Police Department Personal History Statement Form Page 15
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22U)
Trespassing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
V)
Vandalism (including “tagging,” malicious mischief and/or property damage) . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
W) Intentionally writing a bad check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
X)
Filing a false police report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Y)
Any other act amounting to a misdemeanor within the past ten years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If you answered yes to any item(s) in Question 45, fully explain circumstances, including date(s), names of individuals involved, and
resolution. Indicate the corresponding letter (45-A, etc.) for each explanation.
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46. UNDETECTED ACTS – PART 2
At any time in your life have you EVER committed any of the following?
A)
Arson (intentionally destroying property by setting a fire) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
B)
Assault with a deadly weapon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
C)
Theft of a vehicle and/or vehicle parts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
D)
Burglary (entering a structure or vehicle to commit theft or other crime) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
E)
Child molestation (performing unlawful acts with a child) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
F)
Accessing and/or possessing child pornography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
G)
Elder abuse/neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
H)
Embezzlement (theft of money or other valuables entrusted to you) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
I)
Felony drunk driving (involving injuries) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
J)
Forcible rape or other act of unlawful intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
K)
Forgery (falsifying any type of document, check certificate, license, currency, etc.) . . . . . . . . . . . . . . . . . . . . . . Yes No
L)
Hit & run (with injuries) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
M) Hate crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
N)
Insurance fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
O)
Internet fraud (illegal downloading of music and/or videos) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
P)
Grand theft (value of over $400, or any firearm) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Q)
Murder, homicide, or attempted murder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
R)
Perjury (lying under oath) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
S)
Possession of an explosive/destructive device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
T)
Robbery (theft from another person using a weapon, force, or fear) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
U)
Stalking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
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