KYLE POLICE DEPARTMENT
APPLICANT
PERSONAL HISTORY STATEMENT
NAME
DATE ISSUED
COMPLETE AND RETURN BY
I am applying for:
Peace Officer PID#:
______________
Telecommunicator PID#______________
Other Civilian Employment
Position Title:________________________________________
Kyle Police Department
Personal History Statement
Personal History Statement Instructions
Employees are exposed to confidential and law enforcement sensitive information. A thorough background investigation is
required to properly evaluate the suitability of applicants for employment with the agency. Although it is an achievement to
reach the background phase of the hiring process, this is still a competitive process and does not, in any way, guaranty
selection.
These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is
essential that the information is accurate in all respects so please read all instructions carefully before proceeding. The
Personal History Statement will be used as a basis for a background investigation that will determine your eligibility for
becoming an employee.
1.
Your application must be typed or printed legibly in BLACK INK by the applicant. Answer all questions truthfully
and accurately.
2.
If a question is not applicable 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
accurate and in proper sequence before you begin.
4.
You are responsible for obtaining correct and full addresses. If you are not sure of an address, personally verify
before making that entry on this history statement. Errors will not be viewed favorably. ALL ADDRESSES MUST
BE COMPLETE WITH, COUNTY (or PARISH), and ZIP CODES.
5.
If you need additional space for your answers, attach an additional sheet or sheets as needed. Be sure to indicate what
question number and page this refers to.
6.
An accurate and complete form will help expedite your investigation. Omissions or falsifications can result in
disqualification.
7.
Any deficiencies located in the submitted paperwork must be corrected by the time advised by the assigned
background investigator.
8.
You are responsible for furnishing any changes and/or updating your application as needed, such as address changes
or telephone to your background investigator immediately.
9.
Any candidate submitting an incomplete application WILL NOT BE CONSIDERED FOR EMPLOYMENT.
Your application will be evaluated on completeness and neatness.
10. If you have any questions, please contact your assigned background investigator.
11. Applicant is responsible for returning all messages from background investigator. Failure to do so within 72 hrs. will
be grounds for disqualification.
12. All documents requested must be submitted with the application (photocopies are acceptable in most cases).








Copy of your Social Security card.
Original certified copy of your birth certificate. (No photo copy)
Copy of your valid Texas driver license or a copy of another State’s driver license. Applicant must possess
a valid Texas driver license prior to being offered employment.
Copy of your High School diploma or GED certificate.
Sealed original certified copy of your college transcript from any and all colleges attended.
Photocopy of your college diploma.
Copy of your Peace Officer Certificate from your police academy. (Peace Officer Applicants Only)
Copy of your Texas peace officer license and all training certificates awarded to you. (Peace Officer
Applicants Only)
2
Kyle Police Department






Personal History Statement
Copy of your Basic Telecommunicator License and all training certificates awarded to you
(Telecommunicator Applicants Only)
Copy of your DD-214 if applicable. Must possess an honorable discharge.
Original certified copy of your Naturalization papers, if applicable. (No photo copy)
Copy of current proof of automobile liability insurance.
Copy of a credit report from Transunion, Experian, Or Equifax dated within 60 days of the PHS
submission.
Copy of any marriage licenses or divorce decrees that apply to the applicant
13. When submitting the completed documents, please place them in a sealed envelope marked Personal and Confidential
to your assigned background investigator.
14. Completed documents need to be submitted by:
Regular mail: PO BOX 40
Kyle, TX 78640
FED EX/ UPS 111 N Front Street
Kyle, TX 78640
or in person to: 111 N Front Street
Kyle, TX 78640
Applicant Qualification Section
Before you begin to fill out this personal history statement, please ensure that you meet the following
requirements. You must meet all five of these requirements to qualify for licensure as a peace officer or
jailer in Texas.
Initial:
______I am a citizen of the United States of America.
______I have earned a high school diploma or a GED.
______I have never been convicted, plead guilty (nolo contendere), nor have I been on courtordered community service/probation or deferred adjudication for a Class A misdemeanor or a
felony.
______During the last ten (10) years, I have not been convicted, plead guilty (nolo
contendere), been on community service/probation or deferred adjudication for a Class B
misdemeanor in this state, other state, or while serving in the military.
