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United States Department of the Interior
National Park Service
United States Park Police
Washington, DC 20242
Rev: 10/ϭϬ
United States Park Police
PERSONAL HISTORY STATEMENT
Table of Contents
Page
Instructions to Applicant
1
Privacy Act Notice
2
Part I
Papers – Documents that are required
3
Part II
Personal Data
4 - 15
Part III
Selective Service
16
Part IV
Military Data
16 - 19
Part V
Financial Data
20 - 23
Part VI
References
24
Part VII
Personal Associates
25
Part VIII
Residence Data
26 - 29
Part IX
Education
30 - 33
Part X
Employment Data
34 - 39
Part XI
Driving Record
40 - 43
Part XII
Arrest/Conviction Data
44 - 45
Part XIII
Criminal History
46 - 49
Part XIV
Gambling
48 - 49
Part XV
Miscellaneous
50 - 56
Part XVI
Essay
57 - 58
Applicant Signature Page
59
INSTRUCTIONS TO THE APPLICANT
This form must be PRINTED by the applicant and each question answered completely and
accurately. If a q uestion 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 t o process your application. If t he Personal History Statement is incomplete or not
notarized at the time of your written examination, it will be returned to you and you will not move
further in the process 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 b ackground to assi st in d etermining your qualification for the position for which y ou
have applied. Please fill out the questionnaire completely and accurately. Keep in mind that:
The completion of this form is mandatory in order for you to receive consideration for
appointment;
All statements are subject to verification;
Deliberate inaccuracies or incomplete statements may bar or remove you f rom employment
consideration; and
All time periods in your background must be accounted for.
It is to y our 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 a YES answer to any question, type the information on the continuation sheet found after each section. Be sure to identify each entry on the continuations sheets(s)
with the appropriate section and question number. After providing the required information be sure
to review the document to make sure that ALL questions are addressed.
THE LAST PAGE OF THIS DOCUMENT 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 qualification 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) (member Part 4) 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:
No
Yes
to:
Court jurisdiction:
3. Date of Birth (xx/xx/xxxx)
4. Place of Birth (city, county, state/Foreign Country)
5. Place(s) where you grew up (city and state)
7. Social Security Number
8. Sex (mark one box)
Male
9. Citizenship
U.S. Citizen
By Birth
Female
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
10. U.S. Passport
Passport Number
Month/Day/Year Issued
11. Dual Citizenship (If you are (or were) a dual citizen of the United States and another country,
provide the name of that country.
Country _____________________________________
12. List foreign countries you have visited in the last 10 years, 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?
No
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?
No
Yes
If you answered yes to any of these questions provide full details on the continuation sheet.
13. Present Address (House Number, Street, Apt #, city, state, Zip Code)
14. Legal Residence (House Number, Street, Apt #, city state, Zip Code
15. Home Telephone Number
16. Work Telephone Number
17a. E-mail Address:
18. Present Marital Status
17. Mobile Telephone Number
17b. Social Networking Sites (i.e. Facebook)
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
If you are satisfied with your explanations check here.
20. Marriage Data (including present and all former spouses)
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)?
No
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
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?
No
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)
Other Parent
Guardian
Other Parent
Guardian
Name
Address
30. Do you have any dependents other than those listed above?
No
Yes (list below)
Name
Address
Relationship
CONTINUATION PAGE
1
31. Are you receiving and/or responsible for paying any child support?
If yes, is the child support court ordered? No
Yes
No
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.
____________________________________________________________________________
____________________________________________________________________________
1
CONTINUATION PAGE
1
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
1
CONTINUATION PAGE
1
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
No
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)
1
CONTINUATION PAGE
1
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
1
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?
No
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?
2
CONTINUATION PAGE
2
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)?
No
Yes
Are you currently over 90 days delinquent on any debt(s)?
No
Yes
If you answered yes to either question, provide the information requested below.
Type of Debt
When incurredAmount Present Balance To Whom Owed
14. Have you been a party to any public record civil court actions?
No
Yes
If you answered yes, provide the information requested below.
