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BELL COUNTY SHERIFF’S DEPARTMENT

Personal History Statement

NAME: _

DATE ISSUED: __________________

RETURN ON: ___________________

TCOLE PID#: _

TEST Score: Sgt. T. Phelps

111 W. Central Ave. Belton, TX, 76513 (O) 254-933-5992 (F) 254-933-6773

[email protected]

Personal History Statement Instructions

Employees are exposed to confidential and law enforcement sensitive information. A thorough background investigation is required to properly evaluate the suitability of applicants for employment with the agency. Although it is an achievement to reach the background phase of the hiring process, this is still a competitive process and does not, in any way, guaranty selection. Do not un-staple or remove any pages from this packet.

1. These instructions are provided as a guide to assist you in properly completing your Personal

History Statement. It is essential that the information is accurate in all respects so please read all instructions carefully before proceeding. The Personal History Statement will be used as a basis for a background investigation that will determine your eligibility for becoming an employee. When bringing the completed documents, please place them in a sealed envelope marked “Personal & Confidential to Sgt. Phelps.”

2. Your application can be must be printed legibly in Blue or black ink pen by the applicant.

Answer all questions truthfully and accurately. If you have a computer program that will type in this document you are requested to use that program.

3. If a question is not applicable to you, enter N/A in the space provided. Fill in all spaces.

4. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is accurate and in proper sequence before you begin. Do not white out, but cross out with your initials, if you make a mistake.

5. You are responsible for obtaining correct and full addresses. If you are not sure of an

address, personally verify before making that entry on this history statement. Errors will not be viewed favorably. ALL ADDRESSES MUST BE COMPLETE WITH ZIP CODES.

6. If you need additional space for your answers, attach an additional sheet or sheets as needed. Be sure to indicate what page number and question this refers to.

7. An accurate and complete form will help expedite your investigation. Omissions, or

falsifications, will result in disqualification.

8. You are responsible for furnishing any changes and/or updating your application as needed, such as address changes or telephone changes, in writing.

9. Any candidate submitting an incomplete application WILL NOT BE CONSIDERED

FOR EMPLOYMENT. Your application will be evaluated on completeness and neatness.

10. All documents requested must be submitted with this Statement. Some documents take time to retrieve. It is recommended you gather these documents up front so that if you have to request certified copies from a record repository, you will have time to obtain them. They MUST be turned in with this Personal History Statement Packet. No exceptions. A detailed list of the documents needed is on page 4.

I understand these instructions: (Name) (Date)

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Applicant Qualification Section

Before you begin to fill out this personal history statement, please ensure that you meet the following requirements. You must meet all of these requirements to qualify for licensure as a correctional officer, telecommunicator or peace officer with the state of Texas. Initial each line to acknowledge the requirement.

State Requirements:

I am a citizen of the United States of America.

I am 18 years of age or older – if applying for Corrections/Telecommunicator.

I am 21 years of age if applying for a Deputy.

I have earned a high school diploma or a GED.

I am able to legally drive a vehicle (does not apply to telecommunicator).

During the last ten (10) years, I have not been convicted, plead guilty (nolo contendere), been

on Community service/probation or deferred adjudication for a Class B misdemeanor in this

state, other state, or while serving in the military.

______I have never been charged with any level of assault against a family member/domestic

partner.

I have never had been discharged dishonorably from any armed service.

I have never been convicted, plead guilty (nolo contendere), nor have I been on court-

ordered community service/probation or deferred adjudication for a Class A misdemeanor or

a felony.

Requirements (in addition to the above): Must be able to read, write, and speak English in a manner which is understandable and

is discernable to others.

Must be willing to work any shift, any day, any weekend, and/or any holiday.

Must be willing to respond when called to duty outside normal shifts or stay late/come in early.

Must be willing to meet grooming and dress code requirements.

Must be able to successfully pass all tests according to the position you will hold.

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Hiring Process:

You are expected to dress appropriately. If you are unable to keep an appointment due to an emergency or if you decide to discontinue the pre-employment processing, you must notify Sgt. Phelps promptly by telephone, voice mail or email.

Phase 1

• Applicant submits online application for eligibility pool. Phase 2

• Pre -employment reading/comprehension testing letters are sent by mail. • Applicant is instructed by mail to come to BCSD website and download forms needed to

register for testing. • Applicant tests and is informed on pass/fail and an interview given. Tests placed in a

numerical ranking order. Phase 3 • The background investigation begins based on the testing ranking order. • Applicants who are disqualified are sent a letter stating they were disqualified. • Oral Interviews are set up and applicants are mailed and/or emailed the dates/times of their

interviews. • Oral interviews are scored and the eligibility pool is established.

