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IMPORTANT

INFORMATION
TCOLE Personal History Statement Template Instructions
The attached Personal History Statement (PHS) is intended as a sample of
what TCOLE considers to be the minimum information necessary to meet
the reuired !ac"#round In$esti#ation (!I) for any Peace Officer% &ailer% or
Telecommunicator appointed to an a#ency% as defined under TCOLE 'ule
())*)(a)(+)*
,#ency administrators may modify the attached document or use their own
$ersion of a !I or PHS document- as lon# as it is substantially similar to the
attached sample* Indi$idual uestions may be added or deleted accordin# to
the reuirements of the appointin# a#ency* They may also decide at which
sta#e in the pre.appointment process the PHS/!I will be completed% as lon#
as it is done before the applicant is appointed* The ob0ecti$e is to help the
a#ency1s chief administrator to ma"e an informed decision based on factual
and $erifiable information*
The !I/PHS is an auditable document which must be retained alon# with all
other reuired TCLEOSE appointment documents throu#hout the licensee1s
employment and fi$e (2) years after he or she lea$es the a#ency*
PHS 1/1/14
Texas Commission on Law Enforcement Personal History Statement
TEXAS COMMISSION ON LAW ENFORCEMENT
APPLICANTS PERSONAL HISTORY STATEMENT
333Sample333
NAME
DATE ISSUED
COMPLETE AND RETURN BY
I am applying f!"
# $ P%a&% Offi&%! PID'(((((((((((((((
# $ C)n*y +ail%! PID'(((((((((((((((
# $ T%l%&mm)ni&a*! PID'(((((((((((((((
# $ Ci,ilian Emplym%n*
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Texas Commission on Law Enforcement Personal History Statement
Personal History Statement Instructions
Employees are exposed to confidential and law enforcement sensitive information. A thorouh !ac"round
investiation is re#uired to properly evaluate the suita!ility of applicants for employment with the aency.
Althouh it is an achievement to reach the !ac"round phase of the hirin process$ this is still a competitive
process and does not$ in any way$ uaranty selection.
%hese instructions are provided as a uide to assist you in properly completin your Personal History Statement.
It is essential that the information is accurate in all respects so please read all instructions carefully before
proceeding. %he Personal History Statement will !e used as a !asis for a !ac"round investiation that will
determine your elii!ility for !ecomin an employee.
1. &our application must !e printed lei!ly in BLACK INK !y the applicant or typed. Answer all #uestions
truthfully and accurately.
2. 'f a #uestion is not applica!le to you$ enter N/A in the space provided.
(. Avoid errors !y readin the directions carefully !efore ma"in any entries on the form. )e sure your
information is accurate and in proper se#uence !efore you !ein.
4. &ou are responsi!le for o!tainin correct and full addresses. 'f you are not sure of an address$ personally
verify !efore ma"in that entry on this history statement. Errors will not !e viewed favora!ly. ALL
A!"SS"S #$S% B" C&#PL"%" 'I%H (IP C&"S)
*. 'f you need additional space for your answers$ attach an additional sheet or sheets as needed. )e sure to
indicate what #uestion num!er and pae this refers to.
+. An accurate and complete form will help expedite your investiation. &missions or falsifications will
result in dis*ualification)
,. &ou are responsi!le for furnishin any chanes and/or updatin your application as needed$ such as
address chanes or telephone chanes in writin.
-. Any candidate su!mittin an incomplete application 'ILL N&% B" C&NSI"!" +&!
"#PL&,#"N%. &our application -ill be e.aluated on completeness and neatness)
.. All documents re#uested must !e su!mitted with the application /photocopies are accepta!le in most
cases0. 1e#uired documents vary accordin to the position !ein souht and the history of the applicant.
Hirin aency please chec" off documents re#uired2 modify list as necessary
3ompleted Personal History Statement
3opy of your Social Security card.
4riinal certified copy of your !irth certificate. /5o photo copy0
3opy of your valid %exas driver license or a copy of another State6s driver license. Applicant must
possess a valid %exas driver license prior to !ein offered employment.
3opy of your Hih School diploma or 7E8 certificate.
Sealed oriinal certified copy of your collee transcript. /5o photo copy0
Photocopy of your collee diploma.
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PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
3opy of your Peace 4fficer 3ertificate from your police academy. /Peace 4fficer Applicants
4nly0
3opy of your %exas peace officer license and all trainin certificates awarded to you. /Peace
4fficer Applicants 4nly0
3opy of your 882214 if applica!le. :ust possess an honora!le dischare.
4riinal certified copy of your 5aturali;ation papers$ if applica!le. /5o photo copy0
3opy of current proof of automo!ile lia!ility insurance.
3opy of a %34<E approved =irearms >ualifications within the last 12 months.
19. 'f you have any #uestions$ please contact your assined !ac"round investiator
11. ?hen su!mittin the completed documents$ please place them in a sealed envelope mar"ed Personal and
3onfidential to your assined !ac"round investiator.
Appli&an* -)alifi&a*in S%&*in
!efore you be#in to fill out this personal history statement% please ensure that you meet the
followin# reuirements* 4ou must meet all fi$e of these reuirements to ualify for licensure as a
peace officer or 0ailer in Te5as*
Initia
l6
777777I am a citi8en of the 9nited States of ,merica*
777777I ha$e earned a hi#h school diploma or a :E;*
777777I ha$e ne$er been con$icted% plead #uilty (nolo contendere)% nor ha$e I
been on court.ordered community ser$ice/probation or deferred ad0udication for a
Class , misdemeanor or a felony*
777777;urin# the last ten ()<) years% I ha$e not been con$icted% plead #uilty (nolo
contendere)% been on community ser$ice/probation or deferred ad0udication for a
Class ! misdemeanor in this state% other state% or while ser$in# in the military*
777777I ha$e ne$er had a military court martial that resulted in a dishonorable or
bad conduct dischar#e*
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Texas Commission on Law Enforcement Personal History Statement
DIS-UALIFICATION
There are $ery few automatic basis for re0ection* E$en issues of prior misconduct% employee
terminations% and arrests are usually not% in and of themsel$es% automatically disualifyin#*
Howe$er% deliberate misstatements or omissions can and often will result in your application
bein# re0ected% re#ardless of the nature or reason for the misstatements/omissions* In fact%
the number one reason indi$iduals =fail> bac"#round in$esti#ations is because they
deliberately withhold or misrepresent 0ob.rele$ant information from their prospecti$e
employer*
This personal history statement is a #o$ernmental document* !e truthful% as there are
criminal conseuences for lyin# on a #o$ernmental document*
APPLICANT IDENTIFICATION
I?@O'A,TIO? P'OBI;E; I? THIS SECTIO? IS 9SE; @O' I;E?TI@IC,TIO? P9'POSES O?L4*
Last ?ame @irst Aiddle Aaiden
Street ,ddress ,pt* ?o*
City State C Dip Code
Aailin# ,ddress (if different from
residence)
State C Dip Code
Home Telephone ?o* Eor" Telephone ?o* Cellular ?o*
Pa#er ?o*
*
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
;ate of !irth Social Security ?o* ;ri$ers License ?o* C State
Ha$e you e$er been "nown or #one by any other name (e5cludin# nic".names)F If yes% #i$e details*