Month/Year Action
Result
Name of Parties
2
Court
_
CONTINUATION PAGE
2
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
2
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
2
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
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
FOR PRESENT RESIDENCE ONLY:
Do you
Rent
Own
Do you reside with
Self
Spouse & Children (if any)
Dates of Residence
FROM
Neighbors Name (Last, First, MI)
Other____________________
Location of Residence
Street Address (Apt. #, city, state, Zip Code)
TO
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
2
Dates of Residence
FROM
Location of Residence
Street Address (Apt. #, city, state, Zip Code)
TO
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Dates of Residence
FROM
Neighbors Name (Last, First, MI)
Location of Residence
Street Address (Apt. #, city, state, Zip Code)
TO
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
2
Dates of Residence
FROM
Location of Residence
Street Address (Apt. #, city, state, Zip Code)
TO
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Dates of Residence
FROM
Neighbors Name (Last, First, MI)
Location of Residence
Street Address (Apt. #, City, State, Zip Code)
TO
Neighbor’s Telephone Number
Neighbors Address (Street Number, city, state, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
2
Dates of Residence
FROM
Location of Residence
Street Address (Apt. #, City, State, Zip Code)
TO
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Dates of Residence
FROM
Neighbors Name (Last, First, MI)
Location of Residence
Street Address (Apt. #, City, State, Zip Code)
TO
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
Neighbors Name (Last, First, MI)
Neighbor’s Telephone Number
Neighbors Address (Street Number, City, State, and Zip Code)
PERSONAL HISTORY STATEMENT
Part XI. Education Data
1. Name of Senior High School
Address (Street Address, City, State, Zip Code
_________________________________________________________________________________
Dates Attended (Month, Year)
Highest Grade
Did you graduate? No
Yes
From
To
Completed
Did you receive a diploma?
No
Yes
2. Did you pass a General Education Development (G.E.D.) Test?
4. Did you obtain your G.E.D. Certificate from the Armed Forces?
N/A
No
Yes (answer questions 4 through 6)
Yes
5. If you have a G.E.D. certificate, has it been presented to a Board of Education?
N/A
No (Explain on continuation sheet)
Yes (Answer question 8)
6. Did the Board of Education present you with a High School Diploma?
N/A
No
Yes (complete the following)
Name of Board of Education
Board’s Complete Mailing Address
Date Diploma Issued
7. List Athletic, Scholastic, Honors, or other Awards
____________________________________________________________________________________
____________________________________________________________________________________
8. Were you ever Disciplined, Dismissed, Suspended, or Expelled in High School?
No
Yes (Explain)
_______________________________________________________________
______________________________________________________________
______________________________________________________________
3
CONTINUATION PAGE
3
9. List all Colleges and Universities attended
Name of College/University
Location
Dates Attended
How many credit hours did you complete?
Degree Attained
What was your Major?
11. Characterize your grades (check one)
Poor
Passable
Average
Good
Excellent
12. List Athletic, Scholastic, Honors, or other Awards received while in College/University
___________________________________________________________________________________
___________________________________________________________________________________
13. Were you ever Disciplined, Dismissed, Suspended, or Expelled in College/University?
No
Yes _____________________________________________________________________
_____________________________________________________________________
How was your conduct and deportment in college (Give details)?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14. Have you ever been interviewed, cited, detained, arrested, or had any other contact with
any College/University police agency?
No
Yes (Give details on continuation sheet)
3
CONTINUATION PAGE
3
PERSONAL HISTORY STATEMENT
Part X. Employment Data
List your COMPLETE work history, starting with your present position. List all periods of active military duty and all
periods of employment. Include periods of part-time, temporary, voluntary, or unemployment and identify as such.
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: _____________________________________________________________________
EMPLOYER ADDRESS: ____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ___________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): __________________________________________________
SUPERVISOR’S PHONE NUMBER: __________________________________________________
REASON FOR LEAVING: __________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ____________________________________________________________________
EMPLOYER ADDRESS: ___________________________________________________________
JOB TITLE/DESCRIPTION: _____________________________________SALARY: ___________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): __________________________________________________
SUPERVISOR’S PHONE NUMBER: __________________________________________________
REASON FOR LEAVING: ___________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: _____________________________________________________________________
EMPLOYER ADDRESS: ____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ___________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ___________________________________________________
SUPERVISOR’S PHONE NUMBER: ___________________________________________________
REASON FOR LEAVING: ____________________________________________________________
3
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
3
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
3
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
FROM (Month/Year)
TO (Month/Year)
EMPLOYER: ______________________________________________________________________
EMPLOYER ADDRESS: _____________________________________________________________
JOB TITLE/DESCRIPTION: ______________________________________SALARY: ____________
Full-time
Part-time
Temporary
Voluntary Intermittent Unemployed
SUPERVISOR’S NAME (First, Last): ____________________________________________________
SUPERVISOR’S PHONE NUMBER: ____________________________________________________
REASON FOR LEAVING: ____________________________________________________________
3
1. If you are currently unemployed, are you receiving, have you applied for, or do you
intend to apply for
Unemployment Compensation
Welfare Payments
Strike Benefits
Other Sources of Income
No
No
No
No
Yes
Yes
Yes
Yes
If you checked “Yes” to any of the above, give details, including amounts received or to
be received and the Name(s) of the Organization(s) providing the benefits or income.