______I have never had a military court martial that resulted in a dishonorable or bad conduct
discharge.
DISQUALIFICATION
There are very few automatic basis for rejection. Even issues of prior misconduct, employee
terminations, and arrests are usually not, in and of themselves, automatically disqualifying. However,
deliberate misstatements or omissions can and often will result in your application being rejected,
regardless of the nature or reason for the misstatements/omissions. In fact, the number one reason
individuals “fail” background investigations is because they deliberately withhold or misrepresent jobrelevant information from their prospective employer.
This personal history statement is a governmental document. Be truthful, as there are criminal
consequences for lying on a governmental document. For law enforcement positions covered under
the Texas Civil Service laws, please note that laws relating to Civil Service and Meet and Confer will
be applied.
3
Kyle Police Department
Personal History Statement
APPLICANT IDENTIFICATION
INFORMATION PROVIDED IN THIS SECTION IS USED FOR IDENTIFICATION PURPOSES ONLY.
Last Name
First
Middle
Maiden
Street Address
Apt. No.
City
State & Zip Code
Mailing Address (if different from residence)
State & Zip Code
Home Telephone No.
Work Telephone No.
Cellular No.
Date of Birth
Social Security No.
Drivers License No. & State
Have you ever been known or gone by any other name (excluding nick-names)? If yes, give details.
__________
__________________________________________________________________________________________
Place of Birth (City, County, State, Country)
Are you a U.S. Citizen by Birth?
Height
Weight
Are you a Naturalized Citizen?
Eye Color
Hair Color___________
Scars, Tattoos (description and location) or other distinguishing marks
Do you have a social networking, instant messaging, or other internet-based profile(s)? If yes, provide screen
name(s), service provider(s) and direct link if applicable.
__________________________________________________________________________________________
__________________________________________________________________________________________
List ALL E-Mail Addresses(s)
__________________________________________________________________________________________
4
Kyle Police Department
Personal History Statement
__________________________________________________________________________________________
MARITAL & FAMILY HISTORY
Dating
Married
Engaged
Co-habiting
Significant Other‘s name (include maiden name)
Address
Date of Birth
Date of Marriage
Employer(s)
Employer & Address
Home Telephone No.
Work Telephone No.
Current roommate(s)(do not include parents or cohabitants)
Date(s) of birth
If you have been separated, divorced, or widowed, provide details below:
Date of Marriage
City & State
Separated___________
Date
Divorced
Date
Widowed
Date
Annulled
Date
Court or State issued
Ex-spouse’s Name
Date of Birth
Telephone No.
EmailAddress___________________________
Date of Marriage
City & State
Separated
Date
Divorced
Date
Widowed
Date
Annulled
Date
Court or State issued
Ex-spouse’s Name
Date of Birth
Telephone No.
Email Address__________________________
Identify children related to you or your spouse (Natural, Step-Children, Adopted, or Foster Children)
Relation
Name
Date of Birth
5
Address
Kyle Police Department
Personal History Statement
Identify relatives in the following order: Father, Mother (include maiden name), step-parents, brothers and sisters.
Relationship
Name
Roommates
Complete Address
Phone Number
DOB
Identify all roomates you have had since the age of 18:
Name: ________________________________
Phone Number: ____________________________
Name: ________________________________
Phone Number: ____________________________
Name: ________________________________
Phone Number: ____________________________
Name: ________________________________
Phone Number: ____________________________
RESIDENCES
Identify all residences where you have lived in the last 10 years, beginning with the most
recent, including your present address. List date by month/year. Include military assignments. (No TDY’s)
From
To
Address
City
6
County
State & Zip
code
Kyle Police Department
Personal History Statement
PERSONAL REFERENCES
List five (5) persons who know you well enough to provide current information about you. Do not list relatives,
former or present employers, or supervisors.
