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Microsoft Word - 45BAE190-3C38-28233A.docApplicant Personal
History Statement
MINIMUM REQUIREMENTS FOR EMPLOYMENT
PLEASE NOTE
Applicants must be willing to accept any duty assignment and/or work any shift, including weekends, holidays and midnights. Duty assignments, shifts, and /or days off are subject to change without notice.
1. Applicants for security guard positions must be 18 years of age or older.
2. Must possess either a High School Diploma or a G.E.D.
3. Good moral character (as may be determined through a comprehensive background investigation).
4. Good driving record.
5. No DWI/DUI convictions within the last 10 years.
6. No evidence of recent alcohol abuse, or recent narcotics use or involvement.
7. No military discharge under less than or other than honorable conditions.
8. Must not have ever been convicted at any time of a felony offense.
9. Not ever have been or currently on court-ordered community supervision or probation for any criminal offense above the grade of Class B misdemeanor or a Class B misdemeanor within the last ten (10) years.
10. Not currently under indictment for any criminal offense.
11. Not have been convicted of any family violence offense.
12. Not prohibited by state or federal law from operating a motor vehicle.
13. Not prohibited by state or federal law from possessing firearms or ammunition.
For purposes of this document, the word convicted shall be construed to mean a conviction by a verdict, by a plea of guilty, upon a judgment of the court, a jury having been waived, without regard to subsequent disposition of the case or suspension of sentence, probation, deferred adjudication, or otherwise.
INSTRUCTIONS
BEFORE PROCEEDING
Thank you for selecting the Tarrant County College Police Department as a potential employer. The following instructions are provided in order to help guide you through the completion of the Personal History Statement. If you encounter difficulty with any areas of this document, you may call Sgt. C. Lea or Tracey Herrera at (817-515-1911).
Your Personal History Statement will be used as the basis for a background investigation that will determine your eligibility for the position for which you are applying.
1. Your Personal History Statement supplement should be hand printed legibly in ink.
2. Answer all questions completely. If a question does not apply to you, enter “N/A” in the space provided.
3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is correct and in sequence before you begin.
4. You are responsible for obtaining correct addresses (including zip codes.) If you are not sure of an address, check it by personal verification. Your local library may have a directory service or copies of the required directories. Also include the area code with each telephone number.
5. If there is insufficient space on the Personal History Statement form, attach extra sheets. Be sure to reference the relevant section and question before continuing your answer. Do not write on the back of any page.
6. Any copies of documents you are requested to submit should be on an 8 ½” X 11” sheet of paper only. If several small items are copied on one page, place them so that they all appear upright on the page, and leave at the least, a 1” border.
Your failure to properly and thoroughly complete this document may result in your rejection from the hiring process. Deliberate omissions or a deliberate misstatement of required information are grounds for rejection.
DO NOT REMOVE ANY PAGES FROM THIS BOOK
Tarrant County College District
Phone (817) 515-1911 * Fax (817) 515-1929
Thank you for applying with the TCCD Police Department. Attached is a Personal History Statement which you must complete and return within 10 business days of receipt. This form may be returned in person or by mail. It MUST be returned to the Trinity River Campus at:
TCCD TR Police Department
300 Trinity Campus Circle
Fort Worth, TX 76102
If you have any questions, please contact Sgt. C. Lea or Tracey Herrera at the Trinity River Campus at (817) 515 - 1911.
You are also required to return certain documents with the Personal History Statement. These items are listed below. Please submit copies only, do not send originals. If you do not have access to a copy machine, bring the originals to our office and we will copy them for you. If you encounter any problems in obtaining a document, let us know.
If you fail to return your Personal History Statement and the required documents by the date and time that they are due, if your personal history statement is incomplete or not properly completed, or if you fail to follow instructions, processing of your application for employment will be discontinued.
REQUIRED DOCUMENTS
1. Texas Drivers License 6. College Transcripts
2. Vehicle Insurance 7. DD Form 214 (if applicable)
3. Social Security Card 8. Peace Officers License (if applicable)
4. Birth Certificate, or ______9. Divorce or Civil Papers that may apply
Naturalization Certificate
5. High School Diploma, .
Transcripts or GED Certificate
Please indicate the items you have supplied, and return this sheet. State N/A if not applicable. If you do not have the required item in your possession, you will need to begin the process of obtaining it, notify us that you have requested the item, and then provide it when you receive it.
16
300 Trinity Campus Circle, Fort Worth, TX 76102
Office (817) 515-1911, Fax (817) 515-1929
AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN: I am an applicant for a position with the Tarrant County College Police Department (hereafter known as TCC PD.) The department needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied. It is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the above department.
