TEXA
AS TECH PO
OLICE DEPAR
RTMEN
NT
PER
RSONA
AL HIS
STORY
Y STAT
TEMEN
NT
NAME
E:______
_______
________
_______
_______
________
_____
DATE
E ISSUED
D:_____
________
_______
________
_______
_____
a
g for:
I am applying
[ ]
Police
P
Officer PIID#____
________
______
[ ]
Lead
L
Operator PID#____
P
_______
______
[ ]
Guard
G
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
this agency.
READ THESE INSTRUCTIONS CAREFULLY BEFORE PROCEEDING! It is essential that all
instructions be followed exactly and that complete and accurate answers are given for each question. The
Personal History Statement will be used as a basis for a background investigation that will determine your
eligibility to proceed to the interview stage of the hiring process.
1. Your Personal History Statement must be printed legibly in BLACK INK, by the applicant.
Answer all questions truthfully and accurately.
2. If a question is not applicable 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 accurate and in proper sequence before you begin.
4. YOU ARE RESPONSIBLE for obtaining all correct and complete names, addresses and
phone numbers (INCLUDING zip codes and area codes) where requested. If you are not
sure of your information, verify it personally before submitting your Personal History
Statement.
5. If there is not sufficient space on the form for your answers, attach additional sheet or sheets
as needed. Be sure that each additional sheet references the section, question number, and
page number.
6. An accurate and complete form will help expedite your investigation. Omissions or
Falsifications will result in your Automatic Disqualification from the hiring process.
7. Any candidate submitting an incomplete application WILL NOT BE CONSIDERED FOR
EMPLOYMENT. Your application will be evaluated on completeness and neatness.
8. An Authorization to Release Information form must be read, filled in, signed and notarized in
order for the background investigator to obtain the necessary information needed. This form
is required by the Texas Commission on Law Enforcement Standards and Education.
9. All of the following ORIGINAL documents must be submitted with the Personal History
Statement:
A. Original Certified copy of your Birth Certificate.
B. Social Security Card
C. Valid Class C Texas Driver’s License
D. Current Vehicle Liability Insurance Policy/Card
E. High School Transcripts or Diploma
F. Cre dit Report
G. Colle ge Transcripts
H. Marriage Certificate- If Applicable
I. Dissolution of Marriage Decree- If Applicable
J. Military Discharge Papers- DD214 (All copies including Member 4)
K. Naturalization Papers- If Applicable
Photo copies of the above documents will be made at the time the paperwork is turned in and the
originals will be given back to the applicant. If original copies are not available, a letter showing that the
originals have been ordered will be accepted. The original will need to be shown to the Administrative
Captain or the background Investigator before an interview will be granted.
Page 1 of 20
Applicant Qualification Section Before you begin to fill out this Personal History Statement, please ensure that you have read and understand the following: ALL APPLICANTS Initials _________ Once you have submitted your documentation, you will no longer have access to it. _________ I have answered every question completely. _________ I have provided all required documents or proof of documentation ordered. _________ I have added supplemental pages where necessary for additional information. _________ I have contacted the Texas Tech Police Department to clarify any questions I may have. _________ I have included all names, addresses and phone numbers in my PHS. _________ I understand that any omission, falsification, or any other facts in my Personal History Statement that I have intentionally or not intentionally left out is grounds for disqualification. POLICE OFFICER AND LEAD OPERATOR APPLICANTS ONLY Initials ________ I have never been convicted, pledguilty (noloconƚendereͿ͕norhave I beenon courƚ‐
ordered community service/probation or deferred adjudication for a Class A misdemeanor or a felony ________ During the last ten (10) years, I have not been convicted, pled guiůty(noloconƚendereͿ,
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 convicted of any family violence offense. ________ discharge. I have never had a military court martial that resulted in a dishonorable or bad conduct ________ I am eligible for rehire by other law enforcement agencies that I have previously worked for (Automatic Disqualifier). Page 2 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
NAME: FIRST
POLICE OFFICER APPLICANT - PERSONAL BACKGROUND INFORMATION
MIDDLE
MAIDEN
SOCIAL SECURITY NUMBER
ADDRESS:
LAST
DATE OF BIRTH (MM/DD/YYYY)
STREET AND NUMBER
WORK ADDRESS:
STREET AND NUMBER
HOME PHONE
OTHER NAMES AND NICKNAMES
CITY
STATE
ZIP
CITY
STATE
ZIP
WORK PHONE
DRIVERS LICENSE NUMBER
CELL PHONE
STATE
CLASS
DATE OF EXPIRATION (MM/DD/YY)
OTHER NAMES USED
List all previous names that have been used due to marriage or legal name change.