Name
Years known ______
Address
Home Telephone
Alternate Telephone
Nature of Relationship___________________________ Email Address________________________________
Name
Years known ______
Address
Home Telephone
Alternate Telephone
Nature of Relationship___________________________ Email Address________________________________
Name
Years known ______
Address
Home Telephone
Alternate Telephone
Nature of Relationship___________________________ Email Address________________________________
Name
Years known ______
Address
Home Telephone
Alternate Telephone
Nature of Relationship___________________________ Email Address________________________________
Name
Years known ______
Address
Home Telephone
Alternate Telephone
Nature of Relationship___________________________ Email Address________________________________
Identify below any employees of the City of Kyle Employee with whom you are acquainted or related?
__________________________________________________________________________________________
7
Kyle Police Department
Personal History Statement
TRAFFIC RECORD
Identify all vehicles that you currently own or operate:
Year
Make
Model
Color
License Plate No.
Registration
Date
Owner
Please list your current automobile insurance carrier:
Expires:
Have you ever possessed a driver’s license issued by any state other than Texas? Yes
If yes, give details below:
No
Driver’s License No.
State
Date issued
Driver’s License No.
State
Date issued
Have you ever had your driver’s license suspended or revoked? Yes
length of suspension:
No
If yes, give reason, date, and
Have you ever had a warrant issued for your arrest (to include for traffic offenses)? Yes No
If
reason, and date, _______________________________________________________________
yes,
give
Identify all motor vehicle accidents you have been involved in during the last 10 years.
Date
Location
Police
Report:
Yes/No
Police Notified
Yes/No
Cause of Accident (e.g., ran red light, failed to control speed)
Date
Location
Police
Report:
/No
Yes
Police Notified
Yes/No
Cause of Accident (e.g., ran red light, failed to control speed)
Identify all traffic citations you have received within the last 10 years, excluding parking tickets:
Month/Year
Violation
City & State
8
Disposition
dismissed)
(e.g.,
defensive
driving,
Kyle Police Department
Personal History Statement
HISTORY OF POLICE CONTACTS & LEGAL ISSUES
24) YES NO Have you ever been detained by the police for anything other than as a witness or on a
traffic stop?
25) YES NO Have you ever been questioned, detained, interrogated, indicted, arrested or charged with a
crime by any law enforcement agency?
26) YES NO Have you ever lied to law enforcement?
27) YES NO Have you ever been convicted, placed on probation or given deferred adjudication for
any offense(s)?
AGENCY
CHARGE
DATE
DISPOSITION
a.________________________________________________________________________________
b.________________________________________________________________________________
c.________________________________________________________________________________
d.________________________________________________________________________________
e.________________________________________________________________________________
Use space below for any explanations:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
9
Kyle Police Department
Personal History Statement
28) Have you ever been involved, in any way (victim,suspect,witness, involved party), in any of the
following? (Circle the appropriate response)
YES NO Murder
YES NO Subject to Civil Suit
YES NO Assault
YES NO Disorderly conduct
YES NO Assault/ Family Violence
YES NO Stalking
YES NO Injury to a child
YES NO Injury to the elderly
YES NO Terroristic Threat
YES NO Violate protective/ restraining order
YES NO Criminal Mischief
YES NO Robbery
YES NO Burglary (Enter without permission)
YES NO Unauthorized use of Vehicle
YES NO Theft
YES NO Public Intoxication
YES NO Credit Card Abuse
YES NO Unlawful Carry Weapon
YES NO Use of glue/aerosol as an intoxicant
YES NO Indecent Exposure
YES NO Public lewdness (sexual act in public)
YES NO Sexual Assault
YES NO Window peeping (voyeurism)
YES NO Shoplifting
YES NO Viewed/ Possessed/distributed Child Porn
YES NO Stolen anything out of a car
YES NO Fled/run from a Police Officer
YES NO Abuse of Identification ( Altered ID, Possessed Fake ID, Provided ID to Minor).
YES NO Purchased items known or suspected to be stolen
YES NO Possessed anything that you knew was stolen (by you or someone else)
YES NO Possessed any illegal weapon; i.e., knife, gun, explosive, etc.
YES NO Been present when someone else committed a crime
YES NO Ever been subject to a protective order/ restraining order
YES NO Ever been a protected person in a protective/restraining order
YES NO Ever had any involvement with Child Protective Services
YES NO Has a warrant ever been issued for your arrest ( including traffic offenses)
Please provide detailed information on any items that are circled "YES", to include all dates, times
locations and circumstances. If referring to a theft, please describe the item(s), the value of the
items taken and the date(s).
