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Tarrant County College Police Department S. Williams, Chief of Police
Microsoft Word - 45BAE190-3C38-28233A.doc · Web viewNot prohibited by state or federal law from operating a motor vehicle. Not prohibited by state or federal law from possessing
Microsoft Word - 45BAE190-3C38-28233A.docApplicant Personal
History Statement
MINIMUM REQUIREMENTS FOR EMPLOYMENT
PLEASE NOTE
Applicants must be willing to accept any duty assignment and/or
work any shift, including weekends, holidays and midnights. Duty
assignments, shifts, and /or days off are subject to change without
notice.
1. Applicants for security guard positions must be 18 years of age
or older.
2. Must possess either a High School Diploma or a G.E.D.
3. Good moral character (as may be determined through a
comprehensive background investigation).
4. Good driving record.
5. No DWI/DUI convictions within the last 10 years.
6. No evidence of recent alcohol abuse, or recent narcotics use or
involvement.
7. No military discharge under less than or other than honorable
conditions.
8. Must not have ever been convicted at any time of a felony
offense.
9. Not ever have been or currently on court-ordered community
supervision or probation for any criminal offense above the grade
of Class B misdemeanor or a Class B misdemeanor within the last ten
(10) years.
10. Not currently under indictment for any criminal offense.
11. Not have been convicted of any family violence offense.
12. Not prohibited by state or federal law from operating a motor
vehicle.
13. Not prohibited by state or federal law from possessing firearms
or ammunition.
For purposes of this document, the word convicted shall be
construed to mean a conviction by a verdict, by a plea of guilty,
upon a judgment of the court, a jury having been waived, without
regard to subsequent disposition of the case or suspension of
sentence, probation, deferred adjudication, or otherwise.
INSTRUCTIONS
BEFORE PROCEEDING
Thank you for selecting the Tarrant County College Police
Department as a potential employer. The following instructions are
provided in order to help guide you through the completion of the
Personal History Statement. If you encounter difficulty with any
areas of this document, you may call Sgt. C. Lea or Tracey Herrera
at (817-515-1911).
Your Personal History Statement will be used as the basis for a
background investigation that will determine your eligibility for
the position for which you are applying.
1. Your Personal History Statement supplement should be hand
printed legibly in ink.
2. Answer all questions completely. If a question does not apply to
you, enter “N/A” in the space provided.
3. Avoid errors by reading the directions carefully before making
any entries on the form. Be sure your information is correct and in
sequence before you begin.
4. You are responsible for obtaining correct addresses (including
zip codes.) If you are not sure of an address, check it by personal
verification. Your local library may have a directory service or
copies of the required directories. Also include the area code with
each telephone number.
5. If there is insufficient space on the Personal History Statement
form, attach extra sheets. Be sure to reference the relevant
section and question before continuing your answer. Do not write on
the back of any page.
6. Any copies of documents you are requested to submit should be on
an 8 ½” X 11” sheet of paper only. If several small items are
copied on one page, place them so that they all appear upright on
the page, and leave at the least, a 1” border.
Your failure to properly and thoroughly complete this document may
result in your rejection from the hiring process. Deliberate
omissions or a deliberate misstatement of required information are
grounds for rejection.
DO NOT REMOVE ANY PAGES FROM THIS BOOK
Tarrant County College District
Phone (817) 515-1911 * Fax (817) 515-1929
Thank you for applying with the TCCD Police Department. Attached is
a Personal History Statement which you must complete and return
within 10 business days of receipt. This form may be returned in
person or by mail. It MUST be returned to the Trinity River Campus
at:
TCCD TR Police Department
300 Trinity Campus Circle
Fort Worth, TX 76102
If you have any questions, please contact Sgt. C. Lea or Tracey
Herrera at the Trinity River Campus at (817) 515 - 1911.
You are also required to return certain documents with the Personal
History Statement. These items are listed below. Please submit
copies only, do not send originals. If you do not have access to a
copy machine, bring the originals to our office and we will copy
them for you. If you encounter any problems in obtaining a
document, let us know.
If you fail to return your Personal History Statement and the
required documents by the date and time that they are due, if your
personal history statement is incomplete or not properly completed,
or if you fail to follow instructions, processing of your
application for employment will be discontinued.
REQUIRED DOCUMENTS
1. Texas Drivers License 6. College Transcripts
2. Vehicle Insurance 7. DD Form 214 (if applicable)
3. Social Security Card 8. Peace Officers License (if
applicable)
4. Birth Certificate, or ______9. Divorce or Civil Papers that may
apply
Naturalization Certificate
5. High School Diploma, .
Transcripts or GED Certificate
Please indicate the items you have supplied, and return this sheet.
