USPP Form 1 United States Park Police Personal History Statement Que

United States Park Police Personal History Statement Questionnaire

October OMB PHS

US Park Police Personal History Statement Questionnaire

OMB: 1024-0245

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1024-0245 can be found here:

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United States Park Police
PERSONAL HISTORY STATEMENT
Table of Contents
Page
Instructions to Applicant

Privacy Act Notice

Part I

Papers – Documents that are required

Part II

Personal Data

9 - 20

Part III

Selective Service

Part IV

Military Data

21 - 24

Part V

Financial Data

25 - 27

Part VI

References

Part VII

Personal Associates

Part VIII

Residence Data

33 - 36

Part IX

Education

37 - 39

Part X

Employment Data

41 - 46

Part XI

Driving Record

47 - 50

Part XII

Arrest/Conviction Data

51 - 52

Part XIII

Criminal History

53 - 54

Part XIV

Gambling

55 - 56

Part XV

Miscellaneous

57 - 62

Part XVI

Essay

63 - 68

Applicant Signature Page

INSTRUCTIONS TO THE APPLICANT
This form must be PRINTED IN INK by the applicant and each question answered accurately.
If a question does not apply to you, write “N/A” (Not Applicable) as your response to that
question. Incomplete and/or inaccurate answers will substantially extend the time required to
process your application. If the Personal History Statement is incomplete at the time of your
personal interview, the form will be returned to you and the interview will be postponed until the
application is in compliance with the instructions provided herein.
The information you provide in this personal history statement will be used in the investigation
into your background to assist in determining your suitability for the position for which you have
applied. Please fill out the questionnaire completely and accurately. Keep in mind that:
1. the completion of this form is mandatory in order for you to receive
consideration for appointment;
2. all statements are subject to verification;
3. deliberate inaccuracies or incomplete statements may bar or remove
you from employment consideration; and
4. all time periods in your background must be accounted for.
It is to your advantage to respond openly. Any negative factor contained in the information
provided by you will be evaluated in terms of the circumstances and facts surrounding it and its
degree of relevance to the job. On the other hand, you may be disqualified if you intentionally
make a false statement of material fact or intentionally omit a material fact or if you practice or
attempt to practice any form of deception or fraud in this statement.
If additional space is required for an answer to any question, use the continuation sheet
found on the back of each answer sheet for that question, or provide your remarks on
bond paper at the end of the section. Be sure to identify each entry on the continuation
sheet(s) with the appropriate section and question number.

* THE LAST PAGE MUST BE SIGNED AND NOTARIZED *
PUBLIC BURDEN STATEMENT: The public burden for the collection of this information is estimated to be
8 hours per person. This estimate includes reviewing instructions, searching information sources, and gathering
and reporting the information. You may send your comments on the time estimate and other aspects of data
collection including suggestions for reducing the time it takes to complete this form to the Human Resources
Officer, 1100 Ohio Drive S. W., Washington, DC 20024.
Paperwork Reduction Act Statement: A Federal agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a valid OMB control number. This information is
collected to determine suitability for the position of a United States Park Police Officer. The obligation to respond
is required to obtain the position of a United States Park Police Officer.