________________________________________________________________________________
________________________________________________________________________________
2. Have you had any extended work absences for reasons other than earned vacation?
No
Yes (Explain)
3. Have you ever been discharged from employment (fired) for any reason?
No
Yes (Explain)
4. Have you ever resigned (quit) after being informed that your employer intended to discharge (fire) you for any
reason?
No
Yes (Explain)
5. Have you ever resigned (quit) after being informed that your employer intended to take
any form of disciplinary action against you?
No
Yes (Explain)
6. Have you ever walked off (left) a job without giving proper notice?
No
Yes (Explain)
7. Have you ever stolen anything from any of your employers?
No
Yes (Explain)
8. Have you ever used illegal drugs on any job you ever held?
No
Yes (Explain)
9. Have you ever committed any other crimes (EVEN THOSE WHICH WENT UNDETECTED)
while on any job you ever held?
No
Yes (Explain)
CONTINUATION PAGE
PERSONAL HISTORY STATEMENT
Part XI. Driving Record
1. Insert data below for all (even dismissed) traffic violations or citations (excluding Parking Tickets) that you have
received since first receiving a driver’s license. Include in your response, but do not limit it to, such violations as
Speeding, Reckless Driving, Changing Lanes Without Caution, Stop Sign Violations, Red Light Violations, and
Driving While Intoxicated (DWI/DUI).
Date
Violation/Charge
Location (City/State)
Police Agency
___
_____________________________________
___
____________ ___________________________
___
_____________ _________________ ___________
Final Disposition
_
Fine Amt. Points
_________________________
__
___
__
____________
____________ ______________
_
__
________ ______________________________
__ _______________________
__
____
____________ __________________________
_ ________________________
__
___
_____________ ______________________
___________________________
2. Do you currently have a valid driver’s license for the state in which you reside?
No
__
Yes
3. Provide the information requested below on all Driver’s Licenses that are now or have been issued to you from
any state (even though these licenses may now be expired or have been replaced by another issuing agency or
state).
Issuing state
License Number
Expiration Date
Type of License
_______
______________
4. Is your Driver’s License now or has it ever been:
Denied or Refused
Suspended
Revoked
Subjected to any other similar
Penalty or Action
No
No
No
Yes
Yes
Yes
No
Yes
If you answered “Yes” to any of the above, explain in detail below.
________________________________________________________________________________
________________________________________________________________________________
5. Are there any restrictions or special conditions attached with your Driver’s License?
4
CONTINUATION PAGE
4
6. Have you ever obtained or possessed a falsified or fictitious driver’s license?
No
Yes (Explain) _____________________________________________________________
_____________________________________________________________
7. What is your Vehicle(s) Registration (Tag) Number and state?
8. Are your Vehicle License Plates now or have they ever been:
Denied
Suspended
Revoked
Subjected to any other similar
Penalty or Action
No
No
No
Yes
Yes
Yes
No
Yes
If you answered “Yes” to any of the above, explain in detail below.
_________________________________________________________________________________
_________________________________________________________________________________
9. List all Motor Vehicle Accidents (include Date, Time, Place, Charges, Fault, Injuries,
name of Police Agency that made the report, and final disposition of the case.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
10. Is there anything else you wish to state about your driving record? Please use the space
below.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4
CONTINUATION PAGE
4
PERSONAL HISTORY STATEMENT
Part XII. Arrest/Conviction Data
1. Have you ever been
If you answer yes to any of the following questions give full
explanations on the continuation page.