7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Place of !irth (City% County% State% Country) 777777
,re you a 9*S* Citi8en by !irthF ,re you a ?aturali8ed Citi8enF
Hei#ht Eei#ht Eye Color Hair Color
Scars% Tattoos (description and location) or other distin#uishin# mar"s

;o you ha$e a social networ"in#% instant messa#in#% or other internet.based profile(s)F If yes% pro$ide screen name(s)%
ser$ice pro$ider(s)*
List ,LL E.Aail ,ddresses (S) 77777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
MARITAL . FAMILY HISTORY
Sin#le Aarried En#a#ed Co.habitin#
Spouse1s/Co.habitantGs name (include maiden name)
,ddress
;ate of !irth ;ate of Aarria#e
Employer(s)
Employer C ,ddress
Home Telephone ?o* Eor" Telephone ?o*
'oommate(s)(do not include parents or cohabitants)
;ate(s) of birth
+
Texas Commission on Law Enforcement Personal History Statement
If you ha$e been separated% di$orced% or widowed% pro$ide details below6
;ate of Aarria#e ;ate of Aarria#e
City C State City C State
Separated ;ate Separated ;ate
;i$orced ;ate ;i$orced ;ate
Eidowed ;ate Eidowed ;ate
,nnulled ;ate ,nnulled ;ate
Court or State issued Court or State issued
E5.spouse1s ?ame E5.spouse1s ?ame
;ate of !irth ;ate of !irth
Telephone ?o* Telephone ?o*
Identify children related to you or your spouse (?atural% Step.Children% ,dopted% or @oster Children)
'elation ?ame ;ate of !irth ,ddress
Identify relati$es in the followin# order6 @ather% Aother (include maiden name)% step.parents (if any)% brothers and sisters*
'elationship ?ame Complete ,ddress Phone ?umber ;O!
,
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
RESIDENCES
Identify all residences where you ha$e li$ed in the last )< years% /%ginning 0i*1 *1% m2* !%&%n*3 in&l)4ing y)!
p!%2%n* a44!%225 List date by month/year* In&l)4% mili*a!y a22ignm%n*25 6N TDY27
@rom To ,ddress City Sate C Dip code
PERSONAL REFERENCES
List fi$e (2) persons who "now you well enou#h to pro$ide current information about you* ;o not list relati$es% former or
present employers% or super$isors*
?ame 4ears "nown
,ddress
Home Telephone ,lternate Telephone
?ature of 'elationship777777777777777777777777777
-
Texas Commission on Law Enforcement Personal History Statement
?ame 4ears "nown
,ddress
Home Telephone ,lternate Telephone
?ature of 'elationship777777777777777777777777777
?ame 4ears "nown
,ddress
Home Telephone ,lternate Telephone
?ature of 'elationship777777777777777777777777777
?ame 4ears "nown
,ddress
Home Telephone ,lternate Telephone
?ature of 'elationship777777777777777777777777777
?ame 4ears "nown
,ddress
Home Telephone ,lternate Telephone
?ature of 'elationship777777777777777777777777777
Identify below any employees of the Te5as Commission on Law Enforcement with whom you are acuainted6




