The Texas Personal History Statement form is a crucial document required for individuals seeking licensure as peace officers or jailers in Texas. This form collects essential personal information, ensuring that applicants meet specific eligibility criteria. Completing this form accurately and truthfully is vital, as any misrepresentation can lead to disqualification from the application process.
The Texas Personal History Statement form is a crucial document for individuals seeking licensure as peace officers or jailers within the state. This form serves as a comprehensive application that collects essential personal information, including the applicant's full name, contact details, and physical description. It also requires applicants to disclose any previous law enforcement agency applications, ensuring a thorough background check. Key eligibility criteria must be met, such as citizenship, educational qualifications, and a clean criminal record. The form emphasizes the importance of honesty; any deliberate misrepresentation can lead to disqualification from the hiring process. Additionally, it respects applicants' privacy by not requiring medical information until a conditional job offer is made. Completing this form accurately is vital, as it not only reflects the applicant's qualifications but also their integrity, which is paramount in law enforcement roles.
DP-1
THE UNIVERSITY OF TEXAS SYSTEM POLICE
PERSONAL HISTORY STATEMENT
APPLICANT NAME
POSITION
Date Issued:
Return By:
Received On:
Received By:
9.14.11 MT
PERSONAL HISTORY STATEMENT for TEXAS LICENSURE
Instructions to the Applicant
Before you begin to fill out this personal history statement, please ensure that you meet the following requirements. You must meet all five of these requirements to qualify for licensure as a peace officer or jailer in Texas.
I am a citizen of the United States of America.
I have earned a high school diploma or a GED.
I have never been convicted, pleaded guilty to (nolo contendere), nor have I been on court-ordered community service/probation or deferred adjudication for a Class A misdemeanor or a felony.
During the last ten (10) years, I have not been convicted, pleaded guilty to (nolo contendere), been on community service/probation or deferred adjudication for a Class B misdemeanor in this state, other state, or while serving in the military.
I have never had a military court martial that resulted in a dishonorable or bad conduct discharge.
DISQUALIFICATION
There are very few automatic conditions for rejection. Even issues of prior misconduct, employee terminations, and arrests are
usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or omissions can and often will
result in your application being rejected, regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is because they deliberately withhold or misrepresent job-relevant
information from their prospective employer.
This personal history statement is a governmental document. Be truthful, as there are criminal consequences for being untruthful on a governmental document.
Once you begin:
Type or neatly print, in ink, responses to all items and questions. If a question does not apply to you, write “N/A”
(not applicable) in the space provided for your response. If you cannot obtain or remember certain information, indicate so in your response.
If you need more space for any response, use the last page of this form (page 27) and identify the additional information by the question number.
Be as complete, honest and specific as possible in your responses.
Disclosure of Medically-Related Information
In accordance with the U.S. Americans with Disabilities Act, at this stage of the hiring process applicants are not expected or required to reveal any medical or other disability-related information about themselves in response to questions on this form, or to any other inquiry made prior to receiving a conditional offer of employment.
Initial this page to indicate that you have provided complete and accurate information: _____
SECTION 1: PERSONAL
1. YOUR FULL NAME
LAST
FIRST
MIDDLE
2.OTHER NAMES, INCLUDING NICKNAMES, YOU HAVE USED OR BEEN KNOWN BY
3.ADDRESS WHERE YOU RESIDE
NUMBER / STREET
APT / UNIT
CITY
STATE ZIP
4.MAILING ADDRESS, IF DIFFERENT FROM ABOVE
5.CONTACT NUMBERS
HOME (
)
WORK (
EXT
OTHER (
CELL
FAX
6.
EMAIL ADDRESS
HOME
BUSINESS
7.
BIRTH PLACE
(CITY / COUNTY / STATE / COUNTRY)
8. BIRTHDATE
9. SOCIAL SECURITY #
–
10. DRIVER’S LICENSE
NO.
STATE
EXP
11. PHYSICAL DESCRIPTION
HT.
WT.
HAIR COLOR
EYE COLOR
12. Have you ever attended a basic licensing course?
Yes No
If yes, provide the following information: PID:
A)
ACADEMY NAME
FROM
TO
DID YOU GRADUATE?
Yes
No
LOCATION
(CITY / STATE)
NAME OF TRAINING OFFICER / ACADEMY
CONTACT NUMBER
COORDINATOR
(
B)
13.Have you ever applied to any other law enforcement agency in the last ten years (city, county, state or federal)?...