Phase 4 When employment becomes available, the highest ranked candidate is given a conditional offer of employment based on successful completion of:

• Psychological test • Agility Test • Medical Exam/Drug Screen • Fingerprints • Appointment with the Psychologist • Uniform Issue • Bell County Employee Benefits Orientation • Applicant given a perspective start date

DISQUALIFICATION

There are very few automatic basis for rejection. Even issues of prior misconduct, employee terminations, and arrests are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent job- relevant information from their prospective employer.

This personal history statement is a governmental document. Be truthful, as there are criminal consequences for lying on a governmental document.

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Document Checklist needed to be turned in with this Personal History Statement are as follows:

Bring applicable documents with you when you turn in this packet. Copies will be made by departmental personnel & originals returned to you on the same day:

Completed Personal History Statement

Valid Texas driver license or another State’s driver license. Applicant must possess a valid Texas driver license with current address prior to being offered employment.

Social Security card.

High School diploma or GED certificate, or High School Transcript with graduation date on it.

College diploma.

Copy of ALL DD-214 tour of duty forms (Member 4 Form) if applicable. Must possess an honorable discharge.

Certified & Original Certified Documents needed. Copies will be made by departmental personnel & originals returned to you:

Original certified copy of your birth certificate. No photo copy & NOT from a

hospital. O R a n Original certified copy of your Naturalization papers, if

applicable.

Sealed original certified copy of your college transcript.

College transcripts must bear the seal of the institution. If College transcripts must be obtained by mail, have them sent directly to Sgt. Phelps 104 S. Main St., Belton, TX, 76513.

All Court documents from any court charges, whether or not convicted, other than traffic violations.

Check this box if you have sent for your requests for Certified Documents through certified mail or have purchased through an online service, then attach the certified mail receipt to your PHS.

FOR PEACE OFFICERS ONLY. In addition to the above documents, you will also need to provide the following:

Copy of a TCOLE approved Firearms Qualifications within the last 12 months. If you have any questions, please contact your assigned background investigator, Sgt. Phelps, @ 254-933-5992 or email Sgt. Phelps at [email protected].

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PREA REQUIRED BACKGROUND CHECK

PREA is the first United States Federal Law passed dealing with sexual abuse of incarcerated persons. The bill was signed into law on September 4, 2003 and the standards were published in the Federal Register on June 20, 2012 and became effective on August 20, 2012. PREA stands for Prison Rape Elimination Act. Check the word Yes or No as it applies to you.

1) Have you ever engaged in sexual abuse in prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ____ Yes ____ No

2) Have you ever been convicted of engaging or attempting to engage in sexual

activity in the community facilitated by force, overt or implied threats of force or coercion, or if the victim did not consent or was unable to consent or refuse?

____ Yes ____ No

3) Have you ever been civilly or administratively adjudicated to have engaged in the activity described in question two? ____ Yes ____ No

4) Have you resigned from employment during a pending investigation into allegations

that engaged in sexual abuse or sexual harassment? ____ Yes ____ No

5) Have you ever been disciplined, written up, or otherwise investigated for allegations

of sexual harassment? ____ Yes ____ No

If you answered yes to any of these questions, this is not an automatic disqualifier. _________________________________________ _________________________

Printed Name Date of Birth _______________________

Social Security Number

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Your True/Legal Name: _________________ ____________________ ________________ _____ Last First Middle Suffix

Other names used (nicknames, maiden and/or other legal names):

Do you have a name you prefer to be addressed by?

Physical Address

Number Street name, Apt/Lot/Unit

City, State, Zip:

Mailing Address (if different than Physical):

Number Street name, Apt/Lot/Unit

City, State, Zip:

Home phone #: Work phone #:

Alternate phone #: Cell phone #:

Date of Birth: Race: Sex:

Social Security #: U.S. Citizen: Yes No

Driver’s License #, State of Issue, expiration:

Concealed Handgun License #, State of issue, Expiration:

Height: Weight: Hair Color: Eye Color:

Place of Birth (City, State, country):

Primary Email (we will have correspondence thru email):

Personal Information

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Social Media

Personal Information Cont’d

Scars/Marks (location on body. Tab at end of each line. It is not automatic:_______________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Tattoos (description & Location on body, along with the significance of the meaning. Tab at end of each line. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List below ALL social media sites you are a member or have been a member of as well as your screen names.