Arrested
Charged by any Law Enforcement Authority
Convicted of any offense against the law
Subjected to Forfeiture of Collateral in Connection
with an arrest
Placed on Probation
Released on Parole
Required to appear before a Juvenile Court for an act
that would have been a crime if committed by an Adult
Fingerprinted for any reason
Placed in handcuffs for any reason
Investigated or questioned for any reason by any
Law Enforcement Authority
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
Yes
NOTE: List below (see item 6) all charges even those dismissed, expunged, or nolle processed.
If more than one instance, fully explain each instance.
2. Are you now
Charged with an offense by any Law Enforcement Authority
Presently on Bail or Out on Personal Recognizance or
other Conditional Release
On Probation of any type (include restricted drivers license)
No
Yes
No
No
Yes
Yes
3. Are you now or have you ever been involved as a Defendant in any Criminal Court action?
No
Yes
4. Are you now or have you ever been involved as a Plaintiff or Defendant in any Civil Court action?
No
Yes
5. Do you currently have any judgments against you?
No
Yes
6. If you answered “Yes” to any of the questions on this page, give full and complete details below.
Include (as a minimum) the date of the offense, original charge(s), final charge(s), city and state, name
of law enforcement agency involved, Circumstances of case, and final disposition. For judgments give case
number, court location, reason for case, and final disposition.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4
CONTINUATION PAGE
4
PERSONAL HISTORY STATEMENT
Part XIII. Criminal History
1. Do you now, or have you in the past, used, tried, or experimented with
Marijuana (in any form)
Narcotics of any kind (Heroin, Cocaine, Crack,
Morphine, Codeine, etc.)
Dangerous Drugs of any kind (LSD, PCP, MDA, Ecstasy)
Other illegal drugs not mentioned above (Amphetamines,
Barbiturates, Quaaludes, Valium, etc.)
Inhalants (Glue, solvents, aerosols, whip-its, etc.)
No
Yes
No
No
Yes
Yes
No
No
Yes
Yes
2. Do you now, or have you in the past, bought, possessed, sold, or transferred/transported Marijuana, Narcotics,
Or other dangerous or illegal drugs?
No
Yes
3. Have you ever closely associated with or had an ongoing friendship/personal relationship
with anyone you suspected/or knew was a seller of controlled substances? No
Yes
4. Have you been present when controlled substances were either used, sold, possessed, or
delivered?
No
Yes
5. Do you now take, or have you ever taken, any medication other than under your Doctor’s
prescription (with the exception of over-the-counter medications)?
No
Yes
6.
Has your use of alcoholic beverages resulted in any alcohol-related treatment or counseling?
7. Have you ever participated in underage drinking?
No
No
Yes
8. Has any member of your immediate family habitually used alcoholic beverages or habit-forming drugs?
No
Yes
9. Have you ever been in a physical altercation?
No
Yes
10. Have you ever intentionally damaged or defaced someone else’s property?
11. Have you ever stolen/shoplifted?
No
No
Yes
Yes
12. Have you been involved in undetected crimes?
No
Yes
NOTE: If you answered “Yes” to any of the questions on this page, give complete details on the
next continuation sheet on the next page.
4
Yes
CONTINUATION PAGE
4
PERSONAL HISTORY STATEMENT
Part XIV. Gambling
1. Do you gamble?
Never
Seldom
Occasionally
Regularly
If so, on what:
2. Have you ever placed a wager/bet by telephone or made a hand-to-hand transaction with a bookmaker
(bookie or numbers runner) on the results of a professional or collegiate sports event, other than a
legitimate lottery, or other legalized gambling event?
No
Yes (Explain) ____________________________________________________________
____________________________________________________________
3. Have you ever worked for a bookie?
No
Yes (Explain)
_________________________________________________________________________________
4. Have you ever been “paid off” while or after playing any illegal slot machine/video game?
No
Yes (Explain) _____________________________________________________________
5. Do you have any outstanding gambling debts? No
Yes (Explain)
________________________________________________________________________________
6. Have you ever borrowed money to gamble?
No
Yes (Explain)
________________________________________________________________________________
7. Have you ever used an employer’s money to gamble?
No
Yes (Explain)
________________________________________________________________________________
8. Have you ever stolen money with which to gamble?
No
Yes (Explain)
__________________________________________________________________________________
CONTINUATION PAGE
PERSONAL HISTORY STATEMENT
Part XV. Miscellaneous
1. Are you a member of, or have you ever been a member of, any Communist or Subversive Organization
or any Political Party or Organization that advocates the Overthrow of our Constitutional Form of
Government in the United States, or do you have membership in, or any affiliation with any Group,
Association, or Organization that advocates or lends support to any Organization or Movement
advocating the overthrow of our Constitutional Form of Government in the United States?
