Personal History Statement Template - North Carolina Criminal Justice Education And Training Standards Commission Page 13
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16You must include any and all convictions regardless of whether or not the convictions were expunged pursuant to
NCGS 15A-145.4 and 15A-145.5. If you list a charge(s), please attach certified and true copies of warrant(s) and
judgment(s) for each offense, even if documentation and charges have previously been reported to this agency.
49. Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense?
(The term “charged” as used in this question includes being issued a criminal citation or summons.)
Yes
No
If yes, give details below:
A. Offense Charged ____________________________ Law Enforcement Agency _____________________
Date
____________________________ Disposition of Case
_____________________
B. Offense Charged ____________________________ Law Enforcement Agency _____________________
Date
____________________________ Disposition of Case
_____________________
C. Offense Charged ____________________________ Law Enforcement Agency _____________________
Date
____________________________ Disposition of Case
_____________________
(ATTACH EXTRA SHEETS, IF NECESSARY)
50. Have you ever had a Domestic Violence Protection Order issued against you?
(Include both ex-parte Domestic Violence Protective Orders and those entered subsequent to a hearing.)
Yes
No
Date of Issuance:
______________________________________________________________________
County of Issuance:
_____________________________________________________________________
Name of Plaintiff:
______________________________________________________________________
Date of expiration:
______________________________________________________________________
51. Under federal law you may be disqualified to receive or possess a firearm if you meet any of the following conditions:
(a) currently under Indictment or Information in any court for a crime punishable by imprisonment for a term
exceeding one year.
(b) have been convicted in any court of a crime punishable by imprisonment for a term exceeding one year. A person
would not be ineligible under this criteria if the person has been pardoned for the crime or conviction, the crime or
conviction has been expunged or set aside, or the person has had his/her civil rights restored, and under law where
the conviction occurred the person is not prohibited from receiving or possessing any firearm.
(c) are a fugitive from justice.
(d) are an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or any other
controlled substance.
(e) have been adjudicated mentally defective or have been involuntarily committed to a mental institution.
(f) have been discharged from the Armed Forces under dishonorable conditions.
(g) are illegally in the United States.
(h) have renounced your citizenship, having previously been a citizen of the United States.
NOTE: A “crime punishable by imprisonment for a term exceeding one year” as discussed in (a) and (b) above is
defined in federal law so as to exclude most misdemeanors in North Carolina.
If any of the above (a through h) apply, please note below and submit an explanation on a separate sheet of paper
which accompanies this form. Your signature on the attestation found on page 15 of this document indicates you have
read this section and understand each of the disqualifiers.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
F-3(LE) Rev. 12.2.13
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