Form USPP Form 1 USPP Form 1 United States Park Police Personal History Statement

United States Park Police Personal History Statement

USPP 1 - 2014

US Park Police Personal History Statement

OMB: 1024-0245

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USPP Form 1
Revised December 2013

OMB Control No. 1024-0245
Expires: ________________

United States Park Police
Personal History Statement
CONFIDENTIAL
QUESTIONNAIRE
POLICE OFFICER CANDIDATE

United States Department of the Interior
National Park Service
United States Park Police
Washington, DC 20242

United States Park Police
PERSONAL HISTORY STATEMENT
Table of Contents

Page
Instructions to the Applicant

Privacy Act Notice

Part I

Papers – Documents that are required

7-8

Part II

Personal Data

9 - 20

Part III

Selective Service / Part IV Military Data

21 - 24

Part V

Financial Data

25 - 28

Part VI

References

Part VII

Personal Associates

Part VIII

Residence Data

31 - 34

Part IX

Education Data

35 - 38

Part X

Employment Data

39 - 44

Part XI

Driving Record

45 - 48

Part XII

Arrest/Conviction Data

49 - 50

Part XIII

Criminal History

51 - 52

Part XIV

Gambling

53 - 54

Part XV

Miscellaneous

55 - 60

Part XVI

Essay

61 - 63

Applicant Signature Page

INSTRUCTIONS TO THE APPLICANT

This form must be PRINTED by the applicant and each question answered completely and 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 and/or not notarized, it will be returned to you and you will not move forward in the
process until the application is in compliance with the instructions provided herein. The date of the notary seal
must match the date of your signature on the last page and must be completed prior to the date you
submit the form to the United States Park Police.
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;
4. all time periods in your background must be accounted for; and
5. no changes to the document are permitted after it is notarized.
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 removed from further consideration 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.
The employment application form requests specific information. 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.
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 OF THIS DOCUMENT MUST BE SIGNED AND NOTARIZED *
Paperwork Reduction Act Statement. We collect this information to help us determine your suitability for the position of a
United States Park Police Officer. Your obligation to respond is required to obtain the position of a United States Park Police
Officer. A Federal agency may not conduct or sponsor and you are not required to respond to a collection of information unless it
displays a valid OMB control number. We estimate that it will take you 8 hours to complete this form, which includes time to
review instructions, search information sources, and gather and report the information. You may send comments on the time
estimate and other aspects of this information collection to the Information Collection Clearance Officer, National Park Service,
1849 C Street, NW. (2600), Washington, DC 20240.

PRIVACY ACT STATEMENT

Authority: 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.
Purpose: To investigate and determine the applicant’s fitness for employment purposes, including a security
clearance and an evaluation of qualifications, suitability, and loyalty to the United States.
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all or a
portion of the information collected may be disclosed as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: To
the United States or any agency, pursuant to litigation; pursuant to an inquiry from a congressional office; to the
National Archives and Records Administration or other Federal government agencies pursuant to records
management inspections; to an agency or organization for the purpose of performing audit or oversight operations; to
contractors and their agents, grantees, consultants, and others performing on a contract, grant, cooperative
agreement, when necessary to accomplish an agency function; to the Department of Justice and other Federal, State,
and local governmental agencies having a prosecution function; and for civil and other proceedings involving the
USPP protective functions; to Federal, State, and local law enforcement agencies, foreign and domestic, for the
purpose of developing information on subjects involved in USPP protective investigations and evaluation, and
protective functions; 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; to any agency of the Federal Government having a
working relationship with regard to Office of Personnel Management activities; and to the intelligence agencies of the
Federal Government, or to others having reasons as published in the Federal Register.
Disclosure: Furnishing this information is voluntary; however, failure to furnish the requested information may delay
or prevent the completion of your background investigation, which may remove you from the hiring process and you
will not be able to obtain the services, benefits, or processes that you are seeking.
Information Regarding Disclosure of your Social Security Number (SSN) Under Public Law 93-579, Section
7(b) - Solicitation of SSNs by the Office of Personnel Management (OPM) is authorized under provisions of the
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 when directed.
1. Birth Certificate
2. High School Diploma or GED (GED must be accompanied by test scores)
3. College transcripts (transcripts must be official copies provided by the institution in a sealed
envelope) and diploma upon request
4. DD-214(s) for each period of Military Service, as well as all paperwork that supports any judicial
or non-judicial punishment, and all paperwork related to any military discharge considered other
than honorable
5. Selective Service Card (even if you served in the military)
6. Naturalization certificate
7. Marriage license(s)
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, and copies of police reports of
incidents you have been involved in.
9. Driver’s 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 tax transcripts and State Tax forms
(include W-2’s) (contact www.irs..gov and each State tax authority you filed in to obtain transcripts and
copies of filed returns

11. A copy of your credit report, obtained after the opening date of this current vacancy
announcement
Continued…

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. Failure to present required documents could delay your processing or remove you from
further consideration

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 applicant’s 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. Selective Service Number

2. Date of Registration

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 and provide copies of all relevant paperrwork.

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) ______________________________________________________
______________________________________________________
Provide copies of all relevant paperwork

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

Yes (Explain) ______________________________________________________
______________________________________________________
Provide copies of all relevant paperwork

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).
 Self

Source of Income

 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) neighbor’s (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