TRAFFIC RECORD
Identify all $ehicles that you currently own or operate6
4ear Aa"e Aodel Color License Plate ?o* Owner
.
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
Please list your current automobile insurance carrier6 E5pires6
Ha$e you e$er possessed a dri$er1s license issued by any state other than Te5asF 4es ?o
If yes% #i$e details below6
;ri$er1s License ?o* State ;ate issued
;ri$er1s License ?o* State ;ate issued
Ha$e you %,%! had your dri$er1s license suspended or re$o"edF 4es ?o If yes% #i$e reason% date% and len#th of
suspension6

Identify all motor $ehicle accidents you ha$e been in$ol$ed in durin# the last )< years*
;ate Location Police 'eport6 4es/?o
Cause of ,ccident (e*#*% ran red li#ht% failed to
control speed)
;ate Location Police 'eport6 4es /?o
Cause of ,ccident (e*#*% ran red li#ht% failed to
control speed)
Identify all traffic citations you ha$e recei$ed within the last )< years% e5cludin# par"in# tic"ets6
Aonth/4ear Biolation City C State ;isposition (e*#*% defensi$e dri$in#% dismissed)
ARRESTS3 DETENTIONS3 AND LITI8ATION
Ha$e you %,%! been arrested or detained by law enforcementF
4es ?o If yes% complete the followin# table6
19
Texas Commission on Law Enforcement Personal History Statement
,#ency Offense ;ate Location Outcome
Ha$e you %,%! committed an act of family $iolenceF (=@amily $iolence> means an act by a member of a family or
household a#ainst another member of the family or household that is intended to result in physical harm% bodily in0ury%
assault% or se5ual assault or that is a threat that reasonably places the member in fear of imminent physical harm% bodily
in0ury% assault% or se5ual assault% but does not include defensi$e measures to protect oneself*) (Te5as @amily Code Section
H)*<<I) If yes% e5plain6


Ha$e you %,%! assaulted another person since the a#e of se$enteen ()H)F (=,ssault> means to cause bodily in0ury to
another% threaten another with imminent bodily in0ury% or to cause physical contact with another when the person "nows or
should reasonably belie$e that the other will re#ard the contact as offensi$e or pro$ocati$e*) (Te5as Penal Code Section
((*<)) If yes% e5plain6


Ha$e you %,%! been considered or named a suspect in a criminal in$esti#ation or criminal offenseF If yes% e5plain6


Ha$e you %,%! been a party to a ci$il suit or actionF If yes% e5plain6

Ha$e you %,%! been in$ol$ed in any incident (do not include $ehicular accidents) in which a police report was made or law
enforcement was calledF If yes% e5plain6

Other than crimes that would ha$e been sealed by 0u$enile records% ha$e you e$er committed J or assisted another person
in the commission of J a felony crime% serious misdemeanor% or a crime in$ol$in# moral turpitude that went undetected or
unreported to law enforcementF If yes% e5plain6


;o you anticipate bein# sued or named in any type of lawsuit or proceedin#F 4es ?o
FAMILY AND RELATI9ES ARRESTS
Ha$e members of your immediate family or close relati$es ha$e e$er been arrestedF
11
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
4es ?o If yes% complete the followin# table6
?ame/'elationship Char#e/Offense Outcome 4ear ,#ency
FINANCIAL HISTORY
4our current net monthly income Spouse1s current net monthly income
Source Amount Frequency