In law enforcement, you are not entitled to the same rights of privacy as a private citizen. Part of your background investigation is how you conduct yourself on your own time as well. While we do not have hard guidelines about your personal life, we are looking that your personal life mirrors an integrity that does not bring embarrassment or shame to the department. Law enforcement is a highly scrutinized, highly challenged, career that demands its honor and integrity to be maintained at all times. Omission of any type or misrepresentation of any type will be a disqualifier.

website Screen Name Current Member?Yes/No

If you have more information than the space provided here, attach a sheet referencing the page number and description to the end of this personal history statement.

Social Media

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In your own words, print or type a brief description of your life from 17 years of age to present. Include any event that you feel may add to why you are qualified for this position. You do not have to fill the entire page, additionally, if you need more space, please attach another sheet identifying the section you are adding to. At the end of each line, press tab to go to next line. It is not automatic.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Personal Autobiography

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Choose one response.

Currently I have a: Husband Wife Domestic Partner Girlfriend Boyfriend I do not currently have a husband/wife, domestic partner, girlfriend, or boyfriend.

______________________ ____________________ ___________________ _____________________

Last Name First Name Middle Name Former Name

Date of Birth: Deceased: Social Security#:

Date of Marriage/beginning of relationship:

Location of Marriage (City/State):

This person’s current address (City, State, Zip): _

Home Phone#: Cell Phone #:

Place of Employment:

Address of Employment:

Telephone # to Employment:

Biological/Step-Child(ren)/Adopted/Foster Children with this person with this person: Please indicate in status box: B=Biological; S=Stepchild; A=Adopted; F=Foster

Describe your relationship with this person. Any Information may prove useful when we contact this person during your background investigation: __________________________________________________________________________________________________________________________________________________________________________________________________________________

Full Name Birthdate Status Age

Related Persons

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Related Persons Cont’d Most Current Ex-: Husband Wife Domestic Partner Girlfriend Boyfriend.

Last Name First Name Middle Name Former Name

Date of Birth: Deceased: Social Security#:

Date of Marriage/beginning of relationship:

Location of Marriage (City/State):

This person’s current address (City, State, Zip):

Home Phone#: Cell Phone #:

Place of Employment:

Address of Employment:

Telephone # to Employment:

Date of Divorce:

What City, County, State divorce was granted in:

Biological/Step-Child(ren)/Adopted/Foster Children with this person with this person: Please indicate in status box: B=Biological; S=Stepchild; A=Adopted; F=Foster

Describe your relationship with this person. Any Information may prove useful when we contact this person during your background investigation. Tab at end of each line; it is not automatic. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Full Name Birthdate Status Age

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Related Persons Cont’d

Do you have any other children not listed above? If so, please provide their name, age, address and with whom their other parent is:

If you did not have enough room to add your information, please attach another sheet of paper referencing your page number and section to the end of this personal history Statement. Yes No Are you ordered to pay child support or alimony? Yes No Are you currently delinquent on any payments for child support or alimony? Yes No Have you ever been delinquent on any child support or alimony payment?

Other Persons in your household: List all other persons (not previously listed before this section) that reside in your house: example is a roommate.

Full Name Age Address Parent’s Name

Full Name Birthdate Relationship

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Related Persons Cont’d

Identify relatives in the following order: Father, Mother (include maiden name), step-parents (if any), brothers and sisters, including step siblings, Father-in-law, Mother-in- Law, Brother/Sister-in-laws. If a family member is deceased then add the date of death as well as date of birth & place deceased in the address.

Relationship Name Complete Address Phone Number Birthdate

Relationship Name Address Phone Number Birthdate

Describe briefly your relationship with these individuals.Tab at the end of each line, it is not automatic.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you did not have enough room to add your information, please attach another sheet of paper referencing your page number and section to the end of this personal history Statement.

13

Identify all residences where you have lived in the last 10 years, beginning with the most recent, including your present address. List date by month/year. Include military assignments. (No TDY’s)

RESIDENCES

From To Address City Sate & Zip code

Have the police come to any of your residences or a location where you were for any reason? If so, explain. Provide dates, addresses, responding law enforcement agency, & Reason. If you need to add more, please attach a sheet to the end of this personal history statement referencing the page/section.