State N/A if not applicable. If you do not have the required item
in your possession, you will need to begin the process of obtaining
it, notify us that you have requested the item, and then provide it
when you receive it.
16
300 Trinity Campus Circle, Fort Worth, TX 76102
Office (817) 515-1911, Fax (817) 515-1929
AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN: I am an applicant for a position with the
Tarrant County College Police Department (hereafter known as TCC
PD.) The department needs to thoroughly investigate my employment
background and personal history to evaluate my qualifications to
hold the position for which I applied. It is in the public’s
interest that all relevant information concerning my personal and
employment history be disclosed to the above department.
I hereby authorize any representative of the TCC PD bearing this
release to obtain any information in your files pertaining to my
employment records, and I hereby direct you to release such
information upon request of the bearer. I do hereby authorize a
review of and full disclosure of all records, or any part thereof,
concerning myself, by and to any duly authorized agent of the TCC
PD, whether said records are of public, private, or confidential
nature. The intent of this authorization is to provide full and
free access to the background and history of my personal life, for
the specific purpose of pursuing a background investigation that
may provide pertinent data for the TCC PD to consider in
determining my suitability for employment in that department. It is
my specific intent to provide access to personnel information,
however personal or confidential it may appear to be.
I consent to your release of any and all public and private
information that you may have concerning me, my work record, my
background and reputation, my military service records, educational
records, my financial status, my criminal history record, including
any arrest records, any information contained in investigatory
files, efficiency ratings, complaints or grievances filed by or
against me, the records or recollections of attorneys at law, or
other counsel, whether representing me or another person in any
case, either criminal or civil, in which I presently have, or have
had an interest, attendance records, polygraph examinations, and
any internal affairs investigations and discipline, including any
files which are deemed to be confidential, and/or sealed.
I hereby release you, your organization, and all others from
liability or damages that may result from furnishing information
requested, including any liability or damage pursuant to any state
or federal laws. I hereby release you as the custodian of such
records of your organization, including its officers, employees, or
related personnel, both individually and collectively, from any and
all liability for damages of whatever kind, which may at any time
result to me, my heirs, family, or associates because of compliance
with this authorization and request to release information, or any
attempt to comply with it. I direct you to release such information
upon request of the duly accredited representative of the TCC PD
regardless of any agreement I may have made with you previously to
the contrary. The law enforcement organization requesting the
information pursuant to this release will discontinue processing my
application if you refuse to disclose the information
requested.
For and in consideration of the TCC PD’s acceptance and processing
of my application for employment, I agree to hold you, your
organization, its agents and employees harmless from any and all
claims and liability associated with my application for employment
or in any way connected with the decision whether or not to
employee me with the TCC PD. I understand that should information
of a serious criminal nature surface as a result of this
investigation, such information may be turned over to the proper
authorities.
I understand my rights under Title 5, United Stated Code, Section
552a, the Privacy Act of 1974, with regard to access and to
disclosure of records, and I waive those rights with the
understanding that information furnished will be used by the TCC PD
in conjunction with employment procedures.
A photocopy or FAX copy of this release form will be valid as an
original thereof, even though the said photocopy or FAX copy does
not contain an original writing of my signature.
This waiver is valid for a period of 6 months from the date of my
signature.
Should there be any questions as to the validity of this release,
you may contact me at the address listed on this form. I agree to
indemnify and hold harmless the person to whom this request is
presented and his/her agents and employees, from and against all
claims, damages, losses and expenses, including reasonable
attorney’s fees, arising out of or by reason of complying with this
request.
Printed Name Signature
DO NOT SIGN
Unless in the presence of and witnessed by a Notary Public
Address
The State of Texas } {
County of Tarrant } {
Sworn to and subscribed before me on this the day of , 20 .
Notary Public (Seal)
CRIMINAL HISTORY INQUIRY AUTHORIZATION
In accordance with the Federal Privacy Act and other applicable
laws and statutes, I hereby authorize you to release all criminal
history and fingerprint information pertaining to me to agents of
the Tarrant County College Police Department. I am aware and do
consent that such inquiries will be made and that said inquiries
will result in a report containing detailed information about me. I
am also aware, and do further consent and authorize, that such
information obtained under this authorization will be used to
evaluate my candidacy for employment with Tarrant County
College.