I hereby authorize any representative of the TCC PD bearing this release to obtain any information in your files pertaining to my employment records, and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorized agent of the TCC PD, whether said records are of public, private, or confidential nature. The intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the TCC PD to consider in determining my suitability for employment in that department. It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.
I consent to your release of any and all public and private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential, and/or sealed.
I hereby release you, your organization, and all others from liability or damages that may result from furnishing information requested, including any liability or damage pursuant to any state or federal laws. I hereby release you as the custodian of such records of your organization, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct you to release such information upon request of the duly accredited representative of the TCC PD regardless of any agreement I may have made with you previously to the contrary. The law enforcement organization requesting the information pursuant to this release will discontinue processing my application if you refuse to disclose the information requested.
For and in consideration of the TCC PD’s acceptance and processing of my application for employment, I agree to hold you, your organization, its agents and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employee me with the TCC PD. I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.
I understand my rights under Title 5, United Stated Code, Section 552a, the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those rights with the understanding that information furnished will be used by the TCC PD in conjunction with employment procedures.
A photocopy or FAX copy of this release form will be valid as an original thereof, even though the said photocopy or FAX copy does not contain an original writing of my signature.
This waiver is valid for a period of 6 months from the date of my signature.
Should there be any questions as to the validity of this release, you may contact me at the address listed on this form. I agree to indemnify and hold harmless the person to whom this request is presented and his/her agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request.
Printed Name Signature
DO NOT SIGN
Unless in the presence of and witnessed by a Notary Public
Address
The State of Texas } {
County of Tarrant } {
Sworn to and subscribed before me on this the day of , 20 .
Notary Public (Seal)
CRIMINAL HISTORY INQUIRY AUTHORIZATION
In accordance with the Federal Privacy Act and other applicable laws and statutes, I hereby authorize you to release all criminal history and fingerprint information pertaining to me to agents of the Tarrant County College Police Department. I am aware and do consent that such inquiries will be made and that said inquiries will result in a report containing detailed information about me. I am also aware, and do further consent and authorize, that such information obtained under this authorization will be used to evaluate my candidacy for employment with Tarrant County College.
Date of Birth Name (Type or print legibly)
Social Security Number Signature
The State of Texas } {
BEFORE ME, A NOTARY PUBLIC, on this day personally appeared
known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she executed same for the purposes and considerations therein expressed.
DO NOT SIGN
Unless in the presence of and witnessed by a Notary Public
GIVEN UNDER MY HAND AND SEAL of office on this the
day of , 20 .
Printed or typed name of notary
Notary Commission Expires
APPLICANT IDENTIFICATION FORM
1. Name
7. Date of Birth Current Age
8. Drivers License Number State
9. Social Security Number - -
11. Sex |_| Male |_| Female
FOR OFFICE USE ONLY
17. Are you a licensed Texas Peace Officer? |_| Yes |_| No
18. TCLEOSE PID Number (If applicable)
19. If yes, date last worked as a certified officer
What department?
Section - A
FAMILY INFORMATION
Complete this section if you are currently Married or Engaged
Spouse or Fiancée’s Full Name (include maiden name): ________________________________________________________
Complete Mailing Address: ________________________________________________________________________________
If married, date of marriage: / / County & State of Marriage: ________________________________
Complete this section if you have ever been MARRIED (legal or common law) and are divorced – OR – if you have ever been engaged. List all former spouses & fiancée’s / fiancé’s. Use attachment sheet if necessary.
________________________________________________ _____________ _____________
________________________________________________ _______________________ _____ _________
Complete Mailing Address City State ZIP
________________________________________________ _____________ _____________
________________________________________________ _______________________ _____ _________
Complete Mailing Address City State ZIP
Do you have any children or dependents? |_| Yes |_| No If yes, how many? __
If yes, list their name(s), relationship and age: _________
Are you delinquent on child support payment for your children? |_| Yes |_| No |_| N/A
Family: List in the order given, showing the relationships – Parents, Guardians, Stepparents, Foster Parents, Parents’-in-law, Brothers/Sisters (even though deceased). Include any others you have resided with or with whom a close relationship existed or exists. Include fiancé/fiancée or roommates, if any. Use attachment sheet if necessary.
Name: Address:
Education (List all diplomas, degrees and/or certifications and where obtained)
High School Attended:
|_| Obtained a GED: Date of GED: _______________________________
Accredited College or Universities Attended: |_| N/A
Degree |_| Yes |_| No Degree Type & Year _____________________ Courses Studied/Major
GPA School City/State
Dates attended / / to / /
GPA School City/State
Dates attended / / to / /
GPA School City/State
Dates attended / / to / /
School ____________________________________ City/State _________________________________________________
Type:_______________________________________________________________________________ Date:______________
Type:_______________________________________________________________________________ Date:______________
Are you currently attending a college/university or taking any training or continuing education classes? |_| Yes |_| No
If yes, which college/university are you presently attending?
