Police Department Personal History Statement Form (Page 17 of 22) in pdf

49. Have you ever engaged in any of the activities listed below for drugs, narcotics or illegal substances, including marijuana (check

all that apply)?

 Sold

 Purchased

 Cultivated

 Manufactured

 Furnished

 Carried or held for another

If you checked any items above, give details including drug(s) involved, over what time period(s), and circumstances.

_________________________________________________________________________________________________________

MOTOR VEHICLE:

50. Give your current driver’s license information as indicated below:

Driver’s license number __________________________________ State of issue: ___________________________________

Name that appears on this license __________________________________________________________________

51. Have you held a driver’s license in another State or County?

 Yes  No

Driver’s license number ____________________________________ State of issue: _______________________________

Name that appears on this license _____________________________ Expiration date ______________________________

Driver’s license number ____________________________________ State of issue: _______________________________

Name that appears on this license _____________________________ Expiration date ______________________________

Driver’s license number ____________________________________ State of issue: _______________________________

Name that appears on this license _____________________________ Expiration date ______________________________

52. Have you ever been refused a driver’s license in any state or country?

 Yes  No

If yes, explain: ________________________________________________________________________________________

53. Has your driving privilege and/or license ever been suspended, revoked or restricted?

 Yes  No

If yes, explain: ________________________________________________________________________________________

54. Has your driver’s license ever been revoked for late or non-payment of child support?

 Yes  No

If yes, explain: ________________________________________________________________________________________

55. Have you operated a motor vehicle while YOU believe you were under the influence of alcohol and/ordrugs?

 Yes  No

If yes, give details ______________________________________________________________________________________

56. Have you ever been charged with Failure to Appear or Failure to Pay a Fine as a result of a citation

you have received?

 Yes  No

If yes, give details: _____________________________________________________________________________________

57. List all traffic citations (excluding parking tickets) you have received within the past 10 years even if they were subsequently

dismissed or you were found not guilty.

Date and location where issued ______________________ Violation ____________________________________________