Blank Texas Personal History Statement PDF Template
Form Example
THE UNIVERSITY OF TEXAS SYSTEM POLICE
PERSONAL HISTORY STATEMENT
APPLICANT NAME
POSITION
Date Issued: |
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Return By: |
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Received On: |
Received By:
9.14.11 MT
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
Instructions to the Applicant
Before you begin to fill out this personal history statement, please ensure that you meet the following requirements. You must meet all five of these requirements to qualify for licensure as a peace officer or jailer in Texas.
I am a citizen of the United States of America.
I have earned a high school diploma or a GED.
I have never been convicted, pleaded guilty to (nolo contendere), nor have I been on
During the last ten (10) years, I have not been convicted, pleaded guilty to (nolo contendere), been on community service/probation or deferred adjudication for a Class B misdemeanor in this state, other state, or while serving in the military.
I have never had a military court martial that resulted in a dishonorable or bad conduct discharge.
DISQUALIFICATION
There are very few automatic conditions for rejection. Even issues of prior misconduct, employee terminations, and arrests are
usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will
result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent
information from their prospective employer.
This personal history statement is a governmental document. Be truthful, as there are criminal consequences for being untruthful on a governmental document.
Once you begin:
Type or neatly print, in ink, responses to all items and questions. If a question does not apply to you, write “N/A”
(not applicable) in the space provided for your response. If you cannot obtain or remember certain information, indicate so in your response.
If you need more space for any response, use the last page of this form (page 27) and identify the additional information by the question number.
Be as complete, honest and specific as possible in your responses.
Disclosure of
In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring process applicants are not expected or required to reveal any medical or other
9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
SECTION 1: PERSONAL
1. YOUR FULL NAME |
1. YOUR FULL NAME |
1. YOUR FULL NAME |
LAST |
FIRST |
MIDDLE |
2.OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOWN BY
3.ADDRESS WHERE YOU RESIDE
NUMBER / STREET |
APT / UNIT |
CITY |
STATE ZIP |
4.MAILING ADDRESS, IF DIFFERENT FROM ABOVE
5.CONTACT NUMBERS
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EMAIL ADDRESS |
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BUSINESS |
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BIRTH PLACE |
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8. BIRTHDATE |
9. SOCIAL SECURITY # |
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10. DRIVER’S LICENSE |
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11. PHYSICAL DESCRIPTION |
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HT. |
WT. |
HAIR COLOR |
EYE COLOR |
12. Have you ever attended a basic licensing course? |
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A) |
ACADEMY NAME |
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DID YOU GRADUATE? |
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CONTACT NUMBER |
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ACADEMY NAME |
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DID YOU GRADUATE? |
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NAME OF TRAINING OFFICER / ACADEMY |
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CONTACT NUMBER |
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13.Have you ever applied to any other law enforcement agency in the last ten years (city, county, state or federal)?...
Yes
No
If yes, list ALL agencies you have applied to, starting with the most recent (give complete and accurate addresses).
All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for each agency.
If more space is needed, continue your response on page 27.
A) NAME OF AGENCY |
DATE APPLIED |
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ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
CITY |
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CONTACT NUMBER |
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POSITION APPLIED FOR |
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Check each step in the process that you completed, and your status: |
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STEPS: |
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Physical agility |
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Polygraph/CVSA |
Background |
Chief’s oral |
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Conditional job offer |
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STATUS: |
Hired |
On List |
Withdrawn |
Disqualified |
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9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
13. Have you ever applied to any other law enforcement agency… continued
B) NAME OF AGENCY
DATE APPLIED
ADDRESS (NUMBER / STREET) |
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BACKGROUND INVESTIGATOR’S NAME (IF |
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Check each step in the process that you completed, and your status:
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STEPS: |
Application |
Written |
Physical agility |
Oral |
Polygraph/CVSA |
Background |
Chief’s oral |
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STATUS: |
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On List |
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Disqualified |
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C) NAME OF AGENCY |
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DATE APPLIED |
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POSITION APPLIED FOR |
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Check each |
step in the process that you completed, and your status: |
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STEPS: |
Application |
Written |
Physical agility |
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Background |
Chief’s oral |
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Conditional job offer |
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STATUS: |
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On List |
Withdrawn |
Disqualified |
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SECTION 2: RELATIVES AND REFERENCES
14.IMMEDIATE FAMILY
Provide all applicable information in the spaces below.