Date Address Which Agency _________ ____________________________________________ ___________________________ ________________________________________________________________________________________________

Date Address Which Agency _________ _____________________________________________ ___________________________ ________________________________________________________________________________________________

Residences

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Residence Cont’d Have you ever been evicted or asked to move from any residence you occupied? If so, explain. Provide dates, addresses, responding law enforcement agency, & Reason. If you need to add more, please attach a sheet to the end of this personal history statement referencing the page/section.

Date Address Which Agency _________ ____________________________________________ _____________________________ ________________________________________________________________________________________

Date Address Which Agency _________ ____________________________________________ _____________________________ _______________________________________________________________________________________

Have you ever broken a lease/rental agreement? If so, explain. Provide dates, addresses, responding law enforcement agency, & Reason. If you need to add more, please attach a sheet to the end of this personal history statement referencing the page/section.



If you need to further explain, do so here. Tab at end of each line; it is not automatic: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15

FINANCIAL HISTORY

Your current net monthly income: ________

Your spouse/domestic partner’s current net monthly income: ________

Source for both you and your spouse: Amount Frequency

_______________________________________ _________________ ______________________ _______________________________________ _________________ _____________________ _______________________________________ __________________ _____________________ Do you have any accounts with a financial institution? _____ Yes _____ No

Name(s) of financial institution(s)

Type(s) of account(s)

Identify any person or entity to whom you are indebted, and the extent of your indebtedness. Include mortgages, vehicle payments, charge accounts, credit cards, loans, child support payments, and any other debts or payments.

Name of Creditor (e.g., Sears, Citi financial)

Type of Debt (e.g., student loan, automobile)

Monthly Payment

Approx. Balance

Credit History

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Credit Information Cont’d Have you ever filed bankruptcy personally or on behalf of a business? Yes No

• If “Yes” to above, indicate type

Have you ever had any personal or real property repossessed or foreclosed? Yes No

Have you ever failed to pay Federal, state, or other taxes? Yes No

Have you ever failed to file a tax return, when required by law? Yes No

Have you ever had a lien placed against your property for failing to pay taxes or other debts? Yes No

Have you ever had a judgment entered against you? Yes No

Have you ever defaulted on any type of loan? Yes No

Have you ever had bills or debts turned over to a collection agency? Yes No

Have you ever had any credit account suspended, charged off, or cancelled for failure to pay? Yes No

Have you ever written a check that was later returned for Non-Sufficient Funds (NSF)? Yes No

Have you ever been delinquent on court-imposed alimony or child support payments? Yes No

Have you ever been disciplined regarding the use of a travel/credit card provided by an employer? Yes No

Are you currently more than sixty (60) days delinquent on any debts? Yes No

Have you ever applied for unemployment compensation? ___Yes ___No When?

Have you ever received unemployment compensation? ____Yes ____No When?

Identify any person or entity to which you are more than 30 days late in paying. Include mortgages, vehicle payments, charge accounts, credit cards, loans, child support payments, and any other debts or payments.

Name of Creditor (e.g., Sears, Citi financial)

Type of Debt (e.g., student loan, automobile)

Number of Days Late

Reason: no job/emergency. etc.

17

List all high schools, colleges, technological, academies or trade schools you have ever attended regardless of whether you graduated and/or completed the prescribed curriculum. If you are listing colleges/universities, and you did not graduate, indicate the number of credit hours you have earned. If you attended a technological or trade school, indicate your course of study and also note if you were awarded a diploma or certificate.

Check Highest Grade Completed:

High School : ______ College: ___ Associates ___ Bachelors ___ Master ___ Ph.D

EDUCATIONAL HISTORY

High School(s) attended Address Dates attended From-To

Graduated Yes/No

Do you have a G.E.D. Certificate? Date on GED Certificate:

Identify all colleges, universities, or technical schools you have attended: Name City & State Dates attended Hours

completed Major Degree &

Date

Education Information Cont’d

Have you ever been expelled from any school you have attended? Yes No Have you ever been placed on academic probation? Yes No Have you been involved in any community activities? Yes No If yes, list all under ‘explanation’ below. Have you received any awards, commendations or special recognition? Yes No

If yes, list all under ‘explanation’ below.

Education Information

18

Education Information Cont’d

Explanation if you answered yes to previous section. Tab at end of each line; it is not automatic: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List any Memberships/Groups/Associations/Clubs you belong to:

Organization Name Type: Social/Fraternal/ Offices Held Dates of Membership Professional/Etc.