RACE
HAIR
PHYSICAL DESCRIPTION
SEX
HEIGHT
SCARS
CHECK ALL THAT APPLY:
WEIGHT (LBS)
EYES
OTHER DISTINGUISHING FEATURES
BASIC
MASTER
TCLEOSE CERTIFICATION
INTERMEDIATE
INSTRUCTOR
ADVANCED
POLICE ACADEMY ATTENDED
DATE LICENSED FROM TCLEOSE
DATE OF COMPLETION
ADDRESS
CITY
NAME OF ACADEMY DIRECTOR
STATE
ZIP
PHONE NUMBER
TCLEOSE Personal Identification Number (PID #)
Page 3 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
MARITAL STATUS
List all information below if you are or have been married, divorced, widowed, engaged, separated or living with someone. List all marriages that
resulted in separation, divorce, or being widowed. Make a copy of this page if more than one person is listed. LIST ALL CURRENT AND FORMER
SPOUSES. THIS ALSO APPLIES TO YOUR CURRENT STATUS.
CHECK ALL THAT APPLY:
SINGLE
MARRIED
DIVORCED
WIDOWED
ENGAGED
SEPARATED
LIVING WITH SOMEONE
NAME OF SPOUSE: FIRST
MIDDLE
MAIDEN
LAST
ADDRESS:
STREET AND NUMBER
PLACE OF MARRIAGE:
CITY
CITY
PHONE NUMBER
DATE OF BIRTH
STATE
COUNTY
LIVING
PLACE OF BIRTH
DECEASED
CITY
STATE
DATE OF MARRIAGE (MM/DD/YY)
DATE OF DEATH
STATE
OCCUPATION
CURRENT OR FORMER EMPLOYER
DATE OF DIVORCE (MM/DD/YY)
REASON (S) FOR MARRIAGE BEING DISSOLVED
ZIP
COUNTRY
MARITAL STATUS (Cont.)
CHECK ALL THAT APPLY:
NAME OF SPOUSE: FIRST
ADDRESS:
SINGLE
MARRIED
ENGAGED
SEPARATED
MIDDLE
DIVORCED
LIVING WITH SOMEONE
MAIDEN
WIDOWED
CITY
STATE
STREET AND NUMBER
PLACE OF MARRIAGE:
CITY
PHONE NUMBER
DATE OF BIRTH
STATE
LIVING
PLACE OF BIRTH
CITY
COUNTY
DECEASED
STATE
OCCUPATION
CURRENT OR FORMER EMPLOYER
DATE OF DIVORCE (MM/DD/YY)
REASON (S) FOR MARRIAGE BEING DISSOLVED
CHILD SUPPORT
Do you pay child support?
LAST
ZIP
DATE OF MARRIAGE (MM/DD/YY)
DATE OF DEATH
COUNTRY
YES
NO
Page 4 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
NAME: FIRST
ADDRESS:
LIVING
ADDRESS:
CITY
MIDDLE
MIDDLE
DECEASED
ZIP
TELEPHONE NUMBER
RELATIONSHIP
STATE
ZIP
DATE OF BIRTH
TELEPHONE NUMBER
FATHER (Stepfather and/or Guardian)
LAST
DATE OF DEATH
PHONE NUMBER
CITY
PLACE OF BIRTH
OCCUPATION
DATE OF BIRTH
RELATIONSHIP
LAST
STREET AND NUMBER
DATE OF BIRTH
DATE OF BIRTH
TELEPHONE NUMBER
ZIP
STATE
CITY
TELEPHONE NUMBER
RELATIONSHIP
STATE
CITY
MIDDLE
ZIP
LAST
STREET AND NUMBER
NAME: FIRST
STATE
LAST
STREET AND NUMBER
NAME: FIRST
ADDRESS:
MIDDLE
STREET AND NUMBER
NAME: FIRST
ADDRESS:
CITY
DATE OF BIRTH
RELATIONSHIP
LAST
STREET AND NUMBER
NAME: FIRST
ADDRESS:
CHILDREN OR DEPENDENTS (Include partial dependents)
MIDDLE
CITY
STATE
STATE
ZIP
COUNTRY
CURRENT OR FORMER EMPLOYER
EMLOYER ADDRESS
NAME: FIRST
LIVING
ADDRESS:
MIDDLE
DECEASED
MOTHER (Stepmother and/or Guardian)
LAST
DATE OF DEATH
STREET AND NUMBER
DATE OF BIRTH
OCCUPATION
PHONE NUMBER
CITY
PLACE OF BIRTH
CITY
STATE
STATE
ZIP
COUNTRY
CURRENT OR FORMER EMPLOYER
EMLOYER ADDRESS
Page 5 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
NAME: FIRST
ADDRESS:
ADDRESS:
LIVING
MIDDLE
STATE
CITY
LAST
STATE
TELEPHONE NUMBER
TELEPHONE NUMBER
DATE OF BIRTH
ZIP
RELATIONSHIP
CITY
TELEPHONE NUMBER
DATE OF BIRTH
ZIP
TELEPHONE NUMBER
FATHER-IN-LAW
MIDDLE
DECEASED
ZIP
STATE
DATE OF BIRTH
DATE OF BIRTH
RELATIONSHIP
LAST
MIDDLE
ZIP
RELATIONSHIP
CITY
LAST
DATE OF DEATH
PHONE NUMBER
STREET AND NUMBER
DATE OF BIRTH
STATE
LAST
STREET AND NUMBER
NAME: FIRST
ADDRESS:
MIDDLE
STREET AND NUMBER
NAME: FIRST
ADDRESS:
CITY