PRIVACY ACT NOTICE
General
This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for
individuals completing Federal Investigative forms.
Authority
The authority to collect information on the attached form is derived from one or more of the following:
Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301;
sections 8(b), 8(c), and 9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22,
United States Code, sections 1434 and 2585.
Purposes and Uses
The information you supply will be used principally as a basis for an investigation to determine your fitness for
employment purposes, including a security clearance and an evaluation of qualifications, suitability, and loyalty to
the United States. As part of such an investigation, the Standard Form 87 (Fingerprint Chart) will be sent to the
Federal Bureau of Investigation and may be retained there. This information and information developed through
investigation may be furnished to designated officers and employees of agencies and departments of the Federal
Government for employment purposes, including security clearance determination, an access determination, an
evaluation of qualifications, suitability, and loyalty to the U.S. Government, and a determination regarding
qualifications or suitability for performing a contractual service to the Federal Government. The information may
also be disclosed to any agency of the Federal Government having a working relationship with regard to Office of
Personnel Management activities, to the intelligence agencies of the Federal Government, or to others having
reasons as published in the Federal Register.
Effects of Nondisclosure
The employment application form requests specific information. If you omit answering an item, however, you may
not receive full consideration for a position; and without your social security number, we cannot process your
application. Consequently, it is in your best interest to answer all of the questions. The U.S. Criminal Code, Title
18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines
of up to $10,000 or 5 years in prison, or both. Under 5 U.S.C. 8315, a false answer to questions relating to
membership in the Communist Party, U.S.A., or other communist or fascist organizations could deprive you of your
right to an annuity when you reach retirement age. Deliberately and materially making false or fraudulent
statements on this form will be grounds for not granting you a security clearance and not hiring you or for firing you
after you begin work. In addition, these violations will become part of your permanent record for future
employment.
Information Regarding Disclosure of Your
Social Security Number Under Public Law 93-579 Section 7(b)
Disclosure by you of your Social Security Number (SSN) is mandatory to obtain the services, benefits, or
processes that you are seeking. Solicitation of the SSN by the United States Office of Personnel
Management is authorized under provisions of Executive Order 9397, dated November 22, 1943. The SSN
is used as an identifier throughout your Federal career from the time of application through retirement. It
will be used primarily to identify your records with the Office of Personnel Management and other Federal
agencies in connection with lawful requests for information about you from former employers, educational
institutions, and financial or other organizations. The information gathered through the use of the SSN
will be used only as necessary in personnel administration processes carried out in accordance with
established regulations and published notices of system of records. The SSN also will be used for the
selection of persons to be included in statistical studies of personnel management matters. The use of
the SSN is made necessary because of the large number of present and former Federal employees and
applicants who have identical names and birth dates, and whose identities can only be distinguished by
the SSN.

PERSONAL HISTORY STATEMENT
Part I. Papers – Documents that are required
Unless otherwise indicated, the original document (or a certified true copy) and one copy of each
must be presented at the time of the Physical Efficiency Battery (PEB). Copiers will not be
available for Applicant use at the PEB.
1. Birth Certificate
2. High School Diploma or GED (GED must be accompanied by test scores)
3. College Diploma and transcripts (transcripts must be official copies provided by the institution in
a sealed envelope)
4. DD-214(s) for each period of Military Service
5. Selective Service Card (even if you served in the military)
6. Naturalization certificate
7. Marriage license(s) (copy only)
8. Court Orders:
a. Divorce/annulment papers and all other legal documents which
pertain to your present and/or previous marriage(s)
b. Legal Separation(s) (copy only)
c. Child Support
d. Name change(s)
e. Adoption(s)
f. Bankruptcies (copy only)
g. Copy of disposition(s) of any court action(s) civil and criminal
9. Drivers license (actual current license and 3 copies (front and back)) and certified copy of current
driving record(s) from the DMV from all states that you have resided in over the last 10 years.
10. One copy each of the last two years of Federal and State Taxes (include W-2’s)
Birth certificate, marriage license, divorce/annulment papers, and change of name documents must be
notarized if they are not the originals, or they must be annotated as being true copies by the agency
providing the copies.
These documents will be reviewed and the originals will be returned to you at the time they are
presented.

PERSONAL HISTORY STATEMENT
Part II. Personal Data
1. Applicant’s Name (please print) (Last, First, Middle)

2. Aliases, Maiden Names, and Nicknames (specify which)
Have you ever legally changed your name?
If yes, from:

Yes

to:

Court jurisdiction:

3. Date of Birth (Month, Day, Year)

4. Place of Birth (city, county, state/Foreign Country)

5. Place where you grew up (city and state)

7. Social Security Number

10. Citizenship

8. Sex (mark one box)
Female
Male

U.S. Citizen

By Birth

Naturalization

Alien

Alien Registration Number ___________________________________
Date, Place, Court

Certificate Number

Petition Number

Complete this section if your U.S. citizenship was derived from your Parent’s Naturalization
Name of Parent

Certificate Number
Mother
Father

Native country

Date, Place, and Port of Entry into U.S.

