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Form Example

DP-1

THE UNIVERSITY OF TEXAS SYSTEM POLICE

PERSONAL HISTORY STATEMENT

APPLICANT NAME

POSITION

Date Issued:

 

Return By:

 

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 court-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, 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 job-relevant

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 Medically-Related Information

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 disability-related information about themselves in response to questions on this form, or to any other inquiry made prior to receiving a conditional offer of employment.

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

 

HOME (

)

 

WORK (

)

EXT

OTHER (

)

CELL

FAX

 

 

 

 

 

 

 

 

 

 

6.

EMAIL ADDRESS

 

 

 

 

 

 

 

 

HOME

 

 

 

 

 

BUSINESS

 

 

 

 

 

 

 

 

 

 

7.

BIRTH PLACE

(CITY / COUNTY / STATE / COUNTRY)

 

 

8. BIRTHDATE

9. SOCIAL SECURITY #

 

 

 

 

 

 

 

 

 

 

10. DRIVER’S LICENSE

 

 

NO.

STATE

EXP

11. PHYSICAL DESCRIPTION

 

HT.

WT.

HAIR COLOR

EYE COLOR

12. Have you ever attended a basic licensing course?

Yes No

 

 

 

 

 

 

If yes, provide the following information: PID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A)

ACADEMY NAME

 

 

 

FROM

TO

DID YOU GRADUATE?

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

(CITY / STATE)

 

NAME OF TRAINING OFFICER / ACADEMY

CONTACT NUMBER

 

 

 

 

 

COORDINATOR

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

B)

ACADEMY NAME

 

 

 

FROM

TO

DID YOU GRADUATE?

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

(CITY / STATE)

 

NAME OF TRAINING OFFICER / ACADEMY

 

CONTACT NUMBER

 

 

 

 

 

COORDINATOR

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

ADDRESS (NUMBER / STREET)

BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)

CITY

 

 

 

 

ZIP

 

CONTACT NUMBER

 

EXT

 

 

 

 

STAT

 

 

(

)

 

 

 

POSITION APPLIED FOR

 

 

 

 

 

 

EMAIL

 

 

 

 

 

 

 

 

 

 

Check each step in the process that you completed, and your status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEPS:

Application

Written

Physical agility

Oral

Polygraph/CVSA

Background

Chief’s oral

Conditional job offer

 

 

 

 

 

 

 

 

 

 

STATUS:

Hired

On List

Withdrawn

Disqualified

 

 

 

 

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)

 

 

BACKGROUND INVESTIGATOR’S NAME (IF

 

 

 

KNOWN)

 

 

CITY

 

ZIP

CONTACT NUMBER

 

EXT

 

 

 

STAT

 

(

)

 

 

POSITION APPLIED FOR

 

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check each step in the process that you completed, and your status:

 

 

STEPS:

Application

Written

Physical agility

Oral

Polygraph/CVSA

Background

Chief’s oral

 

 

Conditional job offer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS:

 

Hired

On List

Withdrawn

Disqualified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C) NAME OF AGENCY

 

 

 

 

 

 

 

 

DATE APPLIED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

(NUMBER / STREET)

 

 

 

 

 

 

BACKGROUND INVESTIGATOR’S NAME (IF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KNOWN)

 

 

 

 

 

 

CITY

 

 

 

 

 

ZIP

 

CONTACT NUMBER

 

EXT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STAT

 

 

 

(

)

 

 

 

 

 

 

POSITION APPLIED FOR

 

 

 

 

 

 

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check each

step in the process that you completed, and your status:

 

 

 

 

 

 

 

 

 

 

STEPS:

Application

Written

Physical agility

Oral

Polygraph/CVSA

Background

Chief’s oral

 

 

 

Conditional job offer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS:

 

Hired

On List

Withdrawn

Disqualified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

()

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

B. Step-father

 

 

 

 

 

 

 

 

NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

(

)

 

 

 

 

 

 

 

 

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

 

(

)

 

(

)

 

 

 

 

 

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

 

N/A

C. Mother

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

Step-mother

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

()

WORK PHONE

()

CELL PHONE

()

EMAIL

N/A E. Spouse / Registered Domestic Partner

NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

(

)

 

 

 

 

 

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

YEARS OF

 

 

 

 

 

 

 

 

 

 

MARRIAGE

Is there, or has there been, a restraining or stay-away order in effect for this individual?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

F. Father-in-law

 

 

 

 

 

 

 

 

NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

(

)

 

 

 

 

 

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

G. Mother-in-law

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

()

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

H. Former Spouse(s) / Cohabitant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1) NAME

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

ZIP

()

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

(

)

(

)

 

 

 

 

 

 

YEAR OF

 

 

 

 

 

 

 

 

 

DISSOLUTION

Is there, or has there been, a restraining or stay-away order in effect for this individual?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2) 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

ZIP

 

(

)

 

 

 

 

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

YEAR OF

 

 

 

 

 

 

 

 

 

DISSOLUTION

Is there, or has there been, a restraining or stay-away order in effect for this individual?

