Police Department Personal History Statement Form (Page 16 of 22) in pdf

Blackmail or extortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  No

W) Any other act amounting to a felony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  No

If you answered YES to any item(s) in Question 46, fully explain circumstances, including date(s), names of individuals involved,

and resolution. Indicate the corresponding letter (46-A, etc.) for each explanation.

_________________________________________________________________________________________________________

Questions 47 and 48 ask about your current and past recreational drug use. This covers the use of any drug, including the unauthor-

ized use of prescription drugs or over-the-counter drugs. Your answers should include, but not be limited to, your use of

any of the following drugs:

– Amphetamines / Methamphetamines

– Glue

– Morphine

(Uppers, Speed, Crank, etc)

– Hallucinogens

– PCP / Angel Dust

– Barbiturates (Downers)

(Peyote, LSD, Mushrooms)

– Quaaludes

– Cocaine / Crack Cocaine

– Hashish / Hashish Oil

– Steroids

– Designer Drugs

– Heroin / Opium

– Tetrahydrocannabinal (THC)

(Ecstasy, Synthetic Heroin, Spice,

– Marijuana

Bath Salts, etc.)

– Mescaline

– GHB (Date Rape Drug)

47. Within the past six months, have you used any drug(s) as indicated above? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  No

If yes, give details, including drug(s) used, number of times, over what time period(s), and circumstances:

_________________________________________________________________________________________________________

48. Prior to the past six months (check all that apply):

 I have never used any drug recreationally.

 I have tried or used one or more drugs, but only under limited circumstances (for example, experimentation, at parties,

concerts, special events, etc.).

If checked, give details including drug(s) used, estimated number of times, over what time period(s), and circumstances.

_________________________________________________________________________________________________________

 I used illegal drugs on a regular basis (from one to several times a week or more).

If checked, indicate the time period(s) of drug use and the drug(s) used and frequency of use.

_________________________________________________________________________________________________________

Police Department Personal History Statement Form Page 16

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