Mark “N/A” if a category is not applicable or if the individual is deceased.
If more space is needed, continue your response on page 27.
N/A 
A. Father
NAME |
HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
ZIP |
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HOME PHONE |
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
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CELL PHONE |
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HOME PHONE |
WORK ADDRESS |
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WORK PHONE |
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9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
SECTION 2: RELATIVES AND REFERENCES continued
14.IMMEDIATE FAMILY continued
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C. Mother |
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WORK PHONE
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CELL PHONE
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N/A 
E. Spouse / Registered Domestic Partner
NAME |
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YEARS OF |
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MARRIAGE |
Is there, or has there been, a restraining or |
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H. Former Spouse(s) / Cohabitant |
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DISSOLUTION |
Is there, or has there been, a restraining or |
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9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
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HOME PHONE |
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WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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DISSOLUTION |
Is there, or has there been, a restraining or |
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N/A 
I. Brothers and Sisters – list all living siblings, including
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AGE 18 |
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( |
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5) NAME |
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HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
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ZIP |
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M |
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HOME PHONE |
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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F |
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( |
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ZIP |
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UNDER |
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WORK PHONE |
CELL PHONE |
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AGE 18 |
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( |
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( |
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6) NAME |
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HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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ZIP |
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M |
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HOME PHONE |
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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F |
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( |
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ZIP |
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UNDER |
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WORK PHONE |
CELL PHONE |
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AGE 18 |
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( |
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( |
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) |
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N/A |
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J. Children |
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List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you. |
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|
Provide the name and contact information of the custodial parent or guardian, if other than you. |
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1) NAME |
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CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) |
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M |
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CHILD’S AGE |
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ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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F |
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ZIP |
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CONTACT NUMBER |
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2) NAME |
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CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) |
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M |
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CHILD’S AGE |
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ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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ZIP |
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9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

F
CONTACT NUMBER
()
|
3) NAME |
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|
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) |
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M |
CHILD’S AGE |
ADDRESS (NUMBER / STREET / APT) |
CITY |
STATE |
||
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F |
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ZIP |
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CONTACT NUMBER |
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()
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4) |
NAME |
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CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) |
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M |
CHILD’S AGE |
|
ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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F |
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ZIP |
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CONTACT NUMBER |
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( |
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5) |
NAME |
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CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) |
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M |
CHILD’S AGE |
|
ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
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F |
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ZIP |
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CONTACT NUMBER |
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( |
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||||
6) |
NAME |
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CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU) |
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M

F
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT) |
CITY |
STATE |
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ZIP |
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CONTACT NUMBER |
|
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|
()
15.REFERENCES
List
A) NAME
CITY STATE
|
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HOME PHONE |
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CITY |
STATE |
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( |
) |
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WORK PHONE |
CELL PHONE |
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|||
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( |
) |
( |
) |
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|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
||||||
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FAMILY FRIEND, CO- WORKER) |
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|
THIS PERSON? |
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|
B) NAME |
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HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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ZIP |
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|||
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|
HOME PHONE |
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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( |
) |
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ZIP |
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WORK PHONE |
CELL PHONE |
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|||
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( |
) |
( |
) |
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|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
|
||||||
|
|
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
|||
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|||
|
C) NAME |
|
HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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|
ZIP |
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|
HOME PHONE |
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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( |
) |
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ZIP |
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WORK PHONE |
CELL PHONE |
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|||
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|||||
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( |
) |
( |
) |
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|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
||||||
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
|||
D) NAME
HOME ADDRESS (NUMBER / STREET / APT) |
CITY |
STATE |
ZIP |
|
|
9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
|
|
|
HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
|
|
|
( |
) |
|
|
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|
ZIP |