No
Yes (name the organization and give complete details)
__________________________________________________________________________________
__________________________________________________________________________________
2. The U.S Park Police maintains standards for the proficiency in firearms, a 24 hour work schedule and for
minimum appearance and grooming. Is your situation one that could:
Limit or prohibit your use of weapons or firearms
Restrict or prohibit you from working on particular
days or hours
Restrict you from conforming to Departmental Standards
of appearance and/or grooming
No
Yes
No
Yes
No
Yes
If you answered “Yes” give complete details.
________________________________________________________________________________
3. Have you ever been issued a permit or license to carry a handgun or other weapon on your person?
No Yes (Explain) ______________________________________________________________
4. If you have ever been issued a permit or license to carry a handgun, have you ever discharged your
weapon (other than at an approved range), or been the subject of an investigation regarding the discharge
of your weapon?
No
Yes (Explain) _____________________________________________________________
5. List any special skills you possess that you believe may be applicable to the position for which you are
applying (skills with equipment, public speaking experience, membership in a professional, scientific,
community, or other such organization, etc.)
_______________________________________________________________________________
_______________________________________________________________________________
5
CONTINUATION PAGE
5
6. Are you able to communicate in any language other than English (including sign language)?
Enter language and indicate your knowledge of each by placing an “x” in the proper column.
Reading
Language
Exc. Good Fair
Speaking
Exc. Good Fair
Understanding
Exc. Good Fair
Writing
Exc. Good Fair
_____
_____
7. List hobbies and spare-time interests.
________________________________________________________________________________
8. List all police/law enforcement/fire agencies below with whom you have applied. List the steps you have
completed with the agency (written test, oral interview, polygraph, background completed, physical agility,
medical, psychological, etc.) also list final status. If you have applied to the same agency more than once,
list each time separately.
Agency
Address
Date
Applied
Phone
Ann.
No.
Steps
Taken
Investigator
Final
Status
9. Have you ever applied for a police officer position with the U.S. Park Police? No
Yes
If yes, provide dates applications were submitted ___________________________________________
10. Have you ever been denied employment by any Organization noted in items 8 and 9 above?
No Yes (provide agency name and reason for denial)
___________________________________________________________________________________
___________________________________________________________________________________
11. Have you ever applied for any Federal position for which a background investigation was initiated?
No
Yes (provide agency name)
5
CONTINUATION PAGE
5
12. Do you have experience as a sworn police/law enforcement officer?
No
Yes (Provide details) __________________________________________________________
__________________________________________________________
13. Do you have any objections to being reassigned to any area within the United States?
No
Yes
If yes, state objection _______________________________________________________________
_______________________________________________________________
14. If you are selected for appointment, how many days notice do you require? _______
15. List any family member or friend who is currently employed by this Department or who has been
employed by the Department of the Interior in the past.
________________________________________________________________________________
________________________________________________________________________________
16. Are there incidence in your life not mentioned elsewhere herein that may reflect upon your suitability
to perform the duties that you may be called upon to take or that might require further explanation?
No
Yes (If yes, give details) ___________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
5
CONTINUATION PAGE
5
PERSONAL HISTORY STATEMENT
Part XVI. Essay
State in your own words why you want to be a United States Park Police Officer.
5
CONTINUATION PAGE
CONTINUATION PAGE
APPLICANT’S CERTIFICATION AND SIGNATURE
I understand that sworn appointments to the United States Park Police are probationary for a
period of one year from the hire date. During this probationary period officers must demonstrate
their fitness for continued employment with the United States Park Police.
I am aware that withholding/omitting information or making false statements on the Personal
History Statement may be the basis for disapproval before appointment, or dismissal after
appointment, and constitutes a felony violation of the United States Code, Title 18, Section
1001. I hereby acknowledge these conditions and certify that all statements made by me on
this Personal History Statement are true and complete, to the best of my knowledge.
Signature of Applicant ________________________________________
Date ________________________________________20____
SUBSCRIBED AND SWORN TO BEFORE ME
This _________________________ day of _______________ 20 ______
___________________________________________
Notary Public
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| File Type | application/pdf |
| File Title | United States Park Police |
| File Modified | 2010-08-26 |
| File Created | 2010-06-01 |