;o you ha$e any accounts with a financial institutionF 4es ?o
?ame(s) of financial institution(s)
Type(s) of account(s)
Identify any person or entity to whom you are indebted% and the e5tent of your indebtedness* Include mort#a#es% $ehicle
payments% char#e accounts% credit cards% loans% child support payments% and any other debts or payments*
?ame of Creditor (e*#*% Sears% Citi financial) Type of ;ebt (e*#*% student loan% automobile) Aonthly Payment ,ppro5 !alance
CREDIT INFORMATION
12
Texas Commission on Law Enforcement Personal History Statement
Ha$e you %,%! filed ban"ruptcy personally or on behalf of a businessF 4es777777 ?o777777
If =4es> to abo$e% indicate type
Ha$e you %,%! had any personal or real property repossessed or foreclosedF 4es777777 ?o777777
Ha$e you %,%! failed to pay @ederal% state% or other ta5esF 4es777777 ?o777777
Ha$e you %,%! failed to file a ta5 return% when reuired by lawF 4es777777 ?o777777
Ha$e you %,%! had a lien placed a#ainst your property for failin# to pay ta5es or other debtsF 4es777777 ?o777777
Ha$e you %,%! had a 0ud#ment entered a#ainst youF 4es777777 ?o777777
Ha$e you %,%! defaulted on any type of loanF 4es777777 ?o777777
Ha$e you %,%! had bills or debts turned o$er to a collection a#encyF 4es777777 ?o777777
Ha$e you %,%! had any credit account suspended% char#ed off% or cancelled for failure to payF 4es777777 ?o777777
Ha$e you %,%! written a chec" that was later returned for ?on Sufficient @unds (?S@)F 4es777777 ?o777777
Ha$e you %,%! been delinuent on court.imposed alimony or child support paymentsF 4es777777 ?o777777
Ha$e you %,%! been disciplined re#ardin# the use of a tra$el/credit card pro$ided by an employerF 4es777777 ?o777777
,re you currently more than si5ty (K<) days delinuent on any debtsF 4es777777 ?o777777
Ha$e you %,%! applied for unemployment compensationF 4es ?o EhenF
Ha$e you %,%! recei$ed unemployment compensationF 4es ?o EhenF
Identify any person or entity to which you are m!% *1an :; 4ay2 la*% in payin#* Include mort#a#es% $ehicle payments%
char#e accounts% credit cards% loans% child support payments% and any other debts or payments*
?ame of Creditor (e*#*% Sears% Citi financial) Type of ;ebt (e*#*% student loan% automobile) ?umber of ;ays Late 'eason
EMPLOYMENT HISTORY
1(
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
!e#innin# with your present or most recent 0ob% list all employment since the a#e of se$enteen ()H)* Include full.time% part.
time% temporary% seasonal% military assi#nments% or unpaid internships% plus all periods of unemployment*
If y) a!% &)!!%n*ly %mply%43 may 0% &n*a&* y)! p!%2%n* %mply%!< 4es ?o
)* Employer @rom To
,ddress
Telephone ?o*
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


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((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
(* Employer @rom To
14
Texas Commission on Law Enforcement Personal History Statement
,ddress
Telephone ?o*
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


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((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
L* Employer @rom To
,ddress
1*
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
Telephone ?o*
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


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((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
I* Employer @rom To
,ddress
Telephone ?o*
1+
Texas Commission on Law Enforcement Personal History Statement
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


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((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((

2* Employer @rom To
,ddress
1,
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
Telephone ?o*
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
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7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


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((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
K* Employer @rom To
,ddress
Telephone ?o*
1-
Texas Commission on Law Enforcement Personal History Statement
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
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7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


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((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
H* Employer @rom To
,ddress
Telephone ?o*
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
1.
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
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7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


Wa2 *1%!% an )n%mplym%n* p%!i4 /%*0%%n p!%,i)2 %mplym%n* an4 *1% n% li2*%4 a/,%< (((((Y%2 ((((N
If y%23 p!,i4% 4a*%2 an4 %=plain" ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
+* Employer @rom To
,ddress
Telephone ?o*
&ob Title !e#innin# and Endin# Salary 7777777777777777/777777777777777777
29
Texas Commission on Law Enforcement Personal History Statement
Eor" Schedule
?ame of super$isor Super$isor contact information 77777777777777777777777777
?ame of a co.wor"er Co.wor"er contact information
;uties6 7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
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7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
Identify any disciplinary actions you recei$ed6