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|
WORK PHONE |
|
CELL PHONE |
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|||
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|
( |
) |
|
( |
) |
|
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|
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|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
|
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|
E) NAME |
|
|
HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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|
ZIP |
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|
HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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( |
) |
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ZIP |
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WORK PHONE |
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CELL PHONE |
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|||
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|||||
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( |
) |
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( |
) |
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|
|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
|
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||
|
|
F) NAME |
|
|
HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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ZIP |
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|||
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|
HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
|
|
( |
) |
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ZIP |
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WORK PHONE |
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CELL PHONE |
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|||
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|||||
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( |
) |
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( |
) |
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|
|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
|
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|||
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G) NAME |
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HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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ZIP |
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HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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( |
) |
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ZIP |
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||
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WORK PHONE |
|
CELL PHONE |
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|||
|
( |
) |
|
( |
) |
|
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|
||
|
|
|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
|
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|||
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H) NAME |
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HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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ZIP |
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HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
|
( |
) |
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|
ZIP |
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||
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WORK PHONE |
|
CELL PHONE |
|
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|
|||
|
( |
) |
|
( |
) |
|
|
|
|
||
|
|
|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
|
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|
|||
|
|
I) NAME |
|
|
HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
|
|
|
|
|
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|
|
|
ZIP |
|
|
|
|
|
HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
|
|
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|
||||||||
|
( |
) |
|
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|
ZIP |
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||
|
|
|
WORK PHONE |
|
CELL PHONE |
|
|
|
|||
|
( |
) |
|
( |
) |
|
|
|
|
||
|
|
|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
|
J) NAME |
|
|
HOME ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
||||
|
|
|
|||||||||
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ZIP |
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HOME PHONE |
|
WORK ADDRESS |
(NUMBER / STREET / APT) |
CITY |
STATE |
|||
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|
||||||||
|
( |
) |
|
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|
ZIP |
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|
||
|
|
|
WORK PHONE |
|
CELL PHONE |
|
|
|
|||
|
( |
) |
|
( |
) |
|
|
|
|
||
|
|
|
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER, |
HOW LONG HAVE YOU KNOWN |
|||||||
|
|
|
FAMILY FRIEND, CO- WORKER) |
|
|
THIS PERSON? |
|
||||
SECTION 3: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.
9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
16. |
Check applicable: |
High School Diploma |
GED |
|
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|||||
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||
17. List high schools attended: |
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|||
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A) |
NAME |
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FROM |
|
TO |
DID YOU |
|
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||
|
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|
GRADUATE? |
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CITY |
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|
STATE |
Yes |
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||
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|||||
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No |
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B) |
NAME |
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FROM |
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TO |
DID YOU |
|
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||
|
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|
|
GRADUATE? |
|
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CITY |
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STATE |
Yes |
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||
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No |
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||
18. List all colleges or universities attended: |
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|||
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A) |
NAME |
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FROM |
TO |
|
TOTAL UNITS |
TYPE OF |
|
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||
|
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|
EARNED |
DEGREE |
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||
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|
EARNED |
|
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||
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CITY |
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STATE |
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||||
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B) |
NAME |
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FROM |
TO |
|
TOTAL UNITS |
TYPE OF |
|
|
||
|
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|
|
EARNED |
DEGREE |
|
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||
|
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CITY |
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|
STATE |
EARNED |
|
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||
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|||||||
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C) |
NAME |
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FROM |
TO |
|
TOTAL UNITS |
TYPE OF |
|
|
||
|
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|
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|
|
|
EARNED |
DEGREE |
|
|
||
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CITY |
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|
STATE |
EARNED |
|
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||
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|
|||||
|
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|
||||||
19. List any trade, vocational, or business schools/institutes attended: |
|
|
|
|
|
|
|
||||||||
|
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9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
SECTION 3: EDUCATION continued
20. Have you ever been placed on academic discipline, suspended, or expelled from any high school, college/university, business or trade school? 
Yes 
No
If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.

SECTION 4: RESIDENCE
21.LIST OF RESIDENCES
List all residences during the last ten years or since age 15. Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit or apartment number). Do not use P.O. Boxes.
If the residence is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LIST military barracks mates unless you shared individual quarters.
If more space is needed continue on page 27.
A) ADDRESS WHERE YOU NOW LIVE |
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IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
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Names of those with whom you live:
B) FORMER ADDRESS |
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Names of those with whom you lived: |
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Reason for moving: |
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Names of those with whom you lived:
Reason for moving:
9.14.11 MT |
Initial this page to indicate that you have provided complete and accurate information: _____ |
More PDF Templates
Dps Change of Address - The form includes questions about your date of birth and phone number for identification purposes.
Texas Corporation Commission - This form includes instructions to ensure compliance with Texas trademark laws.