What is the purpose of your current training or class?
Have you ever been expelled, suspended or placed on academic probation from any school attended? |_| Yes |_| No
If yes, explain:
_______________________________________________________________________________________________________
Special skills/talents/qualifications: List all special skills, unique licenses, aptitudes, qualifications or foreign languages you speak, read or write. Include office skills, computer skills or other skills that you believe would be beneficial to this department.
Awards, scholarships or special recognitions: List all awards, scholarships or recognitions you received at school, work or for public service:
Organizations: List past and/or present memberships:
Name and Location Type (social, Office(s) Membership Dates
Professional, Held From To
/ /
/ /
/ /
/ /
/ /
/ /
Residences: List all residences, including military and school addresses for the past TEN (10) years. Begin with your present address and go back in chronological order. Use additional sheet if necessary.
Date / From: / To: PRESENT Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
REFERENCES
List a minimum of six (6) persons who know you well enough to provide current information about you. DO NOT USE ANYONE LISTED IN THE ABOVE “FAMILY INFORMATION” section. Include city, state and ZIP code. All information in the section below is required, not optional.
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Section - D
BACKGROUND INFORMATION
Drug and Narcotic Usage: This section covers usage of any controlled substance, dangerous drug, inhalant, marijuana or any illegal drug not prescribed to you by your physician. Usage is the introduction of a substance into your body, through experimentation, snorting, smoking, ingestion, injection, huffing, tasting, trying or via any other means.
Have you ever used any drugs/narcotics illegally? |_| Yes |_| No
If yes, complete the following section.
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
Have you ever bought or sold any illegal drugs/narcotics? |_| Yes |_| No If yes, list the date(s) and details of the incident(s).
Have you ever manufactured any illegal drugs/narcotics? |_| Yes |_| No If yes, list the date(s) and details of the incident(s).
Military Information
Have you served in any branch of the Armed Forces? |_| Yes |_| No If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:
Did you leave the service and then re-enlist? |_| Yes |_| No If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:_________________________________________________________________________
Have you served in any foreign Armed Services? |_| Yes |_| No If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:_________________________________________________________________________
Have you ever been rejected by any branch of the Armed Services for a non-medical reason? |_| Yes |_| No
Date of rejection: ______________
_________________________________________________________________________________________________________
Were you ever disciplined while in military service? (court martial, captain’s masts, company punishment etc.) |_| Yes |_| No
Date: ________________
Charge: __________________________________________________________________________________________________
Disposition: _________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Criminal Activity
Have you ever been arrested by a law enforcement agency? |_| Yes |_| No If yes, complete the following section.
Date of Arrest: ____________ Charge: __________________________________________________________
Conviction Date: ____________
Dismissal Date: _____________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Conviction Date: ____________
Dismissal Date: _____________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you ever been questioned, detained, interrogated, indicted, or charged with a crime by a law enforcement agency?
|_| Yes |_| No If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
Have you ever been banned from or asked to leave any business, school, private residence or other establishment for disturbing the peace or criminal trespass?
|_| Yes |_| No If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
Have you ever been convicted of a crime, placed on court ordered community supervision, or probation? |_| Yes |_| No
If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
Have you or your spouse ever been a party to a civil or criminal action? |_| Yes |_| No
If yes, list the date, reason and disposition of the incident(s). Provide copies of any applicable paperwork for each event.
Have you ever been the subject of a police inquiry into any incidence of family violence? |_| Yes |_| No
If yes, explain.
Have you ever committed a crime in which you were not caught? |_| Yes |_| No
Details: _________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been issued a citation for a non-traffic violation? |_| Yes |_| No If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
DATE VIOLATION CITY/STATE DISPOSITION
Law Enforcement Experience
Are you currently a licensed Peace Officer? |_| Yes |_| No If yes, what state?
Have you ever been employed as a Peace Officer? |_| Yes |_| No If yes, what state?
Have you ever worked as a Reserve Police Officer? |_| Yes |_| No
Have you ever served as a Military Police Officer? |_| Yes |_| No
Have you ever been employed as a Security Officer? |_| Yes |_| No
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been investigated for any violation of Federal law |_| Yes |_| No If yes explain below:
in the course and scope of performing your job as a police officer,
security officer, jailer/ corrections officer, military police officer
(Tort claims, Civil Rights Violations, causing injuries, etc.)?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Do you have any prior or pending Civil Rights actions filed against |_| Yes |_| No If yes explain below:
you while acting in a law enforcement environment?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
If yes to any of the above questions, has your peace officer’s license, jailer/correction officer certification or security officer
certification ever been revoked or suspended? |_| Yes |_| No
Have you ever taken part in a law enforcement internship program? |_| Yes |_| No
If yes, list agency and date(s):
Have you ever applied for a position with another law enforcement agency? |_| Yes |_| No
If yes, complete the following information:
NAME OF AGENCY POSITION DATE OF STATUS OF
APPLICATION APPLICATION
Section - E
DRIVING HISTORY
List all states where you currently possess a driver’s license or have possessed a driver’s license. Include the state and license number. Begin with your current driver’s license.
