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					          University of North Texas
             Police Department

    Personal History Statement




     Name: ___________________________
Position Applied For: __________________________


           Return to: Sgt. David Owen


                                              Revised 02-10
                                                                                                                2
                                              INSTRUCTIONS

            READ THESE INSTRUCTIONS CAREFULLY BEFORE PROCEEDING!!

These instructions are provided as a guide to assist you in properly completing your Personal History
Statement. It is essential that the information be accurate in all respects. It will be used as the basis for a
background investigation that will determine your eligibility for employment.


    1. Your Personal History Statement must be hand-printed and filled out by you personally.

    2. DO NOT type or have anyone else fill out this form for you. Answer all questions to the best of
       your ability.

    3. If a question is not applicable to you, enter N/A in the space provided.

    4. Avoid errors by reading the directions carefully before making any entries on the form.

    5. Be sure your information is correct and in proper sequence before you begin.

    6. You are responsible for obtaining correct information and addresses. If you are not sure of any
       address, check it by personal verification. Your local library may have a directory service or copies of
       local telephone directories.

    7. If there is insufficient space on the form for you to include all information required, attach extra sheets
       to the Personal History Statement. Be sure to reference the relevant section before you continue your
       answer.

    8. ATTACH A COPY OF YOUR BIRTH CERTIFICATE, HIGH SCHOOL DIPLOMA,
       COLLEGE DIPLOMA, TRANCRIPTS, AND OTHER REQUIRED DOCUMENTS WITH
       THIS PERSONAL HISTORY STATEMENT.

    9. ATTACH A COPY OF YOUR DD-214, long form with discharge status.

    10. An accurate and complete form will help expedite your application. On the other hand,

        ANY OMISSIONS OR FALSIFICATION ON THE PERSONAL HISTORY STATEMENT
        WILL RESULT IN YOUR APPLICATION BEING WITHDRAWN!

    11. FAILURE TO COMPLETE THIS FORM WITH ALL INFORMATION AND BLANKS
        FILLED IN CAN TERMINATE YOUR APPLICATION!
                                                                                                           3
University of North Texas
Police Department                                                    Personal History Statement

                                Required Documents Checklist

Copies of the following documents are required to be attached/included with your Personal History Statement,
if applicable.

_____    1.      Birth Certificate

_____    2.      Driver’s License

_____    3.      Naturalization Papers

_____    4.      Social Security Card

_____    5.      Selective Service Verification (www.sss.gov)

_____    6.      High School Diploma (or G.E.D.)

_____    7.      High School Transcripts (Must be certified copy – original stamp or embossed)

_____    8.      College Diploma

_____    9.      College Transcripts (Must be certified copy – original stamp or embossed)

_____    10.     Marriage Certificates

_____    11.     Dissolution of Marriage Papers

_____    12.     Military Discharge Papers (DD214)

_____    13.     Peace Officer/Communications Officer Licenses or Certifications

_____    14.     Personal Automobile Insurance Card, Declarations Page, or Certificate of Coverage

_____    15.    Information Release Form (Provided in this Personal History Statement Packet but must be
                signed and notarized.)

_____    16.     Recent Credit Report – Internet copies are accepted. Credit reports may be obtained by
                 phone or online from the following credit reporting agencies:
                       Trans Union at 800-888-4213 or (www.transunion.com)
                       Experian at 888-EXPERIAN or (www.experian.com)
                       Equifax at 800-685-1111 or (www.equifax.com)
                                                                                                  4


APPLICANT IDENTIFICATION - Information provided in this section is for the purpose of identification
and notification.

1. NAME:_____________________________________________________________________
           Last                          First             Middle

2. ADDRESS:_________________________________________________________________
                 Street                  City              State Zip Code

3. HOME PHONE (______)____________________WORK PHONE(_____)_______________

4. OTHER CONTACT NUMBER, such as pager, mobile phone, etc. (_____)_______________

5. DATE OF BIRTH: _______________                 PLACE OF BIRTH: _____________________

6. ARE YOU A U.S. CITIZEN: ____YES ____NO

7. SOCIAL SECURITY #: ________________________ RACE_________ SEX_________

8. DRIVER LICENSE NUMBER:__________________________STATE:_______TYPE:____


9. NICKNAME(S), MAIDEN NAME OR ANY OTHER NAMES BY WHICH YOU HAVE BEEN
KNOWN:_______________________________________________________________