Sponsor

CONTINUATION PAGE

11. U.S. Passport
Passport Number

Month/Day/Year Issued

12. Dual Citizenship (If you are (or were) a dual citizen of the United States and another country,
provide the name of that country.
Country _____________________________________

13. List foreign countries you have visited, other than on official U.S. Government business,
beginning with the most recent trip.
Month/Year to Month/Year  Country

Reason



Do you have any foreign property, business connections, or financial interests?

Yes

Are you now, or have you ever been, employed by or acted as a consultant for a foreign
Government, firm, or agency? No
Yes
Have you ever had any contact with a foreign government, or its representatives, inside or outside
the U.S., other than on official U.S. Government business? No
Yes
Have you ever had an active passport that was issued by a foreign government?

Yes

If you answered yes to any of these questions provide full details on the continuation sheet.

14. Present Address (House Number, Street, Apt #, city, state, Zip Code)

15. Legal Residence (House Number, Street, Apt #, city state, Zip Code

16. Home Telephone Number

18. Present Marital Status

17. Work Telephone Number

Never Married

Married

Separated

19. Full Name of Spouse (Last, First, Middle, Maiden)
Address of current spouse, if different than your current address:

Divorced

Widowed

CONTINUATION PAGE

20. Marriage Data (including present and all former marriages)
Name (Last, First, Middle, Maiden)

Date of Birth

Country of Citizenship

____________________________
Social Security Number

Date of Marriage

Place of Birth

_________________________________________
Place of Marriage (city and state)
______________________________________________________

Name (Last, First, Middle, Maiden)

Date of Birth

Place of Birth

Country of Citizenship

____________________________
Social Security Number

_________________________________________
Place of Marriage (city and state)
Divorced
Month/Day/Year
Widowed
___
Address of Former Spouse
Telephone Number

Date of Marriage

_____________________
Name (Last, First, Middle, Maiden)

Date of Birth

Place of Birth

Country of Citizenship

____________________________
Social Security Number

_________________________________________
Place of Marriage (city and state)
Divorced
Month/Day/Year
Widowed
____
Address of Former Spouse
Telephone Number

Date of Marriage

`
21. Spouse’s employment (Company Name, Address, city/state, Office Telephone)

22. Do you have any objection to our contacting your spouse/former spouse(s)?

23. Has your spouse, or domestic partner, ever called the police on you for any reason?
If yes, provide dates, reasons, police agency contacted, and disposition

24. Date of Present Legal Separation (if presently separated)

Month

25 Date Final Divorce Decree is expected

Year

Month

Day

Year

Yes
No

Yes

CONTINUATION PAGE

26. Date of Final Divorce Decree (if presently divorced)

27. Have you ever been (check applicable box)
28. Do you pay alimony?

Month

Separated

Day

Year

Divorced

Widowed

Yes (provide amount/frequency) ____________________________

29. List below the Name(s) of each of your children
Name of Child

Date of Birth

Place of Birth

Country of Citizenship
____________

Address where child resides
___________________________________________________________________________________
Name of Child

Date of Birth

Place of Birth

Country of Citizenship
____________

Address where child resides
___________________________________________________________________________________
Name of Child

Date of Birth

Place of Birth

Country of Citizenship
____________

Address where child resides

For each child listed above, enter the Name and Address of the Other Parent/Guardian
(if other than your current spouse)
Name
Other Parent

Guardian

Other Parent

Guardian

Address

30. Do you have any dependents other than those listed above?
No
Yes (list below)
Name

Address

Relationship

CONTINUATION PAGE

31. Are you receiving and/or responsible for paying any child support?
If yes, is the child support court ordered? No
Yes

Yes

If yes, provide the following information.
To Whom Paid or From Whom Received

Amount
Paid

Amount
Received

Frequency Paid
or Received________

32. Have you ever been involved as a complainant or defendant in a paternity proceeding?
No
Yes If yes, enter full details on continuation sheet
33. Information regarding applicants Father
Name (Last, First, Middle)

Home Telephone Number

Address (House Number, Street, Apt. #, city, state, Zip Code)
Place of Birth
Occupation

Date of Birth (Month, Day, Year)
Present Employer

Date of Death (if deceased)

Length of Employment

Age at Death

Cause of Death

34. Information regarding applicants Mother
Name (Last, First, Middle)

Home Telephone Number

Address (House Number, Street, Apt. #, city, state, Zip Code)
Place of Birth
Occupation

