Police Department Personal History Statement Form Page 10
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22RESIDENCES:
17.
In section (a), furnish information concerning places you have lived during the past ten years. Begin with where you
live now and work backward.
17a. Street Address, City, State, Zip
No of Years
Name of landlord or owner
Telephone No.
From/to
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In section (b), list the name, current address and telephone number for person(s) with whom you have lived (excluding
spouse and children) at the respective residence in question 17a. Do not include barracks mates in the military unless you
shared a single room or off-base housing.
17b. Name of roommate
Current Address
Telephone No.
From/to
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
17c. In section c, list neighbors with respect to your residences in question 17a.
Neighbors
Address
Telephone No.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
18.
Have you ever been denied the refund of more than 50% of any security or damage deposit by any landlord?
Yes
No
If yes, explain _______________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
19.
While on duty or at work have you ever consumed alcohol or illegally ingested any controlled substances that may have
violated company rules, or policies or regulations set by your employer?
Yes
No
If yes, explain: _______________________________________________________________________________________
___________________________________________________________________________________________________
20.
Have you ever engaged in sexual activity on-duty or at work?
Yes
No
If yes, explain: _______________________________________________________________________________________
___________________________________________________________________________________________________
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