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have you committed any illegal act not listed above? If yes, list below to include all dates, times,
locations, and circumstances
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
10
Kyle Police Department
Personal History Statement
FAMILY, RELATIVES’, ROOMMATES, CLOSE ASSOCIATES ARRESTS
Have members of your immediate family, close relatives, roommates, or close associates ever been arrested?
Yes
No
Name/Relationship
If yes, complete the following table:
Charge/Offense
Outcome
Year
Agency
FINANCIAL HISTORY
Your current net monthly income
Spouse’s current net monthly income
Source
Amount
Do you have any accounts with a financial institution?
Yes
Frequency
No
Name(s) of financial institution(s)
Type(s) of account(s)
Identify any person or entity to whom you are indebted, and the extent of your indebtedness. Include mortgages,
vehicle payments, charge accounts, credit cards, loans, child support payments, and any other debts or
payments.
Name of Creditor (e.g., Sears, Citi financial)
Type of Debt (e.g., student loan, automobile)
11
Monthly Payment
Approx Balance
Kyle Police Department
Personal History Statement
CREDIT INFORMATION
Have you ever filed bankruptcy personally or on behalf of a business?
If “Yes” to above, indicate type
Yes______ No______
Have you ever had any personal or real property repossessed or foreclosed?
Yes______ No______
Have you ever failed to pay Federal, state, or other taxes?
Yes______ No______
Have you ever failed to file a tax return, when required by law?
Yes______ No______
Have you ever had a lien placed against your property for failing to pay taxes or other debts?
Yes______ No______
Have you ever had a judgment entered against you?
Yes______ No______
Have you ever defaulted on any type of loan?
Yes______ No______
Have you ever had bills or debts turned over to a collection agency?
Yes______ No______
Have you ever had any credit account suspended, charged off, or cancelled for failure to pay?
Yes______ No______
Have you ever written a check that was later returned for Non Sufficient Funds (NSF)?
Yes______ No______
Have you ever been delinquent on court-imposed alimony or child support payments?
Yes______ No______
Have you ever been disciplined regarding the use of a travel/credit card provided by an employer?
Yes______ No______
Are you currently more than sixty (60) days delinquent on any debts?
Yes______ No______
Have you ever applied for unemployment compensation? Yes
No
When?
Have you ever received unemployment compensation?
No
When?
Yes
Identify any person or entity to which you are late in paying. Include mortgages, vehicle payments, charge
accounts, credit cards, loans, child support payments, and any other debts or payments.
Name of Creditor (e.g., Sears, Citi financial)
Type of Debt (e.g., student loan, automobile)
12
Number of
Days Late
Reason
Kyle Police Department
Personal History Statement
EDUCATIONAL HISTORY
Have you ever been placed on academic probation? If yes explain in detail:
__________________________________________________________________________________________
Were you ever expelled from school? If yes, give details:
High School(s) attended
Address
Dates attended
From-To
Graduated
Yes/No
Do you have a G.E.D. Certificate?
Identify all colleges, universities, or technical schools you have attended:
Name
City & State
Dates attended
Hours completed
Major
Degree & Date
EMPLOYMENT HISTORY
Have you ever been afforded the opportunity to resign in lieu of termination from any employment? If yes provide
details:
____________________________________________________________________________________
____________________________________________________________________________________
Have you ever been fired? If yes provide details:
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever stolen property from an employer? If yes provide details:
__________________________________________________________________________________________
_________________________________________________________________________________________
13
Kyle Police Department
Personal History Statement
Beginning with your present or most recent job, list all employment since the age of seventeen (17). Include fulltime, part-time, temporary, seasonal, military assignments, or unpaid internships, plus all periods of
unemployment.
If you are currently employed, may we contact your present employer? Yes
1. Employer
From
No
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
14
Kyle Police Department
Personal History Statement
__________________________________________________________________________________________
2. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
15
Kyle Police Department
Personal History Statement
3. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
16
Kyle Police Department
Personal History Statement
4. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
17
Kyle Police Department
Personal History Statement
5. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
18
Kyle Police Department
Personal History Statement
6. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
19
Kyle Police Department
Personal History Statement
7. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
20
Kyle Police Department
Personal History Statement
8. Employer
From
To__________
Address
Telephone No.