11. TATTOOS, OR OTHER DISTINGUISHING MARKS ( List what they are and where they are
located_____________________________________________________________________

______________________________________________________________________________

12. Are you currently certified by TCLEOSE for the position you applied for? Yes   No

13. Have you ever served in a similar position in Texas?                           Yes   No

14. Have you ever served in a similar position anywhere?                           Yes   No

15. Do you have college degree?                                                    Yes   No

16. How many college hours do you have?                                            ____________
                                                                                                   5




RESIDENCES - List all addresses where you have lived during the past 10 years, beginning with present
address. List date by month and year. Attach an extra copy of page 4 if necessary.




DATES: FROM:________TO:_________                             COMPLETE ADDRESS

______________________________________________________________________________
           Street Number     Street Name                              City   State Zip


______________________________________________________________________________
Apt. complex Name                      Landlord Name-P h.#

Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************


DATES: FROM:_________TO:________                             COMPLETE ADDRESS

______________________________________________________________________________
           Street Number     Street Name                              City   State Zip

______________________________________________________________________________
Apt. complex Name                      Landlord Name-P h.#



Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************


DATES: FROM:_________TO:________                             COMPLETE ADDRESS

______________________________________________________________________________
           Street Number     Street Name                              City   State Zip

______________________________________________________________________________
Apt. complex Name                      Landlord Name-P h.#



Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************


DATES: FROM:_________TO:________                             COMPLETE ADDRESS

______________________________________________________________________________
           Street Number     Street Name                              City   State Zip
                                                                                       6
______________________________________________________________________________
Apt. complex Name                    Landlord Name-P h.#



Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************




DATES: FROM:_________TO:________                           COMPLETE ADDRESS

______________________________________________________________________________
           Street Number   Street Name                              City   State Zip

______________________________________________________________________________
Apt. complex Name                   Landlord Name-P h.#



Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************


DATES: FROM:_________TO:________                           COMPLETE ADDRESS

______________________________________________________________________________
           Street Number   Street Name                              City   State Zip

______________________________________________________________________________
Apt. complex Name                   Landlord Name-P h.#

Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************

******************************************************************************


DATES: FROM:_________TO:________                           COMPLETE ADDRESS

______________________________________________________________________________
           Street Number   Street Name                              City   State Zip

______________________________________________________________________________
Apt. complex Name                   Landlord Name-P h.#

Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************

DATES: FROM:_________TO:________                           COMPLETE ADDRESS

______________________________________________________________________________
           Street Number   Street Name                              City   State Zip

______________________________________________________________________________
Apt. complex Name                   Landlord Name-P h.#

Was a lease signed? Yes____No_____Who was on the lease?_________________
                                                                                                             7
******************************************************************************


DATES: FROM:_________TO:________                               COMPLETE ADDRESS

______________________________________________________________________________
           Street Number        Street Name                             City   State Zip

______________________________________________________________________________
Apt. complex Name                        Landlord Name-P h.#

Was a lease signed? Yes____No_____Who was on the lease?_________________
******************************************************************************
WORK HISTORY - Beginning with your current or most recent job, list all employment since the age of
16, including part-time, temporary or seasonal employment. Include all periods of unemployment. List dates
by month and year. Failure to list any jobs may terminate your application. Attach extra copies of these sheets
if necessary.

FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning :__________Ending:___________


FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________


FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
                                                                                  8
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                 FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________


FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________


FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:______________________________________ ___________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________




FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                               LEAVING:
______________________________________________________________
                                                                                      9
WORK SCHEDULE:_____________________ SALARY: Beginning:__ ________Ending:___________

FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                 FOR                                  LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________

FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:___________________________________________________________ ______________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________

FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:__________ _

FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
                                                                                               10
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                 FOR                                  LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning:__________Ending:___________

FROM:                ________               TO:              ___________EMPLOYER:
___________________________________________
ADDRESS:_________________________________________________________________________
__
PHONE:(____)_________________JOB
TITLE:_____________________________________________
DUTIES:
____________________________________________________________________________
SUPERVISOR: ____________________ CO-WORKER:______________________________________
REASON                                  FOR                                 LEAVING:
______________________________________________________________
WORK SCHEDULE:_____________________ SALARY: Beginning: _________Ending:___________




MILITARY RECORD


Are You Registered With the Draft Board:             YES ____ NO ____ FEMALE ____

                       If yes, list Selective Service number __________________________

Have you ever served with the Armed Forces:          YES ____ NO ____

If you have not been in the military, skip this section.