STREET AND NUMBER
NAME: FIRST
RELATIONSHIP
LAST
STREET AND NUMBER
NAME: FIRST
ADDRESS:
BROTHERS AND SISTERS (Including half, step, and adopted)
MIDDLE
CITY
PLACE OF BIRTH
CITY
STATE
STATE
ZIP
COUNTRY
CURRENT OR FORMER EMPLOYER
OCCUPATION
EMLOYER ADDRESS
NAME: FIRST
LIVING
ADDRESS:
MOTHER-IN-LAW
MIDDLE
DECEASED
LAST
DATE OF DEATH
STREET AND NUMBER
DATE OF BIRTH
OCCUPATION
PHONE NUMBER
CITY
PLACE OF BIRTH
CITY
STATE
STATE
ZIP
COUNTRY
CURRENT OR FORMER EMPLOYER
EMLOYER ADDRESS
Page 6 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
CHECK ALL THAT APPLY:
HIGH SCHOOL DIPLOMA
ASSOCIATES DEGREE
HIGH SCHOOL (S) : Name and Address of School
EDUCATION
HOME SCHOOL DIPLOMA
BACHELOR DEGREE
HIGH SCHOOL
GED
MASTERS DEGREE
PHONE NUMBER
PHONE NUMBER
HIGH SCHOOL (S) : Name and Address of School
DID YOU GRADUATE
YES
NO
COLLEGE
COLLEGE: Name and Address of School (1)
PHONE NUMBER
COLLEGE: Name and Address of School (2)
TOTAL HOURS
GRADUATED
COLLEGE 1
YES
NO
OTHER EDUCATION
DEGREE EARNED
PHONE NUMBER
GRADUATED
COLLEGE 2
YES
NO
TOTAL HOURS
DEGREE EARNED
DO YOU HAVE ANY STUDENT LOANS
YES
NO
HAVE YOU EVER BEEN LATE PAYING A STUDENT LOAN OR ARE YOU CURRENTLY LATE ON PAYING A
STUDENT LOAN?
YES
NO
Are you registered for the Selective Service?
To check selective service registration go to
www.sss.gov. Print a copy and attach to application.
BRANCH OF SERVICE
TYPE OF DISCHARGE
HONORABLE
GENERAL
MILITARY
YES
OTHER THAN HONORABLE
NO
NOT REQUIRED
Selective Service Number
FROM
BAD CONDUCT
DISHONORABLE
TO
RANK
ARE YOU CURRENTLY ENLISTED IN ONE OF THE FOLLOWING?
MILITARY RESERVE
NATIONAL GUARD
OTHER If checked, list unit, supervisor name, location, phone number and date obligation ends:
UNIT
SUPERVISOR NAME
LOCATION
PHONE NUMBER
Page 7 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
RESIDENCES
List all residences for the past ten (10) years. Do not use P.O. Boxes.
ADDRESS (APT#)
CITY
STATE
APARTMENT COMPLEX PHONE #
STATE
STATE
ZIP
FROM
STATE
APARTMENT COMPLEX PHONE #
TO
ZIP
ROOMMATES NAME AND PHONE #
FROM
ADDRESS (APT#)
STATE
APARTMENT COMPLEX PHONE #
TO
ZIP
ROOMMATES NAME AND PHONE #
ADDRESS (APT#)
APARTMENT COMPLEX PHONE #
TO
ROOMMATES NAME AND PHONE #
ADDRESS (APT#)
CITY
ZIP
FROM
APARTMENT COMPLEX PHONE #
CITY
TO
ROOMMATES NAME AND PHONE #
ADDRESS (APT#)
CITY
ZIP
FROM
APARTMENT COMPLEX PHONE #
CITY
PRESENT
ROOMMATES NAME AND PHONE #
ADDRESS (APT#)
CITY
FROM
FROM
STATE
TO
ZIP
ROOMMATES NAME AND PHONE #
Page 8 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
WORK HISTORY
Beginning with your present or most recent job, list all employment for the past ten (10) years including part-time, self-employment, temporary or
seasonal jobs. Include the month and year of the beginning and ending of every job or period of unemployment. For periods of self-employment,
list the type of work you were engaged in along with the names, addresses and phone numbers of customers and/or suppliers who can verify
your self employment. Indicate anything else that you were doing during that time period.
FROM
TO
COMPANY NAME OR EMPLOYER
ADDRESS:
STREET AND NUMBER
TELEPHONE NUMBER
JOB TITLE
SUPERVISOR NAME
CITY
STATUS:
FULL TIME
DISCIPLINED AT
WORK?
YES
NO
PART TIME
STATE
VOLUNTEER
COUNSELED
SUSPENDED
LEAVE WITH PAY
TEMP
ZIP
SELF-EMPLOYED
UNEMPLOYED
WHY DID YOU LEAVE THIS JOB?
