Police Department Personal History Statement Form Page 8
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2211.
Social Security Number _____________________________________ In accordance with the Federal Privacy Act of 1974
disclosure is voluntary. Your SSN will be used to ensure that proper records are obtained. If naturalized, date you applied for
citizenship:_______________________________________________
12.
For the purpose of identification, provide the following:
Height ______________________ Weight ________________ Hair Color _____________ Eye Color __________________
Tattoos or other marks – do NOT list scars of medical origin: _____________________________________________________
RELATIVES, REFERENCES, AND ACQUAINTANCES:
Persons who know you will be contacted and asked to comment on your suitability for this position. Inquiries will be on job-relevant
matters.
13.
Please list the persons identified below. If the category is not applicable, write “NA”
Full Name
Address where the person can be contacted, State and zip code
Telephone numbers
Father __________________________________________________________________________ Day: ________________
Night: _______________
Mother _________________________________________________________________________ Day: ________________
Night: _______________
Fiancé _________________________________________________________________________ Day: ________________
Night: _______________
Spouse _________________________________________________________________________ Day: ________________
Night: ______________
Date Married ____________________________________________________________________ Day: ________________
Night: _______________
Former Spouse __________________________________________________________________ Day: ________________
Night: _______________
Date Divorced ___________________________________________________________________
14.
List other living members of your immediate family in the following order: Your children, in-laws, brothers, sisters, step-parents,
etc. Please state ages of children if applicable.
Telephone numbers
Full Name and address where the person can be contacted (include State and zip code)
_______________________________________________________________________________ Day: ________________
_______________________________________________________________________________ Night: ______________
Relationship to you ___________________________ Occupation: _________________________ Work: ______________
Email address ____________________________________________________________________ Cell: ________________
Other: _______________
Full Name and address where the person can be contacted (include State and zip code)
_______________________________________________________________________________ Day: ________________
_______________________________________________________________________________ Night: ______________
Relationship to you ___________________________ Occupation: _________________________ Work: ______________
Email address ____________________________________________________________________ Cell: ________________
Other: _______________
Full Name and address where the person can be contacted (include State and zip code)
_______________________________________________________________________________ Day: ________________
_______________________________________________________________________________ Night: ______________
Relationship to you ___________________________ Occupation: _________________________ Work: ______________
Email address ____________________________________________________________________ Cell: ________________
Other: _______________
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