Date of Birth Name (Type or print legibly)
Social Security Number Signature
The State of Texas } {
BEFORE ME, A NOTARY PUBLIC, on this day personally appeared
known to me to be the person whose name is subscribed to the
foregoing instrument, and acknowledged to me that he/she executed
same for the purposes and considerations therein expressed.
DO NOT SIGN
Unless in the presence of and witnessed by a Notary Public
GIVEN UNDER MY HAND AND SEAL of office on this the
day of , 20 .
Printed or typed name of notary
Notary Commission Expires
APPLICANT IDENTIFICATION FORM
1. Name
7. Date of Birth Current Age
8. Drivers License Number State
9. Social Security Number - -
11. Sex |_| Male |_| Female
FOR OFFICE USE ONLY
17. Are you a licensed Texas Peace Officer? |_| Yes |_| No
18. TCLEOSE PID Number (If applicable)
19. If yes, date last worked as a certified officer
What department?
Section - A
FAMILY INFORMATION
Complete this section if you are currently Married or Engaged
Spouse or Fiancée’s Full Name (include maiden name):
________________________________________________________
Complete Mailing Address:
________________________________________________________________________________
If married, date of marriage: / / County & State of Marriage:
________________________________
Complete this section if you have ever been MARRIED (legal or
common law) and are divorced – OR – if you have ever been engaged.
List all former spouses & fiancée’s / fiancé’s. Use attachment
sheet if necessary.
________________________________________________ _____________
_____________
________________________________________________
_______________________ _____ _________
Complete Mailing Address City State ZIP
________________________________________________ _____________
_____________
________________________________________________
_______________________ _____ _________
Complete Mailing Address City State ZIP
Do you have any children or dependents? |_| Yes |_| No If yes, how
many? __
If yes, list their name(s), relationship and age: _________
Are you delinquent on child support payment for your children? |_|
Yes |_| No |_| N/A
Family: List in the order given, showing the relationships –
Parents, Guardians, Stepparents, Foster Parents, Parents’-in-law,
Brothers/Sisters (even though deceased). Include any others you
have resided with or with whom a close relationship existed or
exists. Include fiancé/fiancée or roommates, if any. Use attachment
sheet if necessary.
Name: Address:
Education (List all diplomas, degrees and/or certifications and
where obtained)
High School Attended:
|_| Obtained a GED: Date of GED:
_______________________________
Accredited College or Universities Attended: |_| N/A
Degree |_| Yes |_| No Degree Type & Year _____________________
Courses Studied/Major
GPA School City/State
Dates attended / / to / /
GPA School City/State
Dates attended / / to / /
GPA School City/State
Dates attended / / to / /
School ____________________________________ City/State
_________________________________________________
Type:_______________________________________________________________________________
Date:______________
Type:_______________________________________________________________________________
Date:______________
Are you currently attending a college/university or taking any
training or continuing education classes? |_| Yes |_| No
If yes, which college/university are you presently attending?
What is the purpose of your current training or class?
Have you ever been expelled, suspended or placed on academic
probation from any school attended? |_| Yes |_| No
If yes, explain:
_______________________________________________________________________________________________________
Special skills/talents/qualifications: List all special skills,
unique licenses, aptitudes, qualifications or foreign languages you
speak, read or write. Include office skills, computer skills or
other skills that you believe would be beneficial to this
department.
Awards, scholarships or special recognitions: List all awards,
scholarships or recognitions you received at school, work or for
public service:
Organizations: List past and/or present memberships:
Name and Location Type (social, Office(s) Membership Dates
Professional, Held From To
/ /
/ /
/ /
/ /
/ /
/ /
Residences: List all residences, including military and school
addresses for the past TEN (10) years. Begin with your present
address and go back in chronological order. Use additional sheet if
necessary.
Date / From: / To: PRESENT Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
Date / From: / To: / Address:
Apt. # City: State: ZIP:
Apt. Name: Ofc Telephone:
REFERENCES
List a minimum of six (6) persons who know you well enough to
provide current information about you. DO NOT USE ANYONE LISTED IN
THE ABOVE “FAMILY INFORMATION” section. Include city, state and ZIP
code. All information in the section below is required, not
optional.
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Name: Address:
Section - D
BACKGROUND INFORMATION
Drug and Narcotic Usage: This section covers usage of any
controlled substance, dangerous drug, inhalant, marijuana or any
illegal drug not prescribed to you by your physician. Usage is the
introduction of a substance into your body, through
experimentation, snorting, smoking, ingestion, injection, huffing,
tasting, trying or via any other means.