Job Title
Beginning and Ending Salary ________________/__________________Work Schedule (Days/ Hours)
Name of supervisor
Email: ______________________________________
Phone: __________________________
Name of a co-worker
Email: ______________________________________
Phone: __________________________
Duties:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any disciplinary actions you received:
Reason for Leaving:
Was there an unemployment period between previous employment and the one listed above?
_____Yes ____No
If yes, provide dates and explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
21
Kyle Police Department
Personal History Statement
MILITARY OBLIGATION
Have you ever served in the U.S. Armed Forces or State Military Forces? Yes
Served from
to
Date
No________
Highest Rank held_____________
Date
Branch of Service
Unit
Job Title(s) (e.g., Rifleman, Security)
Primary Duties: _____________________________________________________________________________
Type of discharge___________________
Last Duty Station: ______________________________
Are you actively serving in a Reserve Unit (including State Military Forces)? Yes
Serving from
to
No
Current Rank held___________
Date
Date
Branch of Service
Unit
Job Title(s) (e.g., Rifleman, Security)
Have you ever been subject to court martial or any other disciplinary proceeding under the Uniform Code of
Military Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or
authority(ies), and outcome(s).
SPECIAL QUALIFICATIONS & SKILLS
Identify any special licenses you hold (e.g., pilot, radio operator):
__________________________________________________________________________________________
Do you have any experience with firearms? Yes
No
If you know a second language (to include ASL), indicate your fluency in each block below (excellent, good, fair)
Language
Understanding
Speaking
22
Reading
Writing
Kyle Police Department
Personal History Statement
MEMBERSHIP IN ORGANIZATIONS (PAST AND PRESENT)
Name & Address
Type (e.g., social, fraternal, professional)
From
To
Have you ever been an officer or a member of, or made a contribution to, an organization that advocates or
practices the commission of acts of force or violence to discourage others from exercising their rights under the
U.S. Constitution or right granted by law. Yes_______ No_______
PERSONAL DECLARATIONS
Do you consume alcoholic beverages? Yes
No
If
“Yes”,
how
often?
___________________________________________________________
Provide the approximate date in which you have last driven under the influence of an alcoholic beverage and/or
narcotic where you believed you should not have been operating a vehicle._____________________________
How many times do you estimate you have been legally intoxicated from consuming alcoholic beverages within
the last 365 days? ________________________________________________
EXPERIMENTING WITH DRUGS
Experimentation or use of drug refers to any form of introducing a substance into your body's system. This includes
terms such as; "experimentation", "trying", "taking a hit", etc. For this section, the term “drug” means any illegal drug
like marijuana or cocaine. It is also means ingesting a legal prescription drug that was taken unlawfully; such as
taking a prescription medication that was issued to another person; taking diet pills (speed) to stay awake; or taking
hydrocodone or soma to relax, etc, etc.
28) YES NO
Have you ever used/experimented with illegal drugs, or used a legal drug
unlawfully?
If yes, please provide details and circumstances regarding such usage. You need to specify on how many
different occasions you used the drug, your age at the time of use, and dates of use by month/year.
DRUG NAME
YOUR AGE
NUMER OF TIMES
DATE OF LAST USE
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
23
Kyle Police Department
Personal History Statement
(29) YES NO Have you ever sold or provided any illicit drugs, controlled substance, dangerous drugs, or
marijuana whether listed above or not to anyone?
If yes, please explain:
Type of Drug
Sold or Provided
Number of times
________________________________________________________________
________________________________________________________________
(30) YES NO Have you ever used glue, paints, Freon, or petroleum products to get high?
If yes, please explain:
Type of Drug
Number of times
Last time used
________________________________________________________________
________________________________________________________________
(31) YES NO Have you ever bought an illicit drug, controlled substance, dangerous drugs or marijuana?