STATE LICENSE NUMBER EXPIRATION DATE
_________ _________________ ________________
_________ _________________ ________________
_________ _________________ ________________
Citations:
How many moving violations have you received since you began driving? ____________
How many moving citations have you received in the past (5) years? ____________
List all traffic citations (speeding, stop sign, etc.) including red light camera violations which have been issued to you in the last five (5) years. Include the disposition of the citation(s) – deferred adjudication, defensive driving, found not guilty by the court, paid fine, etc. Use attachment sheet if necessary.
DATE VIOLATION CITY/STATE DISPOSITION
Accidents:
How many motor vehicle accidents have you been involved in as a driver? ____________
List all traffic accidents that you have been involved in as the driver in the last five (5) years.
DATE VIOLATION AT FAULT CITY/STATE DISPOSITION
________ ____________________ |_|Yes |_|No ________________________ _____________________________
________ ____________________ |_|Yes |_|No ________________________ _____________________________
________ ____________________ |_|Yes |_|No ________________________ _____________________________
________ ____________________ |_|Yes |_|No ________________________ _____________________________
General driving information:
_____________________________________________________________________________________________________
Has your driver’s license ever been suspended or revoked? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had your driver’s license placed on probation for receiving an excessive number of
traffic citations? |_|Yes |_|No
_____________________________________________________________________________________________________
Have you ever had a hearing for probation/suspension, etc.? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever driven a motor vehicle after your driver’s license was suspended or after it had been
revoked? |_|Yes |_|No
_____________________________________________________________________________________________________
Have you ever been involved in an accident and then left the accident scene without identifying yourself? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever struck an unattended vehicle and then left without leaving your identification? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had your insurance revoked due to the number of traffic citations you have received? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever been placed as an assigned risk for vehicle insurance? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you have a valid driver’s license in more than one state? |_|Yes |_|No
Details: ______________________________________________________________________________________________
Section - F
EMPLOYMENT HISTORY
Have you ever been discharged, fired, asked to resign, furloughed, put on inactive status or given unpaid leave because of disciplinary action?
|_| Yes |_| No
If yes, explain:
Have you ever resigned or quit to avoid being discharged, terminated or fired? |_| Yes |_| No
If yes, explain:
Have you ever been the subject of an administrative investigation by a former employer regarding any type of misconduct?
|_| Yes |_| No
If yes, explain:
Have you previously applied for a job with the Tarrant County College District? |_| Yes |_| No
If yes, when and for what position?
Once assigned to a background investigator, may we contact your current employer? |_| Yes |_| No |_| N/A
If no, explain:
Would you like an investigator to notify you before contacting your current employer? |_| Yes |_| No |_| N/A
Beginning with your current or most recent job, list all jobs you have held in the past ten (10) years, including military service, all part-time, temporary or seasonal employment, and periods of unemployment (including school). Use attachment sheet if necessary.
From: / To: / Supervisor’s Name:
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Section - G
PERSONAL DECLARATIONS
Are there any incidents in your life not mentioned herein which may reflect upon your suitability to
perform the duties of the position for which you are applying that might require further explanation?
|_|Yes |_| No If yes, explain:
If selected for this position are you able to work all shifts, weekends, holidays, midnights and
understand that you may be assigned to any campus within the Tarrant County College District
based on the needs of the department? |_|Yes |_| No If no explain:
If necessary, could you use physical force in the course and scope of performing your duties as a
security officer? |_|Yes |_| No If yes, explain:
Section - H
CERTIFICATION STATEMENT
I certify that there are NO MISREPRESENTATIONS, FALSIFICATIONS OR OMISSIONS in the foregoing statements and answers. All entries are true, complete and correct. I agree and consent in advance to being rejected for employment and understand that if hired, I may be discharged, if any of the information provided contains any misrepresentations, falsifications or if any material information has been omitted.
I further agree that if I fail any portion of the hiring process or I am not hired, that the Tarrant College District Police Department will not discuss with me the reason for me not being selected or hired. If the issue is of a temporary nature I will be notified that I am eligible to re-apply.
I certify that I am not related by blood or marriage to any member of the Tarrant County College District Police Department.