_______________________________ _________________________ _______________ ____________________ _______________________________ _________________________ _______________ ____________________ _______________________________ _________________________ _______________ ____________________ _______________________________ _________________________ _______________ ____________________ _______________________________ _________________________ _______________ ____________________

List any hobbies/sports you partake in: Name of Hobby/Sport Involved how long?

___________________________________ _____________________ ___________________________________ _____________________ ___________________________________ _____________________ ___________________________________ _____________________ ___________________________________ _____________________ ___________________________________ _____________________

19

If you have applied with other law enforcement agencies, (including Bell County Sheriff’s Department prior to this current phase) for any position (including all city, county, State, and federal agencies and any position such as officer, detention officer, firefighter, dispatcher, etc.), please complete the following. Do not fail to list any applications, regardless of the status of your application. (Add additional page(s) if needed)

Check this box if you have NEVER applied with another law enforcement agency.

Check this box if you have ever been a paid or unpaid police informant.

Agency Date Position Applied for

___________________________ _____________ __________________________ Reason not accepted:

Hired Not Selected Not Contacted Rejected (explain why) Other (explain why) __________________________________________________________________________________________

Agency Date Position Applied for ___________________________ _____________ __________________________ Reason not accepted:



Hired Not Selected Not Contacted Rejected (explain why) Other (explain why) __________________________________________________________________________________________ Agency Date Position Applied for

___________________________ _____________ __________________________ Reason not accepted:




Applications with Law Enforcement Agencies

20

List five (5) persons who know you well enough to provide current information about you. Do not list relatives, former or present employers, or supervisors.

Name Years known

Address

Home Telephone Alternate Telephone

Nature of Relationship

Name Years known

Address



Name Years known

Address



Name Years known

Address



Name Years known

Address



Personal References

21

Identify all vehicles that you currently own or operate: Year Make Model Color License Plate No. Who Drives

Have you ever possessed a driver’s license issued by any state other than Texas? Yes No If yes, give details below:

Driver’s License No. State Date issued

Driver’s License No. State Date issued

Have you ever had your driver’s license suspended or revoked? Yes No If yes, give reason, date, and length of suspension. Tab at end of each line; it is not automatic::

Driver License/Vehicle Information

22

Except for class ‘C’ traffic citations, are there any charge(s) that you have been convicted of, plead guilty to (nolo contendere), been on community service/probation or deferred adjudication for any misdemeanor or felony in this state, other state, or while serving in the military? If so, you will need a certified court disposition attached with this personal history statement.

Criminal History Affidavit

This is a signed and notarized document. Integrity of truthfulness is mandatory. Continue with the next section. Write N/A if something does not apply to you. Attach certified copies from each court listed.

Do you have a criminal history? (If none, state N/A):

If so, List as indicated: Offense Date Disposition

I have read the provisions of this document and other than this section, I swear or affirm that I:

• Have never been convicted of a felony in a state as defined in Section 415.058Government Code;

• Have not been convicted of a Class A misdemeanor offense;• Have not been convicted of a Class B misdemeanor offense within the last 10 years;• Have not been convicted of the offense of driving while intoxicated or driving under

the influence of drugs within the past 24 months;• Am not currently on probation for any criminal offense above the grade of Class C;• Not awaiting trial on any misdemeanor or felony.


Criminal History

23

Criminal History Cont’d Traffic Record

Identify all motor vehicle accidents you have been involved in during the last 5 years:

Date Location Police Report: Yes/No

Cause of Accident (e.g., ran red light, failed to control speed)

Date Location Police Report: Yes /No

Cause of Accident (e.g., ran red light, failed to control speed)

Identify all traffic citations you have received within the last 10 years, excluding parking tickets: Month/Year Violation City & State Disposition(e.g., defensive driving, dismissed)

ARRESTS, DETENTIONS, AND LITIGATION

Have you ever been arrested or detained by law enforcement? Yes No

If yes, complete the following table: Agency Offense Date Location Outcome


24

Criminal History Cont’dTab at end of each line; it is not automatic:

Have you ever committed an act of family violence? (“Family violence” means an act bya member of a family or household against another member of the family or household that is intended to result in physical harm, bodily injury, assault, or sexual assault or that is a threat that reasonably places the member in fear of imminent physical harm, bodily injury, assault, or sexual assault, but does not include defensive measures to protect oneself.) (Texas Family Code Section 71.004) If yes, explain: _____________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever assaulted another person since the age of seventeen (17)? (“Assault” meansto cause bodily injury to another, threaten another with imminent bodily injury, or to cause physical contact with another when the person knows or should reasonably believe that the other will regard the contact as offensive or provocative.) (Texas Penal Code Section 22.01) If yes, explain:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been considered or named a suspect in a criminal investigation orcriminal offense? If yes, explain: _________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been listed in an Ex-Parte or a Protective order? If so, with whom, the county,city, state, and the date of that document: _____________________________________________________

_________________________________________________________________________________________________

Have you ever been a party to a civil suit or action? If yes, explain: _____________________________

___________________________________________________________________________________________________

Have you ever been involved in any incident (do not include vehicular accidents) in whicha police report was made or law enforcement was called? If yes, explain: ________________________

__________________________________________________________________________________________________________________________________________________________________________________________________

Other than crimes that would have been sealed by juvenile records, have you evercommitted , or assisted another person, in the commission of – a felony crime, serious misdemeanor, or a crime involving moral turpitude that went undetected or unreported to law enforcement? If yes, explain: __________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_

Do you anticipate being sued or named in any type of lawsuit or proceeding? Yes No

25

Family and Relatives Arrests

Have members of your immediate family or close relatives ever been arrested? Yes No If yes, complete the following table:

Name/Relationship Charge/Offense Year Agency Outcome __________________________ ______________________ ____ ________ _________ __________________________ ______________________ ____ ________ _________ __________________________ ______________________ ____ ________ _________ __________________________ ______________________ ____ ________ _________ __________________________ ______________________ ____ ________ _________ __________________________ ______________________ ____ ________ _________


26

Beginning with your present or most recent job, list all employment for the past 5 years. Include full-time, part-time, temporary, seasonal, military assignments, and/or volunteer/unpaid internships, as well as all periods of unemployment. Do this in sequential order: Start with the most recent to oldest.

If you are currently employed, may we contact your present employer? Yes No

Check Appropriate Job Description(s): Full Part Temporary Seasonal Volunteer

Employer:

Employer’s Address:

Employer’s Telephone Number: Email:

Employment Began On: Ended On: Total Time (years & months):

Position(s) Held with Organization and Duties/Responsibilities:

Title: Time in position:

Did you receive job Performance Evaluations? Yes No Eligible for Re-hire? Yes No

Beginning Salary/Hourly Rate: Ending Salary/Hourly Rate:

Supervisor Name:

Supervisor Phone: Email:

Reason for Leaving: Resignation Termination Temp. Job Lay Off Other (Explain):

Was Notice Given? Yes No Was Notice: Verbal Written

If Notice Given, How Much? (If less than 2 weeks, explain): ________________________________________ ________________________________________________________________________________________________

Were you ever disciplined? If so, for what?

List At Least One Co-Worker: Phone Number:

Co-Worker’s Email Address:

Employment References

27

Employment Cont’d


Employer:








Supervisor Name:




If Notice Given, How Much? (If less than 2 weeks, explain): ________________________________________ _______________________________________________________________________________________________




Employment Cont’d


Employer:








Supervisor Name:


Reason for Leaving: Resignation Termination Temp . Job Lay Off Other (Explain):


If Notice Given, How Much? (If less than 2 weeks, explain): ________________________________________ _______________________________________________________________________________________________




Employment Cont’d


Employer:








Supervisor Name:




If Notice Given, How Much? (If less than 2 weeks, explain): _________________________________________ _________________________________________________________________________________________________




30

Employment Cont’d


Employer:






Did you receive job Performance Evaluations? Yes No Eligible for re-hire? Yes No


Supervisor Name:




If Notice Given, How Much? (If less than 2 weeks, explain): __________________________________________ ____________________________________________________________________________________________________





31

Employment History Cont’d IF YOU ANSWER YES TO ANY QUESTION IN THIS SECTION ABOVE, EXPLAIN.

1. Did you intentionally omit any of your jobs on this Personal History Statement?

Yes No

Note: For the purposes of this Personal History Statement, termination includes, being fired, discharged, dismissed, released, let go and other similar terms; disciplinary action includes being reprimanded, counseled (verbally or in writing), or otherwise put on notice to improve your conduct or performance in the workplace.