If yes, please explain:
Type of Drug
Number of times
Last time bought
________________________________________________________________
________________________________________________________________
(32) YES NO Have you ever been present when someone else was buying, selling or using
drugs? If yes, please explain:
Type of Drug
Number of times
Last time
________________________________________________________________
________________________________________________________________
Use space below for any explanations for "YES" answers to previous questions:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
LAW ENFORCEMENT ACADEMY AND APPLICATIONS
Are you currently enrolled in a police academy? Yes_________ No___________if yes explain:
Academy name_______________________________________ Graduation date: _____________________
Address: ________________________________________________________________________________
24
Kyle Police Department
Personal History Statement
Have you ever been employed by or applied with any other law enforcement agency? Yes
No
If yes, please identify to the best of your knowledge: (Attach extra sheets if necessary)
Agency Name & Address
Position Applied For Date Applied or Hired
Result
List your strengths: __________________________________________________________________________
List your weaknesses: ________________________________________________________________________
Please explain what you can bring to this job that would put you above the other applicants:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I hereby certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and
answers to the above questions. I fully understand that any misrepresentation, omission, or falsification may
deem me permanently unsuitable, or if hired, may lead to the termination my employment.
Signature of applicant
Date
Before me personally appeared
who
stated
this
document and its intent was explained to him/her that he/she has full knowledge of its purpose and that he/she
executed this instrument of his/her free will and accord.
Sworn to and subscribed before me on this
day of
,
______________________________________
Signature of Notary
SEAL
My Commission Expires: _________________________
25
Kyle Police Department
Personal History Statement
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I, _______________________________________________________, do hereby authorize a
review of a full disclosure of all records concerning myself to any duly authorized agent of the
City of Kyle Police Department, whether the said records are of public, private or confidential
nature. Furthermore, I grant permission for this agent to obtain photocopies of any records
concerning myself, that he/she considers relevant to my application for employment with the
City of Kyle Police Department.
The intent of this authorization is to give my consent to 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, polygraph reports, efficiency ratings, complaints or
grievances filed by or against me and the records and recollections of 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 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 the release authorization will
be considered in determining my suitability for employment by the City of Kyle Police
Department. I also certify that any person(s) who may furnish such information concerning me
shall not be held accountable for giving this information; and I do hereby release said
person(s) from any and all liability which may be incurred as a result of furnishing such
information.
I understand that any information obtained by a personal history background investigation,
regardless of the source of that information, that is intended to be used to determine my
suitability for employment by the City of Kyle Police Department, will be kept strictly
confidential by the Kyle Police Department, to the extent permitted by law. Unless otherwise
provided by law or a valid court order, only an authorized agent of the City of Kyle Police
Department will have access to my applicant file and the information contained therein.
I understand that the confidentiality provisions referenced in the preceding paragraph do not
apply to information obtained from any source during the background investigation that
involves suspected or actual criminal conduct on my part for which I am subject to prosecution
under the applicable statute of limitations. Under these circumstances, I understand that the
City of Kyle Police Department may investigate my conduct, may report my actions to another
law enforcement agency for investigation and prosecution, and may contact my current or
former employers should my actions involve suspected or actual criminal misconduct against
that employer or against an individual to whom my employer had a legal relationship.
Applicants Initials __________
I understand and agree that if the release of this information is required by law, by a valid court
order, or when criminal misconduct on my part is suspected, I release the City of Kyle, the Kyle
26
Kyle Police Department
Personal History Statement
Police Department, and its agents and employees, from any and all liability which may be
incurred as a result of the release of such information.
Furthermore, I understand and agree that the confidentiality provisions contained in the Kyle
Police Department’s Authorization for Release of Personal Information shall supercede any
similar or conflicting language contained in any other release.
I also agree to pay any and all charges or fees concerning this request and can be billed for
such charges at the below listed address.
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.
By affixing my signature below, I affirm that I understand and agree to the terms and conditions
imposed upon the City of Kyle Police Department and me as set forth in this Authorization for
Release of Personal Information.
_________________________________________
Print Name – Including Maiden Name
_________________________
Phone Number
_________________________________________
Address
_________________________
Date of Birth
_________________________________________
City, State, Zip
_________________________
Social Security #
_________________________________________
Applicant’s Signature – Including Maiden Name
_________________________
Date
Subscribed and sworn before me, by the said _______________________________________
this ___________ day of _________________, 20_________ to certify which witness my hand
and seal of office.
__________________________________
Notary Public, State of Texas
27
Kyle Police Department
Personal History Statement
28