Date of Service: From _____________ To ______________ Branch ______________________

Military Service #: ________________________ Rank at Discharge: ______________________

Location of Discharge: ____________________ Type of Discharge: ______________________

Are you currently on: Active Reserve____        In-Active Reserve____     National Guard____

Were you ever disciplined while in the Military? ___ YES ___ NO

(Include Court-Martial, Captain's Masts, Company Punishment, etc.)

      CHARGE                        AGENCY                 DATE         DISPOSITION
                                                                                                      11

_______________________ ________________                  _________        ________________________

_______________________ ________________                  _________        ________________________

_______________________ ________________                  _________        ________________________

_______________________          _______________          _________        ________________________

If you received a discharge other than honorable, give complete details:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________




EDUCATIONAL HISTORY
                                                              DATES ATTENDED GRADUATED
HIGH SCHOOL ATTENDED                     CITY & STATE           FROM TO       YES NO

___________________________|__________________|___________________|______|_____|

___________________________|__________________|___________________|______|_____|

___________________________|__________________|___________________|______|_____|

COLLEGES or             CITY &           DATES            TOTAL     MAJOR             DEGREE
UNIVERSITIES            STATE            ATTENDED          HRS      /MINOR            RECEIVED

                    |                |                |         |                |

                    |                |                |         |                |

                    |                |                |         |                |

                    |                |                |         |                |
                                                                                                       12
List other schools attended (academy, trade, vocational, business, etc.). Give name and address of school,
dates attended, course of study, certificate and any other pertinent information.




Have you ever been suspended from any high school, college, university, business, or vocational schools? ___
YES ___ NO If yes, explain: __________________________________________
_____________________________________________________________________________

SPECIAL QUALIFICATIONS & SKILLS: List any other special skills or qualifications you may possess.
List any special licenses you hold such as pilot, radio operator, scuba, etc., showing license authority, original
date of issue and date of expiration.

______________________________________________________________________________________________________________
____
______________________________________________________________________________

If you are fluent in a foreign language, indicate in each area your degree of fluency (excellent, good, fair).
 LANGUAGE                READING            SPEAKING UNDERSTANDING WRITING




ARRESTS, DETENTION AND LITIGATION

Have you ever been arrested for DWI or DUI? ____YES ___NO                     If yes, give detail:




Have you ever been detained, but not arrested, by police for any reason?
____ YES ____ NO            If yes, give details:




OTHER THAN THE ABOVE, have you ever been arrested, detained by police or summoned into court?
____YES ____NO If yes, list all detentions and summons below, including traffic warrants.
                                                                                                    13
OFFENSE CHARGED POLICE AGENCY ,CITY, STATE                            DATE       DISPOSITION

                        |                                         |          |

                        |                                         |          |

                        |                                         |          |

                        |                                         |          |


Have you ever been a party in a civil litigation? ___ YES ___NO




TRAFFIC RECORD

Has your driver's license even been suspended or revoked? ___YES___NO If yes, give dates, locations and
reasons:




With what company do you carry auto insurance?
Make, model, year of vehicle ________________________________________________

List ALL traffic citations you have received, excluding parking tickets. INCLUDE CITATIONS FOR
WHICH YOU HAVE TAKEN DEFENSIVE DRIVING

MONTH/YEAR                  CHARGE                  CITY & STATE                 DISPOSITION
__________|___________________|_______________|____________
__________|___________________|_______________|____________
                                                                                                               14
__________|___________________|_______________|____________
__________|___________________|_______________|____________
__________|___________________|_______________|____________
__________|___________________|_______________|____________
__________|___________________|_______________|____________
__________|___________________|_______________|____________

List any traffic accidents in which you have been involved including dates and locations, city and state, and
describe what happened.