Date of Birth (Month, Day, Year)
Present Employer

Date of Death (if deceased)

Length of Employment

Age at Death

Cause of Death

35. If either Parent is remarried, give name and address of stepparents.
____________________________________________________________________________
____________________________________________________________________________

CONTINUATION PAGE

36. List the names of your Brothers and Sisters, giving date of birth and addresses of each. Also
include any Stepbrothers and Stepsisters.
Name

Date of Birth

Citizenship
_____________________
Relationship

Address

____________________________________________________ ____________________________
Name

Date of Birth

Citizenship
_____________________
Relationship

Address

_____________________
Name

Date of Birth

Citizenship
_____________________
Relationship

Address

_____________________
Name

Date of Birth

Citizenship
_____________________
Relationship

Address

37. If you were raised by anyone other than your natural parents, complete the following
items (Do not include institutions or foster homes)
Name (Last First, Middle)

Relationship

Address (House Number, Street, Apt. #, city, state, Zip Code)
Telephone Number
Give dates under this persons care/charge

CONTINUATION PAGE

PERSONAL HISTORY STATEMENT
Part III. Selective Service
To be completed by male applicants only.
1. Present Selective Service Classification

2. Date of Classification

3. Selective Service Reg. #

Part IV. Military Data
1. Have you ever applied for any
Branch of the military?
No

2. What is the status of your application?

Yes

3. Have you ever been denied entrance to any of the armed forces?
If yes, which branch?

Army

Air Force

Merchant Marines

Yes

Coast Guard

Marine Corp

Navy

National Guard

If yes, explain the basis for your denial.

4. List all of your military service

Branch

Primary MOS/
AFSC
Officer

5. Highest Rank Attained

 Enlisted

Dates of Active Duty Service Number
Entered Released ________________

6. Type of Discharge (i.e., Character of Service)

CONTINUATION PAGE

7. Rank at Time of Discharge

8. Were you recommended for re-enlistment after
each period of military duty?
Yes

No (Explain) _______________________________
________________________________

9. Have you ever received a discharge from the Armed Forces that was other than Honorable?
(If yes, enter type of discharge) ________________________________________
No

Yes (Explain) ______________________________________________________
______________________________________________________

10. Were you ever subjected to any disciplinary actions (Judicial or Non-Judicial) while in the Armed Forces?
No

Yes (Explain) ______________________________________________________
______________________________________________________

11. Were you ever the subject of any criminal investigation that was being conducted by military authorities?
concerning any alleged misconduct on your part?
No

Yes (Explain) _______________________________________________________
________________________________________________________

12. Did you serve in the Reserves? Date of Membership
Began
Ended
No
Yes

Officer Enlisted Service No.

13. National Guard
Membership
No
Yes

Officer Enlisted Service Number

Army
State

Air

Date of Membership
Began
Ended

Name of National Guard Organization and Address

CONTINUATION PAGE

PERSONAL HISTORY STATEMENT
Part V. Financial Data
1. Do you presently hold active or silent controlling interest in any company?
No
Yes (Explain your interest)
________________________________________________________
________________________________________________________

2. Do you now have (or have you ever had) any wage garnishments on your salary?
No
Yes (Explain)
______________________________________________________________
______________________________________________________________

3. Have you ever been found delinquent on Income or Other Tax Payments?
No
Yes (Explain)
______________________________________________________________
______________________________________________________________
Have the taxes been paid?

Yes

4. Have you ever had a lien placed against your property for failing to pay taxes or other debts?
No
Yes (Explain)
______________________________________________________________
______________________________________________________________

5. Have you ever had any real or personal property repossessed?
No
Yes (Explain)
_____________________________________________________________
_____________________________________________________________

6. Have you ever had a court-ordered financial judgment against you?
No
Yes (Explain)
____________________________________________________________
____________________________________________________________

7. Do you presently have a financial judgment pending in court?
No
Yes (Explain)
____________________________________________________________
____________________________________________________________

8. Have you ever filed for or declared bankruptcy or utilized a wage earner’s plan?
No
Yes (Explain)
___________________________________________________________
___________________________________________________________
9. What is your Monthly Net Pay?