RESIGNED/QUIT
TERMINATED/FIRED
RETIRED
LAID OFF
OTHER
SUPERVISOR’S PHONE NUMBER
CO-WORKER’S PHONE NUMBER
CO-WORKER NAME
REASON FOR LEAVING
FROM
ADDRESS:
TO
COMPANY NAME OR EMPLOYER
STREET AND NUMBER
TELEPHONE NUMBER
JOB TITLE
SUPERVISOR NAME
CITY
STATUS:
FULL TIME
DISCIPLINED AT
WORK?
YES
NO
PART TIME
STATE
VOLUNTEER
TEMP
ZIP
SELF-EMPLOYED
UNEMPLOYED
WHY DID YOU LEAVE THIS JOB?
RESIGNED/QUIT
TERMINATED/FIRED
RETIRED
LAID OFF
OTHER
SUPERVISOR’S PHONE NUMBER
COUNSELED
SUSPENDED
LEAVE WITH PAY
CO-WORKER NAME
CO-WORKER’S PHONE NUMBER
REASON FOR LEAVING
FROM
ADDRESS:
TO
COMPANY NAME OR EMPLOYER
STREET AND NUMBER
TELEPHONE NUMBER
JOB TITLE
SUPERVISOR NAME
CO-WORKER NAME
CITY
STATUS:
FULL TIME
DISCIPLINED AT
WORK?
YES
NO
PART TIME
STATE
VOLUNTEER
COUNSELED
SUSPENDED
LEAVE WITH PAY
TEMP
ZIP
SELF-EMPLOYED
UNEMPLOYED
WHY DID YOU LEAVE THIS JOB?
RESIGNED/QUIT
TERMINATED/FIRED
RETIRED
LAID OFF
OTHER
SUPERVISOR’S PHONE NUMBER
CO-WORKER’S PHONE NUMBER
REASON FOR LEAVING
Page 9 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
FROM
ADDRESS:
TO
COMPANY NAME OR EMPLOYER
STREET AND NUMBER
TELEPHONE NUMBER
JOB TITLE
SUPERVISOR NAME
CITY
STATUS:
FULL TIME
DISCIPLINED AT
WORK?
YES
NO
PART TIME
STATE
VOLUNTEER
COUNSELED
SUSPENDED
LEAVE WITH PAY
TEMP
ZIP
SELF-EMPLOYED
UNEMPLOYED
WHY DID YOU LEAVE THIS JOB?
RESIGNED/QUIT
TERMINATED/FIRED
RETIRED
LAID OFF
OTHER
SUPERVISOR’S PHONE NUMBER
CO-WORKER’S PHONE NUMBER
CO-WORKER NAME
REASON FOR LEAVING
FROM
ADDRESS:
TO
COMPANY NAME OR EMPLOYER
STREET AND NUMBER
TELEPHONE NUMBER
JOB TITLE
SUPERVISOR NAME
CITY
STATUS:
FULL TIME
DISCIPLINED AT
WORK?
YES
NO
PART TIME
STATE
VOLUNTEER
COUNSELED
SUSPENDED
LEAVE WITH PAY
CO-WORKER NAME
TEMP
ZIP
SELF-EMPLOYED
UNEMPLOYED
WHY DID YOU LEAVE THIS JOB?
RESIGNED/QUIT
TERMINATED/FIRED
RETIRED
LAID OFF
OTHER
SUPERVISOR’S PHONE NUMBER
CO-WORKER’S PHONE NUMBER
REASON FOR LEAVING
UNEMPLOYMENT
LIST ALL PREVIOUS PERIODS OF UNEMPLOYMENT DURING THE PAST TEN (10) YEARS IF UNEMPLOYED FOR A PERIOD OF MORE THAN 30
DAYS.
FROM
TO
REASON
FROM
TO
REASON
FROM
TO
REASON
FROM
TO
REASON
FROM
TO
REASON
Page 10 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
PREVIOUS LAW ENFORCEMENT AGENCIES
LIST ALL PREVIOUS LAW ENFORCEMENT AGENCIES THAT YOU HAVE WORKED FOR.