Signature of Applicant
Date of preparation
Tarrant
County
College
District
History Statement
MINIMUM REQUIREMENTS FOR EMPLOYMENT
PLEASE NOTE
Applicants must be willing to accept any duty assignment and/or work any shift, including weekends, holidays and midnights. Duty assignments, shifts, and /or days off are subject to change without notice.
1. Applicants for security guard positions must be 18 years of age or older.
2. Must possess either a High School Diploma or a G.E.D.
3. Good moral character (as may be determined through a comprehensive background investigation).
4. Good driving record.
5. No DWI/DUI convictions within the last 10 years.
6. No evidence of recent alcohol abuse, or recent narcotics use or involvement.
7. No military discharge under less than or other than honorable conditions.
8. Must not have ever been convicted at any time of a felony offense.
9. Not ever have been or currently on court-ordered community supervision or probation for any criminal offense above the grade of Class B misdemeanor or a Class B misdemeanor within the last ten (10) years.
10. Not currently under indictment for any criminal offense.
11. Not have been convicted of any family violence offense.
12. Not prohibited by state or federal law from operating a motor vehicle.
13. Not prohibited by state or federal law from possessing firearms or ammunition.
For purposes of this document, the word convicted shall be construed to mean a conviction by a verdict, by a plea of guilty, upon a judgment of the court, a jury having been waived, without regard to subsequent disposition of the case or suspension of sentence, probation, deferred adjudication, or otherwise.
INSTRUCTIONS
BEFORE PROCEEDING
Thank you for selecting the Tarrant County College Police Department as a potential employer. The following instructions are provided in order to help guide you through the completion of the Personal History Statement. If you encounter difficulty with any areas of this document, you may call Sgt. C. Lea or Tracey Herrera at (817-515-1911).
Your Personal History Statement will be used as the basis for a background investigation that will determine your eligibility for the position for which you are applying.
1. Your Personal History Statement supplement should be hand printed legibly in ink.
2. Answer all questions completely. If a question does not apply to you, enter “N/A” in the space provided.
3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is correct and in sequence before you begin.
4. You are responsible for obtaining correct addresses (including zip codes.) If you are not sure of an address, check it by personal verification. Your local library may have a directory service or copies of the required directories. Also include the area code with each telephone number.
5. If there is insufficient space on the Personal History Statement form, attach extra sheets. Be sure to reference the relevant section and question before continuing your answer. Do not write on the back of any page.
6. Any copies of documents you are requested to submit should be on an 8 ½” X 11” sheet of paper only. If several small items are copied on one page, place them so that they all appear upright on the page, and leave at the least, a 1” border.
Your failure to properly and thoroughly complete this document may result in your rejection from the hiring process. Deliberate omissions or a deliberate misstatement of required information are grounds for rejection.
DO NOT REMOVE ANY PAGES FROM THIS BOOK
Tarrant County College District
Phone (817) 515-1911 * Fax (817) 515-1929
Thank you for applying with the TCCD Police Department. Attached is a Personal History Statement which you must complete and return within 10 business days of receipt. This form may be returned in person or by mail. It MUST be returned to the Trinity River Campus at:
TCCD TR Police Department
300 Trinity Campus Circle
Fort Worth, TX 76102
If you have any questions, please contact Sgt. C. Lea or Tracey Herrera at the Trinity River Campus at (817) 515 - 1911.
You are also required to return certain documents with the Personal History Statement. These items are listed below. Please submit copies only, do not send originals. If you do not have access to a copy machine, bring the originals to our office and we will copy them for you. If you encounter any problems in obtaining a document, let us know.
If you fail to return your Personal History Statement and the required documents by the date and time that they are due, if your personal history statement is incomplete or not properly completed, or if you fail to follow instructions, processing of your application for employment will be discontinued.
REQUIRED DOCUMENTS
1. Texas Drivers License 6. College Transcripts
2. Vehicle Insurance 7. DD Form 214 (if applicable)
3. Social Security Card 8. Peace Officers License (if applicable)
4. Birth Certificate, or ______9. Divorce or Civil Papers that may apply
Naturalization Certificate
5. High School Diploma, .
Transcripts or GED Certificate
Please indicate the items you have supplied, and return this sheet. State N/A if not applicable. If you do not have the required item in your possession, you will need to begin the process of obtaining it, notify us that you have requested the item, and then provide it when you receive it.
16
300 Trinity Campus Circle, Fort Worth, TX 76102
Office (817) 515-1911, Fax (817) 515-1929
AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN: I am an applicant for a position with the Tarrant County College Police Department (hereafter known as TCC PD.) The department needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied. It is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the above department.
I hereby authorize any representative of the TCC PD bearing this release to obtain any information in your files pertaining to my employment records, and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorized agent of the TCC PD, whether said records are of public, private, or confidential nature. The intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the TCC PD to consider in determining my suitability for employment in that department. It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.
