Form F-3(Le) - Personal History Statement Page 2
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16NORTH CAROLINA
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
PERSONAL HISTORY STATEMENT
INSTRUCTIONS: Using the online form or legibly printing in ink fill out this form completely and accurately. If you
need extra space, add additional pages and identify the information by item number. If an item does not apply to you,
indicate by entering N/A in the blank.
NOTE: All statements are subject to verification and any incorrect statements or omissions may bar or remove you from
certification. Truthful statements to any item requested will not necessarily exclude you from consideration.
THIS FORM MUST BE NOTARIZED UPON COMPLETION.
NOTE: The Social Security Number is used to make positive identification of applicant and/or law enforcement
personnel. DISCLOSURE IS VOLUNTARY. However, failure to provide this information may result in a delay in the
processing of application materials and may result in inaccurate records being assigned to you.
Position(s) applied for: ________________________________________________________________________
Agency: _____________________________________ Month: _________ Day: _______
Year: ______
PERSONAL
1. Name: __________________________________________
2. Social Security Number: ______________
First
Middle
Last
Maiden Name:
___________________________________________________________________
Other Previous Last Names: ________________________________________________________________
Nicknames or Aliases:
___________________________________________________________________
Has your name been legally changed after age 12?
Yes
No
If yes, submit documentation with date and attach to this form.
3. Present Mailing
____________________________________________________________________
Address:
Street & Number
City
County
State
Zip Code
Permanent Mailing
____________________________________________________________________
Address:
Street & Number
City
County
State
Zip Code
Telephone Number: ____________________________
______________________________________
(Include Area Code)
Home
Work
Cell Phone: ________________________________ Email Address: ______________________________
4. Date of Birth: _______________________________ 5. Place of Birth: _____________________________
Other – Specify
6. Citizenship:
U.S. Born
U.S. Naturalized
_______________________
F-3(LE) Rev. 12.2.13
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