Yes

No

N/A I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc.

 

1) NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

F

 

(

)

 

 

 

 

 

 

 

ZIP

 

 

 

UNDER

 

WORK PHONE

CELL PHONE

 

 

EMAIL

 

 

AGE 18

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2) NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

M

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

F

 

(

)

 

 

 

 

 

 

 

ZIP

 

 

 

UNDER

 

WORK PHONE

CELL PHONE

 

 

EMAIL

 

 

AGE 18

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3) NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

M

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

F

 

(

)

 

 

 

 

 

 

 

ZIP

 

 

 

UNDER

 

WORK PHONE

CELL PHONE

 

 

EMAIL

 

 

AGE 18

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4) NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

M

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

F

 

(

)

 

 

 

 

 

 

 

ZIP

 

 

 

UNDER

 

WORK PHONE

CELL PHONE

 

 

EMAIL

 

 

AGE 18

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5) NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

M

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

F

 

(

)

 

 

 

 

 

 

 

ZIP

 

 

 

UNDER

 

WORK PHONE

CELL PHONE

 

 

EMAIL

 

 

AGE 18

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6) NAME

 

 

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

M

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

F

 

(

)

 

 

 

 

 

 

 

ZIP

 

 

 

UNDER

 

WORK PHONE

CELL PHONE

 

 

EMAIL

 

 

AGE 18

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J. Children

 

 

 

 

 

 

 

 

 

 

 

 

List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you.

 

 

Provide the name and contact information of the custodial parent or guardian, if other than you.

 

 

 

1) NAME

 

 

 

 

 

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

CHILD’S AGE

 

ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

F

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

CONTACT NUMBER

 

EMAIL

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2) NAME

 

 

 

 

 

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

CHILD’S AGE

 

ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.14.11 MT

Initial this page to indicate that you have provided complete and accurate information: _____

HOME ADDRESS (NUMBER / STREET / APT) ZIP
WORK ADDRESS (NUMBER / STREET / APT) ZIP

PERSONAL HISTORY STATEMENT for TEXAS LICENSURE

F

CONTACT NUMBER

()

EMAIL

 

3) NAME

 

 

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

 

 

 

 

 

 

 

 

 

 

 

M

CHILD’S AGE

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

 

F

 

 

 

ZIP

 

 

 

 

 

 

CONTACT NUMBER

EMAIL

 

 

()

 

4)

NAME

 

 

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

CHILD’S AGE

 

ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

F

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

CONTACT NUMBER

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5)

NAME

 

 

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

CHILD’S AGE

 

ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

F

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

CONTACT NUMBER

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

6)

NAME

 

 

CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

CHILD’S AGE

ADDRESS (NUMBER / STREET / APT)

CITY

STATE

 

ZIP

 

 

CONTACT NUMBER

EMAIL

 

 

()

15.REFERENCES

List 710 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.

A) NAME

CITY STATE

 

 

HOME PHONE

 

 

 

 

CITY

STATE

 

 

(

)

 

 

 

 

 

 

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

 

(

)

(

)

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

HOW LONG HAVE YOU KNOWN

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

B) NAME

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

(

)

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

 

(

)

(

)

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

 

 

 

HOW LONG HAVE YOU KNOWN

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

C) NAME

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

ZIP

 

 

 

 

HOME PHONE

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

(

)

 

 

 

ZIP

 

 

 

 

WORK PHONE

CELL PHONE

 

EMAIL

 

 

 

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

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

 

 

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

HOW LONG HAVE YOU KNOWN

 

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E) NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

HOW LONG HAVE YOU KNOWN

 

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

 

F) NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

HOW LONG HAVE YOU KNOWN

 

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

G) NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

HOW LONG HAVE YOU KNOWN

 

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

H) NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,

HOW LONG HAVE YOU KNOWN

 

 

 

FAMILY FRIEND, CO- WORKER)

 

 

THIS PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

I) NAME

 

 

HOME ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

HOME PHONE

 

WORK ADDRESS

(NUMBER / STREET / APT)

CITY

STATE

 

 

 

 

 

(

)

 

 

 

 

ZIP

 

 

 

 

 

WORK PHONE

 

CELL PHONE

 

EMAIL

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. List high schools attended:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A)

NAME

 

 

 

 

 

 

FROM

 

TO

DID YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GRADUATE?