I consent to your release of any and all public and private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential, and/or sealed.
I hereby release you, your organization, and all others from liability or damages that may result from furnishing information requested, including any liability or damage pursuant to any state or federal laws. I hereby release you as the custodian of such records of your organization, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct you to release such information upon request of the duly accredited representative of the TCC PD regardless of any agreement I may have made with you previously to the contrary. The law enforcement organization requesting the information pursuant to this release will discontinue processing my application if you refuse to disclose the information requested.
For and in consideration of the TCC PD’s acceptance and processing of my application for employment, I agree to hold you, your organization, its agents and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employee me with the TCC PD. I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.
I understand my rights under Title 5, United Stated Code, Section 552a, the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those rights with the understanding that information furnished will be used by the TCC PD in conjunction with employment procedures.
A photocopy or FAX copy of this release form will be valid as an original thereof, even though the said photocopy or FAX copy does not contain an original writing of my signature.
This waiver is valid for a period of 6 months from the date of my signature.
Should there be any questions as to the validity of this release, you may contact me at the address listed on this form. I agree to indemnify and hold harmless the person to whom this request is presented and his/her agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request.
Printed Name Signature
DO NOT SIGN
Unless in the presence of and witnessed by a Notary Public
Address
The State of Texas } {
County of Tarrant } {
Sworn to and subscribed before me on this the day of , 20 .
Notary Public (Seal)
CRIMINAL HISTORY INQUIRY AUTHORIZATION
In accordance with the Federal Privacy Act and other applicable laws and statutes, I hereby authorize you to release all criminal history and fingerprint information pertaining to me to agents of the Tarrant County College Police Department. I am aware and do consent that such inquiries will be made and that said inquiries will result in a report containing detailed information about me. I am also aware, and do further consent and authorize, that such information obtained under this authorization will be used to evaluate my candidacy for employment with Tarrant County College.
Date of Birth Name (Type or print legibly)
Social Security Number Signature
The State of Texas } {
BEFORE ME, A NOTARY PUBLIC, on this day personally appeared
known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she executed same for the purposes and considerations therein expressed.
DO NOT SIGN
Unless in the presence of and witnessed by a Notary Public
GIVEN UNDER MY HAND AND SEAL of office on this the
day of , 20 .
Printed or typed name of notary
Notary Commission Expires
APPLICANT IDENTIFICATION FORM
1. Name
7. Date of Birth Current Age
8. Drivers License Number State
9. Social Security Number - -
11. Sex |_| Male |_| Female
FOR OFFICE USE ONLY
17. Are you a licensed Texas Peace Officer? |_| Yes |_| No
18. TCLEOSE PID Number (If applicable)
19. If yes, date last worked as a certified officer
What department?
Section - A
FAMILY INFORMATION
Complete this section if you are currently Married or Engaged
Spouse or Fiancée’s Full Name (include maiden name): ________________________________________________________
Complete Mailing Address: ________________________________________________________________________________
If married, date of marriage: / / County & State of Marriage: ________________________________
Complete this section if you have ever been MARRIED (legal or common law) and are divorced – OR – if you have ever been engaged. List all former spouses & fiancée’s / fiancé’s. Use attachment sheet if necessary.
________________________________________________ _____________ _____________
________________________________________________ _______________________ _____ _________
Complete Mailing Address City State ZIP
________________________________________________ _____________ _____________
________________________________________________ _______________________ _____ _________
Complete Mailing Address City State ZIP
Do you have any children or dependents? |_| Yes |_| No If yes, how many? __
If yes, list their name(s), relationship and age: _________
Are you delinquent on child support payment for your children? |_| Yes |_| No |_| N/A
Family: List in the order given, showing the relationships – Parents, Guardians, Stepparents, Foster Parents, Parents’-in-law, Brothers/Sisters (even though deceased). Include any others you have resided with or with whom a close relationship existed or exists. Include fiancé/fiancée or roommates, if any. Use attachment sheet if necessary.
Name: Address:
Education (List all diplomas, degrees and/or certifications and where obtained)
High School Attended:
|_| Obtained a GED: Date of GED: _______________________________
Accredited College or Universities Attended: |_| N/A
Degree |_| Yes |_| No Degree Type & Year _____________________ Courses Studied/Major
GPA School City/State
Dates attended / / to / /
GPA School City/State
Dates attended / / to / /
GPA School City/State
Dates attended / / to / /
School ____________________________________ City/State _________________________________________________
Type:_______________________________________________________________________________ Date:______________
Type:_______________________________________________________________________________ Date:______________
Are you currently attending a college/university or taking any training or continuing education classes? |_| Yes |_| No
If yes, which college/university are you presently attending?