'eason for Lea$in#6


Wa2 *1%!% an )n%mplym%n* p%!i4 /%*0%%n p!%,i)2 %mplym%n* an4 *1% n% li2*%4 a/,%< (((((Y%2 ((((N
If y%23 p!,i4% 4a*%2 an4 %=plain" ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
EDUCATIONAL HISTORY
Hi#h School(s) attended ,ddress ;ates attended
@rom.To
:raduated
4es/?o
21
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
;o you ha$e a :*E*;* CertificateF
Eere you %,%! e5pelled from schoolF If yes% #i$e details6

Identify all colle#es% uni$ersities% or technical schools you ha$e attended6
?ame City C State ;ates attended Hours completed Aa0or ;e#ree C ;ate
MILITARY OBLI8ATION
Ha$e you e$er ser$ed in the 9*S* ,rmed @orces or State Ailitary @orcesF 4es ?o
Ser$ed from to Hi#hest 'an" held
;ate ;ate
!ranch of Ser$ice 9nit
&ob Title(s) (e*#*% 'ifleman% Security)
Type of dischar#e7777777777777777777 Last ;uty Station6 7777777777777777777777777777777
,re you acti$ely ser$in# in a 'eser$e 9nit (includin# State Ailitary @orces)F 4es ?o
Ser$in# from to Current 'an" held
;ate ;ate
!ranch of Ser$ice 9nit
&ob Title(s) (e*#*% 'ifleman% Security)
Ha$e you %,%! been sub0ect to court martial or any other disciplinary proceedin# under the 9niform Code of Ailitary
&usticeF (Include non.0udicial% CaptainMs mast% etc*) If N4es%N pro$ide date(s)% char#e(s)% military court(s) or authority(ies)%
and outcome(s)*


7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777
SPECIAL -UALIFICATIONS . S>ILLS
Identify any special licenses you hold (e*#*% pilot% radio operator)6
If you "now a forei#n lan#ua#e% indicate your fluency in each bloc" below (e5cellent% #ood% fair)
Lan#ua#e 9nderstandin# Spea"in# 'eadin# Eritin#
22
Texas Commission on Law Enforcement Personal History Statement
;o you ha$e any e5perience with firearmsF 4es ?o
MEMBERSHIP IN OR8ANI?ATIONS 6PAST AND PRESENT7
?ame C ,ddress Type (e*#*% social% fraternal% professional) @rom To
Ha$e you %,%! been an officer or a member of% or made a contribution to% an or#ani8ation that ad$ocates or practices the
commission of acts of force or $iolence to discoura#e others from e5ercisin# their ri#hts under the 9*S* Constitution or ri#ht
#ranted by law* 4es7777777 ?o7777777
PERSONAL DECLARATIONS
;o you consume alcoholic be$era#esF 4es ?o If =4es>% how oftenF 77777777777777777
Ha$e you %,%! used mari0uana or hashishF 4es ?o If yes% when last usedF
Ha$e you %,%! used any ille#al dru# (includin# a performance.enhancin# steroid) not prescribed by a physicianF
4es ?o If yes how often77777777777 Ehen last used77777777777777
Pro$ide e5planation6
Ha$e you %,%! sold or furnished controlled substances or prescription dru#s to anyoneF 4es ?o
If yes% #i$e details6

,re there any incidents in your life% or details not mentioned herein% which may influence this
department1s e$aluation of your suitability for employment as a police officerF
If yes% e5plain6
777777777777777777777777777777777777777777777777777777777777777777777777777777777
77777777777
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77777777777
2(
PHS 91/91/14
Texas Commission on Law Enforcement Personal History Statement
Ha$e you %,%! been employed by or applied with any other law enforcement a#encyF 4es ?o

If yes% please identify to the best of your "nowled#e6
,#ency ?ame C ,ddress ;ate ,pplied or Hired 'esult
Identify any additional information you thin" should be considered in your application for the position you are see"in#%
and/or any further e5planation of answers to pre$ious uestions6



I hereby certify that there are no misrepresentations% omissions% or falsifications in the fore#oin# statements and answers
to the abo$e uestions* I fully understand that any misrepresentation% omission% or falsification may deem me permanently
unsuitable% or if hired% may lead to the termination my employment*

Si#nature of applicant

;ate
!efore me personally appeared who stated this document and its
intent was e5plained to him/her that he/she has full "nowled#e of its purpose and that he/she e5ecuted this instrument of
his/her free will and accord*
Sworn to and su!scri!ed !efore me on this day of $
24
Texas Commission on Law Enforcement Personal History Statement
77777777777777777777777777777777777777
7777777
SE,L or ST,AP Si#nature of ?otary
Ay Commission E5pires6
7777777777777777777777777
2*
PHS 91/91/14