FROM
ADDRESS:
TO
STREET AND NUMBER
TELEPHONE NUMBER
FROM
ADDRESS:
TO
ADDRESS:
TO
ADDRESS:
TO
ADDRESS:
TO
ADDRESS:
TO
TEMP
CITY
STATUS:
FULL TIME
PART TIME
ZIP
RETIRED
RESERVE
STATE
TEMP
ZIP
RETIRED
COMPANY NAME OR EMPLOYER
CITY
STATUS:
FULL TIME
PART TIME
RESERVE
STATE
TEMP
ZIP
RETIRED
COMPANY NAME OR EMPLOYER
CITY
STATUS:
FULL TIME
PART TIME
RESERVE
STATE
TEMP
ZIP
RETIRED
COMPANY NAME OR EMPLOYER
CITY
STATUS:
FULL TIME
PART TIME
RESERVE
STATE
TEMP
ZIP
RETIRED
COMPANY NAME OR EMPLOYER
STREET AND NUMBER
TELEPHONE NUMBER
RESERVE
STATE
COMPANY NAME OR EMPLOYER
STREET AND NUMBER
TELEPHONE NUMBER
FROM
PART TIME
STREET AND NUMBER
TELEPHONE NUMBER
FROM
STATUS:
FULL TIME
STREET AND NUMBER
TELEPHONE NUMBER
FROM
CITY
STREET AND NUMBER
TELEPHONE NUMBER
FROM
COMPANY NAME OR EMPLOYER
CITY
STATUS:
FULL TIME
PART TIME
RESERVE
STATE
TEMP
ZIP
RETIRED
Page 11 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
REFERENCES
List five (5) references. DO NOT duplicate references listed as relatives, employers or co-workers
CELL PHONE NUMBER
NAME: FIRST
MIDDLE
LAST
OFFICE PHONE NUMBER
ADDRESS:
HOME PHONE NUMBER
STREET AND NUMBER
NAME: FIRST
ADDRESS:
ADDRESS:
MIDDLE
LAST
CITY
MIDDLE
STREET AND NUMBER
NAME: FIRST
LAST
CITY
STREET AND NUMBER
NAME: FIRST
ADDRESS:
MIDDLE
STREET AND NUMBER
NAME: FIRST
ADDRESS:
CITY
LAST
CITY
MIDDLE
STREET AND NUMBER
LAST
CITY
STATE
ZIP
CELL PHONE NUMBER
STATE
ZIP
CELL PHONE NUMBER
STATE
ZIP
CELL PHONE NUMBER
STATE
ZIP
CELL PHONE NUMBER
STATE
ZIP
OFFICE PHONE NUMBER
HOME PHONE NUMBER
OFFICE PHONE NUMBER
HOME PHONE NUMBER
OFFICE PHONE NUMBER
HOME PHONE NUMBER
OFFICE PHONE NUMBER
HOME PHONE NUMBER
NEIGHBORS
List three (3) neighbors at your current (last) normal residence. If you have lived in your current residence for less than 1 month list neighbors from
previous residence.
NAME: FIRST
MIDDLE
LAST
CELL PHONE NUMBER OFFICE PHONE NUMBER
ADDRESS:
STREET AND NUMBER
NAME: FIRST
ADDRESS:
MIDDLE
STREET AND NUMBER
NAME: FIRST
ADDRESS:
CITY
CITY
MIDDLE
STREET AND NUMBER
LAST
LAST
CITY
STATE
ZIP
CELL PHONE NUMBER
STATE
ZIP
CELL PHONE NUMBER
STATE
PROFESSIONAL SOCIETIES AND ORGANIZATIONS
ZIP
HOME PHONE NUMBER
OFFICE PHONE NUMBER
HOME PHONE NUMBER
OFFICE PHONE NUMBER
HOME PHONE NUMBER
NAME
ADDRESS- STREET ADDRESS, CITY, STATE AND ZIP CODE
DATES OF MEMBERSHIP
NAME
ADDRESS- STREET ADDRESS, CITY, STATE AND ZIP CODE
DATES OF MEMBERSHIP
NAME
ADDRESS- STREET ADDRESS, CITY, STATE AND ZIP CODE
DATES OF MEMBERSHIP
Page 12 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
CRIMINAL RECORD
List all arrests, detentions or contacts with a police agency where you have been a suspect or person of interest. List the date, police department, city
and state and types of charges.
DATE
AGENCY
CITY AND STATE
CHARGES
DATE
CHARGES
DATE
CHARGES
DATE
CHARGES
FINAL DISPOSITION
GUILTY
NOT GUILTY
FINED
AGENCY
DEFERRED
DISMISSED
CITY AND STATE
FINAL DISPOSITION
GUILTY
NOT GUILTY
FINED
AGENCY
DEFERRED
DISMISSED
CITY AND STATE
FINAL DISPOSITION
GUILTY
NOT GUILTY
FINED
DEFERRED
DISMISSED
CITY AND STATE
AGENCY
FINAL DISPOSITION
GUILTY
NOT GUILTY
FINED
DEFERRED
DISMISSED
TRAFFIC CITATIONS
List all traffic citations that you have received for the past ten (10) years.
AGENCY
DATE
CHARGES
DATE
CHARGES
DATE
CHARGES
DATE
CHARGES
DATE
CHARGES
FINAL DISPOSITION
GUILTY
NOT GUILTY
CITY AND STATE
FINED
FINED
AGENCY
FINAL DISPOSITION
GUILTY
NOT GUILTY
FINED
DISMISSED
DEFERRED
DISMISSED
CITY AND STATE
FINED
DEFERRED
DISMISSED
CITY AND STATE
AGENCY
FINAL DISPOSITION
GUILTY
NOT GUILTY
DEFERRED
CITY AND STATE
AGENCY
FINAL DISPOSITION
GUILTY
NOT GUILTY
DISMISSED
CITY AND STATE
AGENCY
FINAL DISPOSITION
GUILTY
NOT GUILTY
DEFERRED
FINED
DEFERRED
DISMISSED
Page 13 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
TRAFFIC ACCIDENTS
List all traffic accidents that you were involved in for the past ten (10) years.
DATE
AGENCY
FINAL DISPOSITION
GUILTY
NOT GUILTY
DEFERRED
DISMISSED
CHARGES
DATE
FINAL DISPOSITION
GUILTY
NOT GUILTY
DEFERRED
DISMISSED
DATE
FINAL DISPOSITION
GUILTY
NOT GUILTY
DEFERRED
DISMISSED
AGENCY
CHARGES
REPORTED TO LAW ENFORCEMENT.