Burden of Proof in Civil Cases - Statistical data collected may assist in further judicial administrative planning.
Common mistakes
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Inaccurate Personal Information: Applicants often make mistakes by providing incorrect names, addresses, or contact numbers. It is crucial to double-check this information for accuracy.
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Failure to Disclose Other Names: Some individuals forget to include all names they have used, including nicknames. This omission can lead to complications during the background check process.
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Missing Social Security Number: Not providing a Social Security number can delay the processing of the application. Ensure this number is entered correctly.
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Incomplete Employment History: Applicants sometimes fail to list all law enforcement agencies they have applied to in the past ten years. It is important to include every agency, regardless of the outcome.
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Neglecting to Indicate N/A: When a question does not apply, some applicants forget to write "N/A." This can leave reviewers confused about whether the question was overlooked or simply does not pertain to the applicant.
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Omitting Required Signatures: Some individuals forget to initial or sign the document where indicated. This can lead to the application being considered incomplete.
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Inconsistent Information: Providing conflicting information between different sections of the form can raise red flags. Consistency is key, so review all entries carefully.
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Ignoring Space for Additional Information: If more space is needed for a response, applicants sometimes neglect to use the designated area on the last page. Always provide complete answers.
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Providing Insufficient Detail: Being vague in responses can hinder the review process. It is essential to be as specific and thorough as possible.
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Not Following Instructions: Ignoring the instructions provided at the beginning of the form can lead to mistakes. Carefully read and follow all guidelines to ensure a smooth application process.
Key takeaways
Here are some important points to consider when filling out and using the Texas Personal History Statement form:
- Eligibility Requirements: Ensure you meet all five eligibility requirements before starting the form. This includes being a U.S. citizen, having a high school diploma or GED, and having no serious criminal convictions.
- Truthfulness is Key: Be honest in your responses. Misstatements or omissions can lead to rejection of your application.
- Document Accuracy: This form is a governmental document. Providing accurate information is crucial, as there are legal consequences for being untruthful.
- Clear Responses: Type or neatly print your answers. If a question does not apply to you, write “N/A” in the space provided.
- Additional Space: If you need more room for any response, use the last page of the form and reference the question number.
- Medical Information: You are not required to disclose any medical or disability-related information until you receive a conditional job offer.
- Complete Contact Details: Provide accurate contact information, including phone numbers and email addresses, for yourself and your references.
- Relatives and References: Fill out the section on immediate family thoroughly. If a category is not applicable, mark it as “N/A.”
- Prior Applications: List all law enforcement agencies you have applied to in the last ten years, regardless of the outcome.
- Initial for Accuracy: Don’t forget to initial the pages to confirm that you have provided complete and accurate information.
Following these guidelines can help ensure a smoother application process. Take your time and review your answers carefully before submission.
Steps to Using Texas Personal History Statement
Completing the Texas Personal History Statement form is an important step in your application process. It's essential to provide accurate and thorough information to ensure your application is processed smoothly. Follow these steps carefully to fill out the form correctly.
- Read the instructions: Before starting, familiarize yourself with the requirements to ensure you meet all qualifications.
- Gather necessary information: Collect your personal details, including your full name, address, contact numbers, birth date, and Social Security number.
- Fill in your personal details: Start with Section 1. Write your full name, any other names you’ve used, and your current address. Include your contact numbers and email address.
- Provide your birth information: Enter your birthplace and birth date. Don’t forget your driver’s license number and physical description.
- Training history: If you’ve attended any basic licensing courses, provide the details, including the academy name, dates, and whether you graduated.
- Law enforcement applications: List any law enforcement agencies you’ve applied to in the last ten years, starting with the most recent. Include the agency name, date applied, and other requested details.
- Complete family information: In Section 2, provide details about your immediate family. If a category does not apply, write “N/A.” Include names, addresses, phone numbers, and emails where applicable.
- Review your answers: Go over your responses to ensure accuracy. Any misstatements can lead to disqualification.
- Initial the form: At the designated places, initial to confirm that the information you provided is complete and accurate.
- Submit the form: Once everything is filled out, return the form by the specified deadline.
Following these steps will help you complete the Texas Personal History Statement form accurately. Be honest and thorough, as this information is crucial for your application process.