Have you, regardless of whether the matter is or was appealed, regardless of whether the matter is part of your official record, regardless of whether you believe or think that it might not still be in your file:

1. Ever been terminated from employment for any reason? Yes No

2. Ever resigned in lieu of termination (after being told your employer intended to terminate you)? Yes No

3. Ever resigned in lieu of disciplinary action (after being told your employer intended to take disciplinary action against you)? Yes No

4. Ever quit because you suspected you were going to be terminated or disciplined or you were under an Internal Affairs investigation? Yes No

5. Did you falsify any of the reasons for leaving any of your employers? Yes No

6. Have you even been employed in an illegal occupation? Yes No

7. To your knowledge, would any former employer give you an unfavorable recommendation? Yes No

8. Have you ever worked for a governmental agency? Yes No

Check this box if you have NEVER been fired or asked to resign from a job.

32

Employment Cont’d

Employment information explanation if you checked yes to previous questions. Tab at end of each line; it is not

automatic:

This is a signed and notarized document. Integrity of truthfulness is mandatory. Continue with the next section. Write N/A if something does not apply to you.

Statement of Military Affidavit:

Applicant Name (last, first, middle):

SSN: DL#: State of Issue:

I have read the provisions of this affidavit and I swear or affirm that I:

I have never been in the military.

I have been in the military more than once.

I have never had a military court martial that resulted in a dishonorable or bad conduct charge.


Military Obligations

33

Military Obligations Cont’d

Have you ever served in the U.S. Armed Forces or State Military Forces?____Yes ____No

Served from to Highest Rank held Date Date

Branch of Service Unit

Job Title(s) (e.g., Rifleman, Security)

Type of discharge Last Duty Station:

Have you served in a second tour with any U.S. Armed Forces or State Military Forces?____Yes ____No

Served from to Highest Rank held Date Date



Type of discharge Last Duty Station:

Are you actively serving in a Reserve Unit (including State Military Forces)?____Yes ____No

Serving from to Current Rank held Date Date



If you have been discharged from the military, are you eligible for re-entry into the military?____Yes ____No

Have you ever been subject to court martial or any other disciplinary proceeding under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and outcome(s). Tab at end of each line; it is not automatic


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SPECIAL QUALIFICATIONS & SKILLS

Do you, or have you, possessed a TCOLE (formerly known as TCLEOSE) license for telecommunicator, jailer, or peace officer? ____Yes ____No If yes, what is your TCOLE PID#? ______________________ Identify any special licenses you hold (e.g., pilot, radio operator): _____________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ If you know a foreign language, indicate your fluency in each block below (excellent, good, fair)

Language Understanding Speaking Reading Writing

Do you have any experience with firearms? ____Yes ____No Have you ever been an officer or a member of, or made a contribution to, an organization that advocates or practices the commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or right granted by law? ____Yes ____No

Special Skill/Qualifications

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Personal Declarations

Do you consume alcoholic beverages? ____Yes ____No If “Yes”, how often?_____________________

Have you ever used marijuana or hashish? ____Yes ____No If yes, when last used?___________________

Have you ever used any illegal drug (including a performance-enhancing steroid) not prescribed by a physician?

____Yes ____No If yes how often:_________________ When last used:______________________ Provide explanation:_______________________________________________________________________________________________________________________________________________________________________________________________

Have you ever sold or furnished controlled substances or prescription drugs to anyone? ____Yes ____No

If yes, give details:____________________________________________________________________________________ ______________________________________________________________________________________________________

Are there any incidents in your life, or details not mentioned herein, which may influence this department’s evaluation of your suitability for employment as an employee of the Bell County Sheriff’s Department? If yes, explain: ___________________________________________________________ ______________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Identify any additional information you think should be considered in your application for the position you are seeking, and/or any further explanation of answers to previous questions: ____________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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**DO NOT SIGN THIS PAGE UNTIL YOU ARE IN FRONT OF A NOTARY**

I hereby certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers to the above questions. I fully understand that any misrepresentation, omission, or falsification may deem me permanently unsuitable, or if hired, may lead to the termination my employment.

I also understand that departmental personnel will place any attached extra information sheets needed to expound on information within this document and it will become part of the notarized legal packet known as the ‘Personal History Statement”.

Signature of applicant

Date

Before me personally appeared who stated this document and its intent was explained to him/her that he/she has full knowledge of its purpose and that he/she executed this instrument of his/her free will and accord.

Sworn to and subscribed before me on this _____ day of _____________, 20_____.

SEAL or STAMP Signature of Notary My Commission Expires:

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