YES
NO
FINED
WERE YOU AT FAULT
YES
NO
REPORTED TO LAW ENFORCEMENT.
YES
NO
FINED
WERE YOU AT FAULT
YES
NO
CITY AND STATE
AGENCY
CHARGES
WERE YOU AT FAULT
YES
NO
CITY AND STATE
AGENCY
CHARGES
DATE
CITY AND STATE
REPORTED TO LAW ENFORCEMENT.
YES
NO
FINED
CITY AND STATE
FINAL DISPOSITION
GUILTY
NOT GUILTY
DEFERRED
DISMISSED
WERE YOU AT FAULT
YES
NO
REPORTED TO LAW ENFORCEMENT.
YES
NO
FINED
DRIVERS LICENSE HELD
List all states and license numbers for states in which you have held a driver license or permit to learn to drive a motor vehicle.
DRIVER LICENSE NUMBER
STATE
STATE
DRIVER LICENSE NUMBER
STATE
DRIVER LICENSE NUMBER
DRIVERS LICENSE SUSPENSIONS, REVOCATION, DENIALS, PROBATIONS
If your driver license has ever been suspended, revoked, cancelled or denied, or your driving privilege probated, list the date, state and reason for such
action.
REASON
STATE
DATE
DATE
STATE
REASON
DATE
STATE
REASON
CIVIL SUITS
List all civil suits in which you have been a defendant and include dates and disposition. (e.g., small claims actions, dissolutions, child custody, paternity,
support, etc)
REASON
DATE
DISPOSITION
REASON
DATE
DISPOSITION
REASON
DATE
DISPOSITION
Page 14 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
GENERAL QUALIFICATIONS
Are you now or have you ever been a licensed or certified member of any trade or
profession, such as a Pilot, Electrician, Radio Operator, Teacher, Peace Officer,
etc. If you answered yes, list the certificate or license.
CERTIFICATE OR LICENSE
ISSUING AGENCY
CERTIFICATE OR LICENSE
ISSUING AGENCY
CERTIFICATE OR LICENSE
ISSUING AGENCY
YES
NO
OTHER QUALIFICATIONS
List any areas in which you have expertise, such as , Foreign Languages, Computer Software, Technical Equipment, etc.
COMPLAINTS & COMMENDATIONS
List any complaints and/or commendations you have received in the past five (5) years. Include date and findings.
COMPLAINT/COMMENDATION
DATE
DISPOSITION
COMPLAINT/COMMENDATION
DATE
DISPOSITION
COMPLAINT/COMMENDATION
DATE
DISPOSITION
COMPLAINT/COMMENDATION
DATE
DISPOSITION
FORMER TEXAS TECH POLICE DEPARTMENT EMPLOYEES
List all duty assignments you have had with the Texas Tech Police Department. Complete the following information.
LOCATION
DEPARTMENT
TO
FROM
SUPERVISOR
FROM
SUPERVISOR
TO
DEPARTMENT
LOCATION
Page 15 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
LAW ENFORCEMENT APPLICATIONS
Have you ever made application for employment with this or any other law
enforcement or related agency? If so, give the following information.
DATE APPLIED
YES
AGENCY
PHONE NUMBER
STATUS AND REASON IF NOT HIRED
ADDRESS
STEPS:
STATUS:
Application
Written
Physical agility
Oral
Hired
Not Hired
Currently In Application Process
DATE APPLIED
Polygraph
Withdrawn
Application
Written
Physical agility
Oral
Hired
Not Hired
Currently In Application Process
Polygraph
Withdrawn
AGENCY
Application
Written
Physical agility
Oral
Hired
Not Hired
Currently In Application Process
Polygraph
Withdrawn
Interview
Unknown
Conditional job offer
Background
Disqualified
Interview
Unknown
Conditional job offer
PHONE NUMBER
AGENCY
ADDRESS
STATUS AND REASON IF NOT HIRED
Application
Written
Physical agility
Oral
Hired
Not Hired
Currently In Application Process
DATE APPLIED
Polygraph
Withdrawn
AGENCY
Background
Disqualified
Interview
Unknown
Conditional job offer
PHONE NUMBER
ADDRESS
STATUS AND REASON IF NOT HIRED
Application
Written
Physical agility
Oral
Hired
Not Hired
Currently In Application Process
DATE APPLIED
Polygraph
Withdrawn
AGENCY
Background
Disqualified
Interview
Unknown
Conditional job offer
PHONE NUMBER
STATUS AND REASON IF NOT HIRED
ADDRESS
STEPS:
STATUS:
Background
Disqualified
STATUS AND REASON IF NOT HIRED
DATE APPLIED
STEPS:
STATUS:
Conditional job offer
PHONE NUMBER
ADDRESS
STEPS:
STATUS:
Interview
Unknown
STATUS AND REASON IF NOT HIRED
DATE APPLIED
STEPS:
STATUS:
Background
Disqualified
PHONE NUMBER
AGENCY
ADDRESS
STEPS:
STATUS:
NO
Application
Written
Physical agility
Oral
Hired
Not Hired
Currently In Application Process
Polygraph
Withdrawn
Background
Disqualified
Interview
Unknown
Conditional job offer
Page 16 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
GENERAL QUESTIONS: IF ANSWER IS YES, EXPLAIN ON LAST PAGE.