What is the purpose of your current training or class?
Have you ever been expelled, suspended or placed on academic probation from any school attended? |_| Yes |_| No
If yes, explain:
_______________________________________________________________________________________________________
Special skills/talents/qualifications: List all special skills, unique licenses, aptitudes, qualifications or foreign languages you speak, read or write. Include office skills, computer skills or other skills that you believe would be beneficial to this department.
Awards, scholarships or special recognitions: List all awards, scholarships or recognitions you received at school, work or for public service:
Organizations: List past and/or present memberships:
Name and Location Type (social, Office(s) Membership Dates
Professional, Held From To
/ /
/ /
/ /
/ /
/ /
/ /
Residences: List all residences, including military and school addresses for the past TEN (10) years. Begin with your present address and go back in chronological order. Use additional sheet if necessary.
Date / From: / To: PRESENT Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
REFERENCES
List a minimum of six (6) persons who know you well enough to provide current information about you. DO NOT USE ANYONE LISTED IN THE ABOVE “FAMILY INFORMATION” section. Include city, state and ZIP code. All information in the section below is required, not optional.
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Section - D
BACKGROUND INFORMATION
Drug and Narcotic Usage: This section covers usage of any controlled substance, dangerous drug, inhalant, marijuana or any illegal drug not prescribed to you by your physician. Usage is the introduction of a substance into your body, through experimentation, snorting, smoking, ingestion, injection, huffing, tasting, trying or via any other means.
Have you ever used any drugs/narcotics illegally? |_| Yes |_| No
If yes, complete the following section.
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
Have you ever bought or sold any illegal drugs/narcotics? |_| Yes |_| No If yes, list the date(s) and details of the incident(s).
Have you ever manufactured any illegal drugs/narcotics? |_| Yes |_| No If yes, list the date(s) and details of the incident(s).
Military Information
Have you served in any branch of the Armed Forces? |_| Yes |_| No If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:
Did you leave the service and then re-enlist? |_| Yes |_| No If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:_________________________________________________________________________
Have you served in any foreign Armed Services? |_| Yes |_| No If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:_________________________________________________________________________
Have you ever been rejected by any branch of the Armed Services for a non-medical reason? |_| Yes |_| No
Date of rejection: ______________
_________________________________________________________________________________________________________
Were you ever disciplined while in military service? (court martial, captain’s masts, company punishment etc.) |_| Yes |_| No
Date: ________________
Charge: __________________________________________________________________________________________________
Disposition: _________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Criminal Activity
Have you ever been arrested by a law enforcement agency? |_| Yes |_| No If yes, complete the following section.
Date of Arrest: ____________ Charge: __________________________________________________________
Conviction Date: ____________
Dismissal Date: _____________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Conviction Date: ____________
Dismissal Date: _____________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you ever been questioned, detained, interrogated, indicted, or charged with a crime by a law enforcement agency?
|_| Yes |_| No If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
Have you ever been banned from or asked to leave any business, school, private residence or other establishment for disturbing the peace or criminal trespass?
|_| Yes |_| No If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
Have you ever been convicted of a crime, placed on court ordered community supervision, or probation? |_| Yes |_| No
If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
Have you or your spouse ever been a party to a civil or criminal action? |_| Yes |_| No
If yes, list the date, reason and disposition of the incident(s). Provide copies of any applicable paperwork for each event.
Have you ever been the subject of a police inquiry into any incidence of family violence? |_| Yes |_| No
If yes, explain.
Have you ever committed a crime in which you were not caught? |_| Yes |_| No
Details: _________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been issued a citation for a non-traffic violation? |_| Yes |_| No If yes, list the date(s), reason(s) and disposition(s) of the incident(s).
DATE VIOLATION CITY/STATE DISPOSITION
Law Enforcement Experience
Are you currently a licensed Peace Officer? |_| Yes |_| No If yes, what state?
Have you ever been employed as a Peace Officer? |_| Yes |_| No If yes, what state?
Have you ever worked as a Reserve Police Officer? |_| Yes |_| No
Have you ever served as a Military Police Officer? |_| Yes |_| No
Have you ever been employed as a Security Officer? |_| Yes |_| No
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been investigated for any violation of Federal law |_| Yes |_| No If yes explain below:
in the course and scope of performing your job as a police officer,
security officer, jailer/ corrections officer, military police officer
(Tort claims, Civil Rights Violations, causing injuries, etc.)?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Do you have any prior or pending Civil Rights actions filed against |_| Yes |_| No If yes explain below:
you while acting in a law enforcement environment?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
If yes to any of the above questions, has your peace officer’s license, jailer/correction officer certification or security officer
certification ever been revoked or suspended? |_| Yes |_| No
Have you ever taken part in a law enforcement internship program? |_| Yes |_| No
If yes, list agency and date(s):
Have you ever applied for a position with another law enforcement agency? |_| Yes |_| No
If yes, complete the following information:
NAME OF AGENCY POSITION DATE OF STATUS OF
APPLICATION APPLICATION
Section - E
DRIVING HISTORY
List all states where you currently possess a driver’s license or have possessed a driver’s license. Include the state and license number. Begin with your current driver’s license.
