Police Department Personal History Statement Form (Page 19 of 22) in pdf

GENERAL TOPICS:

General topics related to other issues that have not been addressed specifically elsewhere on this form.

62. Have you ever called in sick when you were in fact not sick or caring for a family member who was sick?

 Yes  No

If yes, explain: ________________________________________________________________________________________

63. Have you ever been implicated in the sexual harassment of a superior, co-worker or subordinate employee?

 Yes  No

If yes, explain: ________________________________________________________________________________________

64. Has an employer of yours ever been sued as a result of your conduct or duties (this would include vehicle collisions in your

employer’s vehicles, persons injured or killed as a result of your duties, claims of false arrest, unlawful im prisonment, excessive

use of force, etc.)?

 Yes  No

If yes, explain: ________________________________________________________________________________________

65. List any friends, roommates, associates or relatives, past and present, which have been convicted of a felony or participated in a

criminal act. Give a brief explanation of your relationship to the person and criminal activity in which they are or were involved.

_____________________________________________________________________________________________________

66. Have you ever been refused a permit to carry a concealed weapon?

 Yes  No

67. Are you now, or have you ever been, a member or associate of a criminal enterprise, street gang, or any other group that

advocates violence against individuals because of their race, religion, political affiliation, ethnic origin, nationality, gender, sexual

preference, or disability?

 Yes  No

68. Do you have, or have you ever had, a tattoo signifying membership in, or affiliation with, a criminal enterprise, street gang, or

any other group that advocates violence against individuals because of their race, religion, political affiliation, ethnic origin,

nationality, gender, sexual preference, or disability?

 Yes  No

69. Since the age of 16, have you ever been involved in an anger-provoked physical fight, confrontation or other violent act?

 Yes  No

70. Have you ever hit or physically overpowered a spouse or romantic partner?

 Yes  No

71. Are you now, or have you ever been, a member of any organized association, movement, group, or combination of persons

which advocated or advocates the overthrow of our constitutional form of government by any means other than the democratic

procedures provided by our form of government?

 Yes  No

72. Are you now, or have you ever been, a member of any organized association, movement, group, or combination of persons which

advocated or advocates acts of force or violence to deny other persons their rights under the Constitution of the United States by

unconstitutional means?

 Yes  No

73. Are you now associating with, or have you ever associated with, any individuals, including relatives, who you know or have

reason to believe are, or have been, members of any of the type of organizations identified above?

 Yes  No

If you answered YES to any of Questions 65 - 73, give details including dates and circumstances; indicate corresponding number.

________________________________________________________________________________________________________________

Police Department Personal History Statement Form Page 19