If yes, list ALL agencies you have applied to, starting with the most recent (give complete and accurate addresses).
All agencies MUST be listed regardless of the outcome or current status. Check all boxes that apply for each agency.
If more space is needed, continue your response on page 27.
A) NAME OF AGENCY
DATE APPLIED
ADDRESS (NUMBER / STREET)
BACKGROUND INVESTIGATOR’S NAME (IF KNOWN)
ZIP
STAT
POSITION APPLIED FOR
EMAIL
Check each step in the process that you completed, and your status:
STEPS:
Application
Written
Physical agility
Oral
Polygraph/CVSA
Background
Chief’s oral
Conditional job offer
STATUS:
Hired
On List
Withdrawn
Disqualified
13. Have you ever applied to any other law enforcement agency… continued
B) NAME OF AGENCY
BACKGROUND INVESTIGATOR’S NAME (IF
KNOWN)
C) NAME OF AGENCY
ADDRESS
(NUMBER / STREET)
Check each
step in the process that you completed, and your status:
SECTION 2: RELATIVES AND REFERENCES
14.IMMEDIATE FAMILY
Provide all applicable information in the spaces below.
Mark “N/A” if a category is not applicable or if the individual is deceased.
N/A A. Father
NAME
HOME ADDRESS
(NUMBER / STREET / APT)
HOME PHONE
WORK ADDRESS
()
WORK PHONE
CELL PHONE
N/A
B. Step-father
SECTION 2: RELATIVES AND REFERENCES continued
14.IMMEDIATE FAMILY continued
C. Mother
D.
Step-mother
N/A E. Spouse / Registered Domestic Partner
YEARS OF
MARRIAGE
Is there, or has there been, a restraining or stay-away order in effect for this individual?
F. Father-in-law
G. Mother-in-law
H. Former Spouse(s) / Cohabitant
1) NAME
YEAR OF
DISSOLUTION
2) NAME
N/A I. Brothers and Sisters – list all living siblings, including half-siblings, step-siblings, foster siblings, etc.
M
F
UNDER
AGE 18
3) NAME
4) NAME
5) NAME
6) NAME
J. Children
List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you.
Provide the name and contact information of the custodial parent or guardian, if other than you.
CUSTODIAL PARENT OR GUARDIAN (IF OTHER THAN YOU)
CHILD’S AGE
ADDRESS (NUMBER / STREET / APT)
4)
5)
6)
15.REFERENCES
List 7–10 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.
A) NAME
CITY STATE
HOW DO YOU KNOW THIS PERSON? (FOR EXAMPLE: FRIEND, TEACHER,
HOW LONG HAVE YOU KNOWN
FAMILY FRIEND, CO- WORKER)
THIS PERSON?
B) NAME
C) NAME
D) NAME
HOME ADDRESS (NUMBER / STREET / APT)
E) NAME
F) NAME
G) NAME
H) NAME
I) NAME
J) NAME
SECTION 3: EDUCATION
NOTE: You will be required to furnish transcripts or other proof to support all of your educational claims.
16.
Check applicable:
High School Diploma
GED
17. List high schools attended:
DID YOU
GRADUATE?
18. List all colleges or universities attended:
TOTAL UNITS
TYPE OF
EARNED
DEGREE
C)
19. List any trade, vocational, or business schools/institutes attended:
COMPLETE
TYPE OF SCHOOL OR TRAINING
THE COURSE?
SECTION 3: EDUCATION continued
20. Have you ever been placed on academic discipline, suspended, or expelled from any high school, college/university, business or trade school? Yes No
If yes, describe in detail below. Starting with high school, list any and all disciplinary actions received in any school or educational institution. Include when the disciplinary action(s) occurred, name of school(s), and explanation of circumstances.
SECTION 4: RESIDENCE
21.LIST OF RESIDENCES
List all residences during the last ten years or since age 15. Provide complete addresses (include markers such as Street, Drive, Road, East, West, etc., and unit or apartment number). Do not use P.O. Boxes.
If the residence is a military base, identify name of base in address, nearest city, state and zip code. DO NOT LIST military barracks mates unless you shared individual quarters.
If more space is needed continue on page 27.
A) ADDRESS WHERE YOU NOW LIVE
Present
IF RENTING: PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER
(NUMBER /
STREET / APT)
Names of those with whom you live:
B) FORMER ADDRESS
Names of those with whom you lived:
Reason for moving:
C) FORMER ADDRESS
IF RENTING: PROPERTY MANAGER, RENT
COLLECTOR, OR OWNER
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