--
--
identification purposes to ensure that proper records are obtained.)
Marital Status
9.
Single
Married
Widowed
Separated
Annulled
Divorced
Spouse
Age
Address (include City, State, Zip Code
Home (
)
Work (
)
Home
Work
Spouse’s maiden name
Spouse’s date of birth
Date of marriage
Place of marriage
Other names spouse has used
Spouse’s employer (name and address)
Occupation
How Long
Telephone
(
)
Name of former spouse/parent of mutual children
Date of Marriage
Date of Divorce City, State of Divorce
Amount of alimony or child support received or paid (circle one)
Have you ever been delinquent in making required payment(s)?
Alimony
Paid
Received
Child Support
Paid
Received
Yes
No
Approx. Times:
Present address of former spouse/parent of mutual children
Telephone
(
)
Name of former spouse/parent of mutual children
Date of Marriage
Date of Divorce
City/State of Divorce
Amount of alimony or child support received or paid (circle one)
Have you ever been delinquent in making required payment(s)?
Alimony
Paid
Received
Child Support
Paid
Received
Yes
No
Approx. Times:
Present address of former spouse/parent of mutual children
Telephone
(
)
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