STATE LICENSE NUMBER EXPIRATION DATE
_________ _________________ ________________
_________ _________________ ________________
_________ _________________ ________________
Citations:
How many moving violations have you received since you began driving? ____________
How many moving citations have you received in the past (5) years? ____________
List all traffic citations (speeding, stop sign, etc.) including red light camera violations which have been issued to you in the last five (5) years. Include the disposition of the citation(s) – deferred adjudication, defensive driving, found not guilty by the court, paid fine, etc. Use attachment sheet if necessary.
DATE VIOLATION CITY/STATE DISPOSITION
Accidents:
How many motor vehicle accidents have you been involved in as a driver? ____________
List all traffic accidents that you have been involved in as the driver in the last five (5) years.
DATE VIOLATION AT FAULT CITY/STATE DISPOSITION
________ ____________________ |_|Yes |_|No ________________________ _____________________________
________ ____________________ |_|Yes |_|No ________________________ _____________________________
________ ____________________ |_|Yes |_|No ________________________ _____________________________
________ ____________________ |_|Yes |_|No ________________________ _____________________________
General driving information:
_____________________________________________________________________________________________________
Has your driver’s license ever been suspended or revoked? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had your driver’s license placed on probation for receiving an excessive number of
traffic citations? |_|Yes |_|No
_____________________________________________________________________________________________________
Have you ever had a hearing for probation/suspension, etc.? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever driven a motor vehicle after your driver’s license was suspended or after it had been
revoked? |_|Yes |_|No
_____________________________________________________________________________________________________
Have you ever been involved in an accident and then left the accident scene without identifying yourself? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever struck an unattended vehicle and then left without leaving your identification? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had your insurance revoked due to the number of traffic citations you have received? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever been placed as an assigned risk for vehicle insurance? |_|Yes |_|No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you have a valid driver’s license in more than one state? |_|Yes |_|No
Details: ______________________________________________________________________________________________
Section - F
EMPLOYMENT HISTORY
Have you ever been discharged, fired, asked to resign, furloughed, put on inactive status or given unpaid leave because of disciplinary action?
|_| Yes |_| No
If yes, explain:
Have you ever resigned or quit to avoid being discharged, terminated or fired? |_| Yes |_| No
If yes, explain:
Have you ever been the subject of an administrative investigation by a former employer regarding any type of misconduct?
|_| Yes |_| No
If yes, explain:
Have you previously applied for a job with the Tarrant County College District? |_| Yes |_| No
If yes, when and for what position?
Once assigned to a background investigator, may we contact your current employer? |_| Yes |_| No |_| N/A
If no, explain:
Would you like an investigator to notify you before contacting your current employer? |_| Yes |_| No |_| N/A
Beginning with your current or most recent job, list all jobs you have held in the past ten (10) years, including military service, all part-time, temporary or seasonal employment, and periods of unemployment (including school). Use attachment sheet if necessary.
From: / To: / Supervisor’s Name:
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Section - G
PERSONAL DECLARATIONS
Are there any incidents in your life not mentioned herein which may reflect upon your suitability to
perform the duties of the position for which you are applying that might require further explanation?
|_|Yes |_| No If yes, explain:
If selected for this position are you able to work all shifts, weekends, holidays, midnights and
understand that you may be assigned to any campus within the Tarrant County College District
based on the needs of the department? |_|Yes |_| No If no explain:
If necessary, could you use physical force in the course and scope of performing your duties as a
security officer? |_|Yes |_| No If yes, explain:
Section - H
CERTIFICATION STATEMENT
I certify that there are NO MISREPRESENTATIONS, FALSIFICATIONS OR OMISSIONS in the foregoing statements and answers. All entries are true, complete and correct. I agree and consent in advance to being rejected for employment and understand that if hired, I may be discharged, if any of the information provided contains any misrepresentations, falsifications or if any material information has been omitted.
I further agree that if I fail any portion of the hiring process or I am not hired, that the Tarrant College District Police Department will not discuss with me the reason for me not being selected or hired. If the issue is of a temporary nature I will be notified that I am eligible to re-apply.
I certify that I am not related by blood or marriage to any member of the Tarrant County College District Police Department.
Signature of Applicant
Date of preparation
Tarrant
County
College
District