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B)

NAME

 

 

 

 

 

 

FROM

 

TO

DID YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GRADUATE?

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. List all colleges or universities attended:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A)

NAME

 

 

 

 

 

FROM

TO

 

TOTAL UNITS

TYPE OF

 

 

 

 

 

 

 

 

 

 

 

 

EARNED

DEGREE

 

 

 

 

 

 

 

 

 

 

 

 

 

EARNED

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B)

NAME

 

 

 

 

 

FROM

TO

 

TOTAL UNITS

TYPE OF

 

 

 

 

 

 

 

 

 

 

 

 

EARNED

DEGREE

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

EARNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C)

NAME

 

 

 

 

 

FROM

TO

 

TOTAL UNITS

TYPE OF

 

 

 

 

 

 

 

 

 

 

 

 

EARNED

DEGREE

 

 

 

 

 

 

 

 

CITY

 

 

 

STATE

EARNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. List any trade, vocational, or business schools/institutes attended:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A)

NAME

 

 

 

 

 

 

FROM

 

TO

DID YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE

 

 

 

 

TYPE OF SCHOOL OR TRAINING

 

 

CITY

 

 

 

STATE

THE COURSE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B)

NAME

 

 

 

 

 

 

FROM

 

TO

DID YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE

 

 

 

 

TYPE OF SCHOOL OR TRAINING

 

 

CITY

 

 

 

STATE

THE COURSE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C)

NAME

 

 

 

 

 

 

FROM

 

TO

DID YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE

 

 

 

 

TYPE OF SCHOOL OR TRAINING

 

 

CITY

 

 

 

STATE

THE COURSE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

(NUMBER / STREET / APT)

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

 

 

 

 

FROM

TO

 

Present

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

 

 

 

 

 

 

 

ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

(NUMBER /

CONTACT NUMBER

STREET / APT)

 

 

 

 

(

)

 

 

 

 

 

 

 

CITY

STATE

ZIP

 

EMAIL

 

 

 

 

 

 

 

 

 

Names of those with whom you live:

B) FORMER ADDRESS

(NUMBER / STREET / APT)

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

 

 

 

 

FROM

TO

 

 

IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

 

ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

(NUMBER /

 

CONTACT NUMBER

 

STREET / APT)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Names of those with whom you lived:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for moving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C) FORMER ADDRESS

(NUMBER / STREET / APT)

 

 

 

 

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

IF RENTING: PROPERTY MANAGER, RENT

 

 

 

 

 

 

COLLECTOR, OR OWNER

 

ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER

(NUMBER /

 

CONTACT NUMBER

 

STREET / APT)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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: _____

Common mistakes

  1. 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.

  2. 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.

  3. Missing Social Security Number: Not providing a Social Security number can delay the processing of the application. Ensure this number is entered correctly.

  4. 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.

  5. 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.

  6. Omitting Required Signatures: Some individuals forget to initial or sign the document where indicated. This can lead to the application being considered incomplete.

  7. Inconsistent Information: Providing conflicting information between different sections of the form can raise red flags. Consistency is key, so review all entries carefully.

  8. 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.

  9. Providing Insufficient Detail: Being vague in responses can hinder the review process. It is essential to be as specific and thorough as possible.

  10. 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.

  1. Read the instructions: Before starting, familiarize yourself with the requirements to ensure you meet all qualifications.
  2. Gather necessary information: Collect your personal details, including your full name, address, contact numbers, birth date, and Social Security number.
  3. 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.
  4. Provide your birth information: Enter your birthplace and birth date. Don’t forget your driver’s license number and physical description.
  5. Training history: If you’ve attended any basic licensing courses, provide the details, including the academy name, dates, and whether you graduated.
  6. 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.
  7. 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.
  8. Review your answers: Go over your responses to ensure accuracy. Any misstatements can lead to disqualification.
  9. Initial the form: At the designated places, initial to confirm that the information you provided is complete and accurate.
  10. 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.