Have you ever held a driver's license in any other state and/or country, including an international license?
___YES __ NO

State:_______ DL#______________________ Date:________ Type:______
State:_______ DL#______________________ Date:________ Type:______

MARITAL & FAMILY INFORMATION

Status: Single____               Separated__              Divorced__
        Married__                Engaged___               Widowed__

Current, if applicable:
Name of Spouse/Fiancée:_____________________ Date of Birth______________________
Home Address:________________________________        Home Phone:________________
Work Address: ________________________________       Work Phone:________________
Work Schedule:_________________________________________

If married: Date: _________________ Maiden Name:________________________________


Previous marriage, if applicable:    (list all previous spouses)
Separated____           Divorced____            Widowed____               Annulled____
                                                                                                        15
Date of Marriage: ____________ City & State:______________________________________
Date of Order/Decree_________________Court & State Where Issued____________________
Ex-spouse's Name: _____________________________ Maiden name___________________
Present Address: _____________________________________________________________
Phone: home_______________________work _____________________________________

Do you pay child support: ____YES         ____NO

List all children related to you or your spouse (natural, stepchildren, adopted and foster children):
                                             DATE                                  SUPPORTED
          NAME              RELATION OF BIRTH                 ADDRESS               BY WHOM
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
List all other dependents:

    NAME                                 ADDRESS                                     RELATION
___________________________________________________
___________________________________________________
___________________________________________________



List other relatives in the following order: Father, Mother (include maiden name), brothers and sisters. If
deceased, so indicate.
NAME                      ADDRESS               PHONE#         RELATION              DATE OF
                                                                                     BIRTH
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
                                                                                                16
FINANCIAL

Your monthly salary? ____________               Your spouse’s monthly salary? __________
Other monthly income - describe:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


Do you own any real estate? YES_____ NO_____
Location:______________________________________________________ Value:__________
Location:______________________________________________________ Value:__________

Do you own any bonds?        YES_____  NO____    Value:__________
Do you own any corporate stock?   YES_____  NO____      Value:__________
Do you have a bank account?       YES_____  NO____

List ALL Savings
Average Balance                 Name and Address of Bank
_________________________________________________________
_________________________________________________________

List ALL Checking
Average Balance               Name and Address of Bank
_________________________________________________________
_________________________________________________________
_________________________________________________________
Have you ever been delinquent on payments of any loans / charge accounts? YES ____ NO ____
Have you ever filed for or declared bankruptcy?                              YES ____ NO ____
Have any of your bills ever been turned over to a collection agency?   YES ____ NO ____
Have you ever had purchased goods repossessed?                         YES ____ NO ____
Have your wages ever been garnished?                                   YES ____ NO ____
Have you ever been delinquent on income or other tax payments?               YES ____ NO ____
Have you ever had a check returned for insufficient funds?                   YES ____ NO ____
If yes to any of the above questions, please explain: ____________________________________
_________________________________________________________
_________________________________________________________
                                                                                                                17
Please list all of your financial liabilities (charge accounts, rent, mortgage, car payments, etc.)

  Name, Address,                  Reason for Debt              Account                 Total          Monthly
  Phone of Creditor               or item Purchased             Number                 Balance        Payment

___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____
___________|_____|___________|___|____

PERSONAL DECLARATIONS

1) Have you ever used any illegal drug or a prescription drug that was not prescribed to you by physician?
      YES_____ NO_____

2) Have you ever furnished drugs or narcotics to anyone? YES_____ NO_____

3) Have you ever sold drugs or narcotics to anyone?         YES_____ NO_____

4) Have you ever bought drugs or narcotics?                      YES ____ NO _____

5) Have you ever provided money for the purchase of drugs or narcotics? YES ___ NO ____
                                                                                                         18

If yes to any of the above questions, explain in detail; include dates, number of times used and types of
drugs.




6) If it became necessary to take a human life in the course of your duties as a police officer, could you?
YES _____ NO _____ NOT APPLICABLE _____ If no, explain.




7) Do you have a lifestyle that would prevent you from fully performing the duties required of the position,
including working on weekends or on evening/night shifts? YES _____ NO _____
If yes, explain.




8) Have you ever made application for employment with this or any other law enforcement or related agency?
YES_____ NO____

If yes, list ALL agencies, dates and status of application.