1. Have you ever been disciplined at work? (This includes written warnings, formal letters of counseling, reprimands,
suspensions, reductions in pay, reassignments or demotions)
2. Have you ever been fired, released during probation, or asked to resign from any place of employment?
3. Have you ever been involved in a physical/verbal altercation with a supervisor, co-worker, or customer?
4. Have you ever quit without giving proper notice?
5. Have you ever resigned in lieu of termination?
6. Have you ever been accused of discrimination (such as sexual harassment, racial bias, etc.) by a co-worker, superior,
subordinate or customer?
7. Have you ever been the subject of a written complaint at work?
8. Have you ever been counseled at work due to tardiness or absences?
9. Have you ever received an unsatisfactory performance evaluation?
10. Have you ever sold, released, or given away legally confidential information?
11. Have you ever used sick leave when you were neither sick nor caring for a sick family member?
If yes, how much sick leave have you used in the past five years, which was not due to illness? _______________
12. Have you ever been the subject of any judicial or non-judicial disciplinary action (such as, court martial, captain’s mast,
article 15, letters of reprimand, counseling, etc.)?
13. Have you EVER been detained for investigation, held on suspicion, questioned, arrested, indicted, criminally charged,
convicted of any misdemeanor or felony offense, or been on probation or parole in this state or in any other legal jurisdiction
(Including offenses punishable under the Uniform Code of Military Justice)?
14. Have you ever been fingerprinted for any reason?
15. Have you ever been a party in a civil lawsuit (e.g., small claims actions, dissolutions, child custody, paternity, support,
etc)?
16. Have the police ever been called to your home for any reason?
17. Have you or your spouse/partner ever been referred to Child Protective Services?
18. Have you ever been the subject of an emergency protective order/restraining order/stay-away order?
19. Have you settled any civil suit in which you, your insurance company, or anyone else on your behalf was required to
make payment to the other party?
20. Have you ever fraudulently received welfare, unemployment compensation, workers’ compensation, or other state or
federal assistance?
21. Have you filed a false insurance or workers’ compensation claim?
22. Have you ever applied for or been denied a handgun permit?
23. If it became necessary to take a human life in the course of your duties as a police officer, would any beliefs prevent you
from doing so?
24. Is there anything, which would prevent you from fully performing your duties including working weekends, evenings,
nights, and holidays?
DRIVERS LICENSE
25. Have you ever driven a vehicle without auto insurance, as required by law?
26. Has your driver’s license ever been placed on probation, suspended, revoked or in danger of suspension or revocation?
YES
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
NO
YES
YES
YES
NO
NO
NO
YES
NO
YES
YES
NO
NO
CRIMINAL ACTS
Within the past ten years OR at any time if you were employed in law enforcement, have you ever committed any of the following misdemeanors?
27. Assault
YES
28. Displaying a weapon or carrying an illegal weapon (illegal knife, club or handgun)
YES
29. Theft , Theft of Service, Intentionally Writing a Bad Check
YES
30. Driving While Under the Influence of Alcohol and/or drugs (DWLI or DWI)
YES
31. Hit and Run
YES
32. Public Intoxication
YES
33. Impersonating a Peace Officer
YES
34. Possession of Falsified or Altered Identification, including use of another person’s ID (for any reason)
YES
35. Possession of Alcohol by a Minor
YES
36. Possession of Stolen Property
YES
37. Resisting Arrest (including evading or eluding the police)
YES
38. Warrant issued for your arrest for any reason.
YES
39. Criminal Mischief or Trespassing
YES
40. Any felony
YES
ALCOHOL AND DRUGS
41. At anytime in your life have you EVER engaged in selling, cultivating, purchasing, manufacturing, furnishing or
possessing drugs, narcotics or illegal substances, including marijuana and steroids?
42. Have you ever used marijuana or any other drug not prescribed to you by a physician?
43. Have you ever been arrested or convicted for a drug-related offense?
44. In the past five years, have you missed days or been late to work due to drug or alcohol consumption?
45. Do you consume alcohol? And if so how frequently.
46. Are you currently using drugs illegally?
IF YOU ANSWERED YES TO ANY ONE OF THESE QUESTIONS PLEASE EXPLAIN IN THE NEXT SECTION.
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Page 17 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
ANSWERS TO GENERAL AND OTHER QUESTIONS
Question #
Explanation
If you answered yes to something that relates to an action towards you involving disciplinary action(s), complaints, legal action(s), Child Protective
Service complaints, litigation, and anything that you may think might influence our decision about your employment you must attach any and all
documentation to this Personal History Statement. A background investigator might ask for this or other paperwork which you may need to provide.