Have you ever used any drugs/narcotics illegally? |_| Yes |_|
No
If yes, complete the following section.
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
What type: How many times? Last usage date: / /
Have you ever bought or sold any illegal drugs/narcotics? |_| Yes
|_| No If yes, list the date(s) and details of the
incident(s).
Have you ever manufactured any illegal drugs/narcotics? |_| Yes |_|
No If yes, list the date(s) and details of the incident(s).
Military Information
Have you served in any branch of the Armed Forces? |_| Yes |_| No
If yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary assignment:
Did you leave the service and then re-enlist? |_| Yes |_| No If
yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary
assignment:_________________________________________________________________________
Have you served in any foreign Armed Services? |_| Yes |_| No If
yes, complete the following section.
Branch: Rank: Date of Entry:
Type of discharge received: Date of Separation:
What is/was your primary
assignment:_________________________________________________________________________
Have you ever been rejected by any branch of the Armed Services for
a non-medical reason? |_| Yes |_| No
Date of rejection: ______________
_________________________________________________________________________________________________________
Were you ever disciplined while in military service? (court
martial, captain’s masts, company punishment etc.) |_| Yes |_|
No
Date: ________________
Charge:
__________________________________________________________________________________________________
Disposition:
_________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Criminal Activity
Have you ever been arrested by a law enforcement agency? |_| Yes
|_| No If yes, complete the following section.
Date of Arrest: ____________ Charge:
__________________________________________________________
Conviction Date: ____________
Dismissal Date: _____________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Conviction Date: ____________
Dismissal Date: _____________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you ever been questioned, detained, interrogated, indicted, or
charged with a crime by a law enforcement agency?
|_| Yes |_| No If yes, list the date(s), reason(s) and
disposition(s) of the incident(s).
Have you ever been banned from or asked to leave any business,
school, private residence or other establishment for disturbing the
peace or criminal trespass?
|_| Yes |_| No If yes, list the date(s), reason(s) and
disposition(s) of the incident(s).
Have you ever been convicted of a crime, placed on court ordered
community supervision, or probation? |_| Yes |_| No
If yes, list the date(s), reason(s) and disposition(s) of the
incident(s).
Have you or your spouse ever been a party to a civil or criminal
action? |_| Yes |_| No
If yes, list the date, reason and disposition of the incident(s).
Provide copies of any applicable paperwork for each event.
Have you ever been the subject of a police inquiry into any
incidence of family violence? |_| Yes |_| No
If yes, explain.
Have you ever committed a crime in which you were not caught? |_|
Yes |_| No
Details:
_________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been issued a citation for a non-traffic violation?
|_| Yes |_| No If yes, list the date(s), reason(s) and
disposition(s) of the incident(s).
DATE VIOLATION CITY/STATE DISPOSITION
Law Enforcement Experience
Are you currently a licensed Peace Officer? |_| Yes |_| No If yes,
what state?
Have you ever been employed as a Peace Officer? |_| Yes |_| No If
yes, what state?
Have you ever worked as a Reserve Police Officer? |_| Yes |_|
No
Have you ever served as a Military Police Officer? |_| Yes |_|
No
Have you ever been employed as a Security Officer? |_| Yes |_|
No
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you ever been investigated for any violation of Federal law
|_| Yes |_| No If yes explain below:
in the course and scope of performing your job as a police
officer,
security officer, jailer/ corrections officer, military police
officer
(Tort claims, Civil Rights Violations, causing injuries,
etc.)?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Do you have any prior or pending Civil Rights actions filed against
|_| Yes |_| No If yes explain below:
you while acting in a law enforcement environment?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
If yes to any of the above questions, has your peace officer’s
license, jailer/correction officer certification or security
officer
certification ever been revoked or suspended? |_| Yes |_| No
Have you ever taken part in a law enforcement internship program?
|_| Yes |_| No
If yes, list agency and date(s):
Have you ever applied for a position with another law enforcement
agency? |_| Yes |_| No
If yes, complete the following information:
NAME OF AGENCY POSITION DATE OF STATUS OF
APPLICATION APPLICATION
Section - E
DRIVING HISTORY
List all states where you currently possess a driver’s license or
have possessed a driver’s license. Include the state and license
number. Begin with your current driver’s license.
STATE LICENSE NUMBER EXPIRATION DATE
_________ _________________ ________________
_________ _________________ ________________
_________ _________________ ________________
Citations:
How many moving violations have you received since you began
driving? ____________
How many moving citations have you received in the past (5) years?