           AGENCY                                   DATE                      STATUS

____________________________ ______________ ___________________

____________________________ ______________ ___________________
                                                                                                         19
____________________________ ______________ ___________________

____________________________ ______________ ___________________

____________________________ ______________ ___________________

____________________________ ______________ ___________________

____________________________ ______________ ___________________

9) Have you ever been disciplined, discharged, asked to resign, or resigned prior to being disciplined by any
employer             YES              NO If yes, please explain.

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________




10) If you have previously served a law enforcement agency, have you ever been disciplined or the subject of
an internal investigation at any law enforcement employer?     YES          NO
If yes, please explain.

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
                                                                        20
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_____________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________

11) Are there any other incidents in your life or details not mentioned herein which may influence this
department’s evaluation of your suitability for employment?  YES          NO
If yes, please explain:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_____



REFERENCES - List five persons who know you well enough to provide current information about you.
DO NOT list relatives, former employers, supervisors or anyone listed previously in this statement. Include
people that see you regularly in social settings, not friends of your parents.


NAME_____________________________________HOME PHONE(____)_ _________
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
                                                                                                        21
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
ADDRESS_________________________________________________________ ______
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______




List neighbors that live on both sides of your current residence and previous or permanent residence. If you
don't know your neighbors, meet them. If a house or apartment is empty, make a notation. This section must
be complete.



NAME_____________________________________HOME PHONE(____)__________
ADDRESS_____________________________________________________ __________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME__________________________________ ___HOME PHONE(____)__________
                                                                                                 22
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)______ ____
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
ADDRESS____________________________________ ___________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______



NAME_____________________________________HOME PHONE(____)__________
ADDRESS_______________________________________________________________
BUSINESS NAME___________________________WORK PHONE (____)__________
BUSINESS ADDRESS_____________________________________________________
HOURS OF WORK__________________________________YEARS KNOWN_______




In your own words, explain why you want to work for the UNT Police Department. (minimum 100 words)
                                                                                                                23




                                          AGREEMENT
I hereby certify that there are no misrepresentations, omissions or falsifications in the foregoing
statements and answers. I am fully aware that any such misrepresentations, omissions or
falsifications can be grounds for immediate rejection or termination of employment.

_________________________________                                   _________________
   SIGNATURE OF APPLICANT                                                DATE


                      UNIVERSITY OF NORTH TEXAS POLICE DEPARTMENT
                   AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION


I, _____________________________________________ do hereby authorize a review of and full
disclosure of all records concerning myself to any duly authorized agent of the University of North Texas Police
Department, whether the said records are of a public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of: the records of
educational institutions; financial or credit institutions, including records of loans, the records of commercial or
retail credit agencies (including credit reports and/or ratings); and other financial statements and records
wherever filed; employment and pre-employment records, including background reports, efficiency ratings,
complaints, grievances, and disciplinary actions filed by or against me and the records and recollections of
                                                                                                               24
attorneys at law, or of 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.

I understand that any information obtained by a personal history background investigation, which is developed
directly, or indirectly, in whole or in part, upon this release authorization will be considered in determining my
suitability for employment by the University of North Texas Police Department.

I also certify that any person(s) and governmental entit(y)(ies) who may furnish such information concerning me
shall not be held accountable for giving this information; and I hereby release, indemnify, and hold harmless said
person(s) and governmental entit(y)(ies) from any and all liability which may be incurred as a result of furnishing
such information. I also release and hold harmless the University of North Texas from any claim or demand
related to the University of North Texas obtaining and/or considering any such information.

I also authorize the release of my name and full disclosure of all records concerning myself to verify past and
future applications with other law enforcement agencies.

A photocopy of this release form will be valid as an original thereof, even though said photocopy does not contain
an original writing of my signature.
                                                           ____________________________________
                                                           Applicant's Printed Name (Include maiden name)

_____________________                                     ____________________________________
Witness                                                         Signature (including maiden name)


                                                          ____________________________________
                                                          Date

State of Texas
County of _________________________

This instrument was acknowledged before me on the _______ of ____________________, 20______ by

_______________________________________________.

                                                                  ________________________________
(Seal)                                                                  Notary Public’s Signature

				
DOCUMENT INFO
Description: Texas Marriage Certificates Online document sample