Page 18 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
PERSONAL DECLARATIONS
ARE THERE ANY INCIDENTS IN YOUR LIFE OR DETAIL NOT MENTIONED HEREIN
WHICH MAY INFLUENCE THIS AGENCY’S EVALUATION OF YOUR SUITABILITY
FOR EMPLOYMENT? IF YES EXPLAIN BELOW.
DESCRIBE ANY BELIEFS OR PRECEPTS YOU MAY HAVE WHICH WOULD
PREVENT YOU FROM PERFORMING THE DUTIES OF A LAW ENFORCEMENT
OFFICER INCLUDING WORKING WEEKENDS, EVENINGS, NIGHTS, AND
HOLIDAYS? IF YES EXPLAIN BELOW.
ARE YOU OR WILL YOU BE INVOLVED WITH ANY ACTIVITY THAT WILL
PREVENT YOU FROM TRAINING ON EVERY SHIFT FOR THE INITIAL TRAINING
PROGRAM IF YOU WERE TO BE HIRED. THIS INCLUDES BUT IS NOT LIMITED
TO ANY SCHOOL, TRAINING OR OTHER EMPLOYMENT. (INITIAL TRAINING
PROGRAM LASTS 6 WEEKS FOR GUARD/LEAD OPERATORS AND 15 WEEKS
FOR POLICE OFFICERS) SHIFT WORK IS WORKING THE FOLLOWING SHIFTS.
DAYS: 6AM-2PM, EVENINGS: 2PM-10PM, OR MIDNIGHTS: 10PM-6AM.
THIS INCLUDES SATURDAY, SUNDAY AND HOLIDAYS.
YES
NO
YES
NO
YES
NO
I CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND BELIEF, I HEREBY GRANT AUTHORIZATION TO THE TEXAS TECH POLICE DEPARTMENT TO
CONTACT ANY PERSON OR ORGANIZATION FOR INFORMATION AND/OR DOCUMENTS TO VERIFY THE
VALIDITY OF ANY PREVIOUS STATEMENT REGARDING MY PREVIOUS EMPLOYMENT, CHARACTER, AND
CONDUCT. I ALSO CERTIFY THAT I HAVE READ THE INSTRUCTIONS AND I AM AWARE THAT NOT
COMPLETING ALL INFORMATION AND TURNING IN THE REQUIRED DOCUMENTS COULD DISQUALIFY ME
FROM THE APPLICATION PROCESS.
SIGNED AT _____________________________________________________ DATE _________________________
(CITY)
_______________________________________________
(Signature of Applicant)
(STATE)
______________________________________________________
(Witness)
Page 19 of 20
TEXAS TECH POLICE OFFICER APPLICANT – PERSONAL HISTORY STATEMENT
APPLICANT INSTRUCTIONS: WRITE NAME ON LINE ABOVE. EVERYTHING BELOW THIS BOX IS TO BE FILLED OUT BY TEXAS TECH
DEPARTMENT PERSONNEL ONLY WHEN THE APPLICANT HAS TURNED IN THE PERSONAL HISTORY STATEMENT.
OFFICE USE ONLY
DATE:
REVIEWED BY:
INSTRUCTIONS FOR REVIEWER: VERIFY ALL DOCUMENTS ARE ORIGINAL OR A CERTIFIED TRUE COPY. MAKE PHOTOCOPIES OF ALL
ORIGINAL DOCUMENTS AND GIVE ORIGINAL DOCUMENTS BACK TO THE APPLICANT. CHECK YES IF THE PERSON HAS TURNED IN AN
ORIGINAL COPY. IF THE PERSON HAS NOT TURNED IN AN ORIGINAL COPY PLEASE CHECK THE ORIGINAL NEEDED BOX. IF THE PERSON
DOES NOT HAVE AN ORIGINAL PLEASE CHECK NO AND WRITE A COMMENT IN THE BLOCK STATING THE EXPLANATION FOR NOT HAVING
THE DOCUMENT.
BIRTH CERTIFICATE
DOCUMENT PROVIDED
Yes
No
Original Needed
SOCIAL SECURITY CARD
Yes
No
Original Needed
DRIVER’S LICENSE
Yes
No
Original Needed
VEHICLE LIABILITY INSURANCE POLICY
Yes
No
Original Needed
HIGH SCHOOL TRANSCRIPTS OR DIPLOMA
Yes
No
Original Needed
CREDIT REPORT
Yes
No
Original Needed
COLLEGE TRANSCRIPTS
Yes
No
N/A
Original Needed
MARRIAGE CERTIFICATE – IF APPLICABLE
Yes
No
N/A
Original Needed
DISSOLUTION OF MARRIAGE DECREE– IF APPLICABLE
Yes
No
N/A
Original Needed
NATURALIZATION PAPERS – IF APPLICABLE
Yes
No
N/A
Original Needed
MILITARY DISCHARGE PAPERS – DD214 (ALL COPIES INCLUDING MEMBER 4)
Yes
No
N/A
Original Needed
All documents required must be original. If the document is not an original the original must be shown on date of interview to be hired.
HIRING MANAGER USE ONLY:
Background Investigator:
Date Given:
Return
Date:
Page 20 of 20