10. Your Spouse’s Monthly Net Pay?

CONTINUATION PAGE

11. Do you or your spouse have any other source(s) income?
No
Yes (list below the source(s) of such income and the monthly amount(s).
Source of Income

 Self

 Spouse  Monthly Income

12. List all current loans, credit cards, mortgage/rent, contractual agreements for which you have payments.
Type of Debt

 Monthly Payment  Present Balance  To Whom Owed

13. Have you been over 180 days delinquent on any debt(s)?

Yes

Are you currently over 90 days delinquent on any debt(s)?

Yes

If you answered yes to either question, provide the information requested below.
Type of Debt

 When incurredAmount  Present Balance  To Whom Owed

14. Have you been a party to any public record civil court actions?

Yes

If you answered yes, provide the information requested below.
Month/Year Action

 Result

 Name of Parties

 Court

CONTINUATION PAGE

Part VI. References
Give the data requested below on three (3) references who:
a. Are not related to you by blood or marriage,
b. Are not former employers and not mentioned elsewhere in this form,
c. Are responsible adults of reputable standing in their community, and are located in the United
States,
d. Are aware of your qualifications and fitness for this position, and
e. Have known you well for at least five (5) years.
Check One
Name (Last, First, Middle)
Mr.
Ms.
Mrs
Miss
Residence Address (Street Number, city, state, and Zip Code

Years known

Citizenship

Home Telephone Number

_______________________________________________________ _____________________________
Occupation
Place of Employment
__________________________________ __________________________________________________
Address of Employment (Street Number, city, state, Zip Code)
Business Phone Number

Check One
Name (Last, First, Middle)
Mr.
Ms.
Mrs
Miss
Residence Address (Street Number, city, state, and Zip Code)

Years known

Citizenship

________________
Home Telephone Number

____________________________________________________________________________________
Occupation
Place of Employment
__________________________________ _________________________________________________
Address of Employment (Street Number, city, state, Zip Code)
Business Phone Number

Check One
Name (Last, First, Middle)
Mr.
Ms.
Mrs
Miss
Residence Address (Street Number, city, state, and Zip Code

Years known

Citizenship

________________
Home Telephone Number

____________________________________________________________________________________
Occupation
Place of Employment
___________________________________ ________________________________________________
Address of Employment (Street Number, city, state, Zip Code)
Business Phone Number

PERSONAL HISTORY STATEMENT
Part VII. Personal Associates
Give the data requested below on three (3) persons with whom you have associated (i.e., persons
whom you have seen frequently) during the past three (3) years. Do not include relatives, former
employers, or any persons mentioned elsewhere in this form.
Check One
Name (Last, First, Middle)
Mr.
Ms.
Mrs
Miss
Residence Address (Street Number, city, state, and Zip Code

Years known
_________________
Home Telephone Number

_____________________________________________________________ ________________________
Occupation
Place of Employment
___________________________________ _________________________________________________
Address of Employment (Street Number, city, state, Zip Code)
Business Phone Number

Check One
Name (Last, First, Middle)
Mr.
Ms.
Mrs
Miss
Residence Address (Street Number, city, state, and Zip Code

Years known
_________________
Home Telephone Number

_____________________________________________________________ _______________________
Occupation
Place of Employment
____________________________________________________________________________________
Address of Employment (Street Number, city, state, Zip Code)
Business Phone Number

Check One
Name (Last, First, Middle)
Mr.
Ms.
Mrs
Miss
Residence Address (Street Number, city, state, and Zip Code

Years known
_________________
Home Telephone Number

___________________________________________________________________________________
Occupation
Place of Employment
_____________________________________________________________________________________
Address of Employment (Street Number, city, state, Zip Code)
Business Phone Number

PERSONAL HISTORY STATEMENT
Part VIII. Residence Data
Provide the information requested below on all your residences during the last fifteen (15) years,
beginning with your present residence. In each case, provide the name and present correct street
address of two (2) neighbors (not necessarily a personal acquaintance). Include your mailing and/or
street addresses during all periods of Military Service.
Dates of Residence
FROM
Month
Day

Location of Residence
Street Address (Apt. #, city, state, Zip Code)

TO
Year
Present