____________
List all traffic citations (speeding, stop sign, etc.) including
red light camera violations which have been issued to you in the
last five (5) years. Include the disposition of the citation(s) –
deferred adjudication, defensive driving, found not guilty by the
court, paid fine, etc. Use attachment sheet if necessary.
DATE VIOLATION CITY/STATE DISPOSITION
Accidents:
How many motor vehicle accidents have you been involved in as a
driver? ____________
List all traffic accidents that you have been involved in as the
driver in the last five (5) years.
DATE VIOLATION AT FAULT CITY/STATE DISPOSITION
________ ____________________ |_|Yes |_|No ________________________
_____________________________
________ ____________________ |_|Yes |_|No ________________________
_____________________________
________ ____________________ |_|Yes |_|No ________________________
_____________________________
________ ____________________ |_|Yes |_|No ________________________
_____________________________
General driving information:
_____________________________________________________________________________________________________
Has your driver’s license ever been suspended or revoked? |_|Yes
|_|No
Details:
______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had your driver’s license placed on probation for
receiving an excessive number of
traffic citations? |_|Yes |_|No
_____________________________________________________________________________________________________
Have you ever had a hearing for probation/suspension, etc.? |_|Yes
|_|No
Details:
______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever driven a motor vehicle after your driver’s license
was suspended or after it had been
revoked? |_|Yes |_|No
_____________________________________________________________________________________________________
Have you ever been involved in an accident and then left the
accident scene without identifying yourself? |_|Yes |_|No
Details:
______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever struck an unattended vehicle and then left without
leaving your identification? |_|Yes |_|No
Details:
______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had your insurance revoked due to the number of
traffic citations you have received? |_|Yes |_|No
Details:
______________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever been placed as an assigned risk for vehicle
insurance? |_|Yes |_|No
Details:
______________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you have a valid driver’s license in more than one state? |_|Yes
|_|No
Details:
______________________________________________________________________________________________
Section - F
EMPLOYMENT HISTORY
Have you ever been discharged, fired, asked to resign, furloughed,
put on inactive status or given unpaid leave because of
disciplinary action?
|_| Yes |_| No
If yes, explain:
Have you ever resigned or quit to avoid being discharged,
terminated or fired? |_| Yes |_| No
If yes, explain:
Have you ever been the subject of an administrative investigation
by a former employer regarding any type of misconduct?
|_| Yes |_| No
If yes, explain:
Have you previously applied for a job with the Tarrant County
College District? |_| Yes |_| No
If yes, when and for what position?
Once assigned to a background investigator, may we contact your
current employer? |_| Yes |_| No |_| N/A
If no, explain:
Would you like an investigator to notify you before contacting your
current employer? |_| Yes |_| No |_| N/A
Beginning with your current or most recent job, list all jobs you
have held in the past ten (10) years, including military service,
all part-time, temporary or seasonal employment, and periods of
unemployment (including school). Use attachment sheet if
necessary.
From: / To: / Supervisor’s Name:
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Business Name:
Why did/would you leave?
Section - G
PERSONAL DECLARATIONS
Are there any incidents in your life not mentioned herein which may
reflect upon your suitability to
perform the duties of the position for which you are applying that
might require further explanation?
|_|Yes |_| No If yes, explain:
If selected for this position are you able to work all shifts,
weekends, holidays, midnights and
understand that you may be assigned to any campus within the
Tarrant County College District
based on the needs of the department? |_|Yes |_| No If no
explain:
If necessary, could you use physical force in the course and scope
of performing your duties as a
security officer? |_|Yes |_| No If yes, explain:
Section - H
CERTIFICATION STATEMENT
I certify that there are NO MISREPRESENTATIONS, FALSIFICATIONS OR
OMISSIONS in the foregoing statements and answers. All entries are
true, complete and correct. I agree and consent in advance to being
rejected for employment and understand that if hired, I may be
discharged, if any of the information provided contains any
misrepresentations, falsifications or if any material information
has been omitted.
I further agree that if I fail any portion of the hiring process or
I am not hired, that the Tarrant College District Police Department
will not discuss with me the reason for me not being selected or
hired. If the issue is of a temporary nature I will be notified
that I am eligible to re-apply.
I certify that I am not related by blood or marriage to any member
of the Tarrant County College District Police Department.
Signature of Applicant
Date of preparation
Tarrant
County
College
District