Police Department Personal History Statement Form Page 14
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
2241. Have you ever been the subject of an emergency protective order/restraining order/stay-away order? . . . . . . . . Yes No
42. Have you settled any civil suit in which you, your insurance company,
or anyone else on your behalf was required to make payment to the other party? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
43. Have you ever fraudulently received welfare, unemployment compensation,
workers’ compensation, or other state or federal assistance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
44. Have you ever filed a false insurance or workers’ compensation claim? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If you answered yes to any of Questions 36–44, explain (include court case or document, dates, and circumstances; indicate corre-
sponding number): _________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
45. UNDETECTED ACTS – PART 1
Within the past ten (10) years OR at any time after you were first employed in law enforcement, have you EVER committed any
of the following misdemeanors?
A)
Annoying / obscene phone calls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
B)
Battery (use of force or violence upon another) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
C)
Brandishing a weapon (any type of weapon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
D)
Carrying a concealed weapon without a permit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
E)
Contributing to the delinquency of a minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
F)
Defrauding an innkeeper (not paying for food or room at a hotel/motel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
G)
Driving under the influence of alcohol and/or drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
H)
Drunk in public (being so intoxicated in a public place that you’re not able to care for yourself) . . . . . . . . . . . . Yes No
I)
Hit & run collision (no injuries) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
J)
Hunting/fishing without a license . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
K)
Illegal gambling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
L)
Impersonating a peace officer (pretending to be a police officer) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
M) Indecent exposure (including flashing or mooning) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
N)
Joyriding (using a car or other vehicle without owner’s permission) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
O)
Petty theft (value up to $400, including shoplifting/switching price tags,
illegally downloading music or videos) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
P)
Possession of alcohol as a minor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Q)
Possession of falsified or altered identification, including use of another person’s ID (for any reason) . . . . . . . . Yes No
R)
Possession of stolen property (including vehicles) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
S)
Prostitution or soliciting a prostitute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
T)
Resisting arrest (including running from the police) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal